Inspection on 20/09/05 for Manor Green Road (62)

This inspection was carried out on 20th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Green Road (62) 18/01/07

Manor Green Road (62) 30/01/06

Manor Green Road (62) 05/10/04

Manor Green Road (62) 12/05/04

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Southfields

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Manor Green Road (62) 62 Manor Green Road Epsom Surrey KT19 8RN Lead Inspector Lisa Johnson Announced Inspection 20th September 2005 10:00 Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manor Green Road (62) Address 62 Manor Green Road Epsom Surrey KT19 8RN 01372 726131 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CMG Homes Ltd Mrs Rosaleen Ann Leen Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One person may be over the age of 65 years The age/age range of the persons to be accommodated will be: 29 65 YEARS 5th October 2004 Date of last inspection Brief Description of the Service: 62 Manor Green Road is a converted detached property providing accommodation for five service users with a learning disability. The home is located in a quiet residential area of Epsom and has easy access to shops, public transport and other local amenities. The accommodation is provided over two floors. All bedrooms are single rooms with two rooms with en-suite facilities. The communal areas consist of a medium sized lounge, dining room and kitchen/diner area. There are suitable bathroom facilities provided and the home has a large, secure garden to the rear of the property. There is space for one car to park off-street at the front of the property and ample on-street parking. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 4 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. Cathy Clarke, Regulation Inspector, carried out this inspection Mrs Rosaleen Ann Leen Registered Manager was present as the representative for the establishment. A full tour of the premises took place and documents inspected included care plans, menu plans, medication administration records, staff records, policies and procedures. Two service users were spoken to during the inspection. Comments received from service users, a consultant psychiatrist, relatives and representatives have been included in the report. This was a positive inspection. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? The statement of purpose and service user guide have both been reviewed and updated since the last inspection and a copy of the last inspection report has been included in the service user guide. Epilepsy and fire safety training has been provided for care staff since the last inspection. The practice of secondary dispensing of medication has ceased. The upstairs bathroom has been refurbished and the lounge, dining room, hall, landing and upstairs bathroom have been redecorated. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 6 The premises risk assessment has been updated and the fire risk assessment has been signed and dated. Two staff now sign handover records relating to service users money. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Comprehensive information regarding the home is available for prospective service users and planned assessments are undertaken prior to moving into the home. EVIDENCE: The statement of purpose and service user guide have been reviewed and updated since the last inspection and include details of the new registered manager for the service. A copy of the last inspection report has been attached to the service user guide. There have been no new service users since the last inspection. There is a clear admissions procedure in place and a trial period of twelve weeks is offered. Each service user has a resident’s agreement on file, which is to be updated with the latest contract, which has been developed in a pictorial format. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10 Care plans and risk assessments are clear and set out the achievements made by service users. EVIDENCE: Three care plans were sampled during the inspection and they were found to be clear and concise. Each service user has a review document, which brings together all aspects of their daily lives. Each service user has a missing person procedure and description on file. Regular reviews were seen on file and service users contribute to their activity plans and both the service user and their key worker sign these. Confidentiality of information is observed and there is a statement in the service user guide. Staff talk to service users to ensure that information can be shared and ascertain who they wish to be involved in their reviews. Records are stored in a locked cabinet in the office. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Service users are actively encouraged to live as independent a lifestyle as possible and take a full part in the community in which they live. EVIDENCE: One of the service users spoken to during the inspection works in a café and helps out in the local market. He informed the inspector that he gets ups early in the morning to help set up the stalls in the market and get rid of any rubbish. He enjoys his work very much and it gives him the opportunity to meet people and to live more independently. The service user is also looking forward to assisting wheelchair users in Lourdes this year. One comment received from this service user is that he likes the staff and enjoys going out for coffee, and looking around the shops. He has stated, “We have lots of jokes”. Another of the service users likes a very structured day with a set routine, going into the town in the morning for her newspaper and returning to the home to listen to her music and watch some television in the privacy of her Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 11 room. Staff will assist her on outings to restaurants in the local community, which she enjoys very much. One of the care plans sampled identified that one of the service users likes to attend college and has enrolled on various courses including film studies, computer training and music appreciation. A review of care needs is to be undertaken by the care manager for one of the service users who is very independent to ascertain the best placement for him. The service user frequently stays out at friend’s homes and this has been risk assessed. Service users like to go to local cafes, college, cinema, theatre, and shopping. Two service users enjoy work making badges and putting leaflets in envelopes. The home has a good relationship with neighbours and friends and family are encouraged to visit. The statement of purpose does ask that service users inform others in the home of planned visits. There are private areas within the home and all visitors are required to sign the visitor’s book. One relative has commented that staff are aware of service users likes and dislikes and seem to understand them very well, another relative has stated that all the staff are wonderful, kind, helpful and understanding at all times. Two service users have a set menu, which they will not change. The registered manager informed the inspector that staff have tried to introduce changes to their diets but this has been unsuccessful. One of the service users has a tendency to lose weight and this is monitored regularly. The other service users have a varied diet. Service users were out at lunchtime and therefore meals were not observed. Since the last inspection two staff sign handover records relating to service users money. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Personal support is offered taking into account the individuals needs and level of independence. Health care needs are monitored and regularly reviewed. Medication records are clear and concise. Current photographs are to be added to records and a record is to be kept of all received and returned medicines. EVIDENCE: The registered manager informed the inspector that personal care is not required for service users. Occasionally staff may prompt service users but most are self-sufficient. Service users records sampled showed that their health needs are assessed and monitored and referrals are made to health care professionals where required. A consultant psychiatrist has commented that the home works in partnership, communicates clearly, and staff demonstrate a clear understanding of the care needs of service users. A monitored dosage system is used for medication and each service user has a medication profile. Staff signatures are on file for verification and medication administration records sampled were correctly signed. Medication is stored Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 13 appropriately and the medication key is kept in a locked key cabinet. The practice of secondary dispensing of medication has ceased. The evening medicines were checked against the records, blister pack and eye drops and found to be correct. Pharmaceutical guidelines are available for staff. All medicines received into the home and returned to the pharmacy must be recorded and a current photograph of the service user attached to each of their medication records. All service users have been asked if they wish to make a will. Arrangements following the death of a service user are noted on care records including religious observances. Please see requirements section of this report. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Policies and Procedures are in place for complaints and the protection of vulnerable adults. EVIDENCE: There have been no formal complaints or vulnerable adult investigations since the last inspection. Complaint records are available for inspection. One of the service users has commented that he knows who to complain to if he is unhappy. The majority of relatives and carers are aware of the homes complaints procedure and the consultant psychiatrist has stated that no complaints have been received about the home. Staff are aware of the Surrey Multi Agency Approach to vulnerable adult investigations and risk assessments identify the vulnerability of the service users. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,29,30 The home is clean, and tidy with much of the home being redecorated. Refurbishment of the kitchen is planned. The garden to the rear of the property is large and kept in good order. The patio area needs to have moss removed. EVIDENCE: The registered manager informed the inspector that the kitchen is planned for refurbishment in October 2005. Kitchen units are to be replaced. The fridge in the kitchen was registering 8 degrees and it was recommended that a new fridge thermometer be purchased in order to confirm the temperature. Temperatures should be monitored and recorded for both the fridge and freezer. The upstairs bathroom has been refurbished and the lounge, dining room, hall, landing and upstairs bathroom have been redecorated. During the inspection the hot water in the main house was not working and the maintenance department had been alerted. Window restrictors are not in place in all rooms on the first floor the inspector has advised that where restrictors are not used that risk assessments must be Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 16 undertaken and action taken where risk is identified. Window dressings in the sleep in room must be affixed. The garden to the rear of the property is laid to lawn. There was moss on the patio area, which must be removed to ensure that service users do not trip or fall. Dead trees and bushes should be removed to improve the look of the garden. Disability equipment is not required for service users presently living in this home. Call alarm systems are used for the two bedrooms, which are attached to the house on the ground floor. The home is very clean and tidy throughout. One of the service users rooms in the garden was not inspected because he was out at work and the room locked. One of the bedrooms inspected had a hole in one of the curtains and a small worn area on the duvet cover. The inspector asked the service user whether they wished this to be changed and was informed that the service user did not want these to be changed. All other bedrooms inspected were nicely decorated and reflected the service users personality and choice. Please see requirements section of this report. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 The home is staffed using a combination of permanent and relief staff from another service managed by the registered manager. The recruitment records need to be checked for validation. EVIDENCE: The home is staffed by a combination of permanent staff and relief staff from another home within the area. The registered manager informed the inspector that a proposal has been forwarded to the Commission for Social Care Inspection outlining the current staffing arrangements. Staff files for staff that work at both homes are to be kept in both establishments. During the inspection the staffing rota identified one member of care staff on duty, one member of staff on call and one sleep in night duty carer and the registered manager. Most service users were out at college and work. One service user likes to go out for short periods during the day. Staff recruitment files were sampled and included job descriptions, induction records, signed policies and procedures record, a supervision contract and individual training record. Discussion was held with the registered manager regarding the validity of staff records and it was recommended that records be further checked. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 18 Training programmes are in place and staff have accessed training on Epilepsy and Fire Safety training since the last inspection. The registered manager is undertaking NVQ Level 4 Registered Managers Award and the deputy manager is to undertake this award. One member of staff is nearing completion of Level 2 NVQ. Please see requirements and recommendations section of this report. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42 Service users benefit from a well managed home and their views are listened to and acted upon. Health and safety procedures within the home protect service users from harm. EVIDENCE: The registered manager has many years experience of working with people with learning disabilities and understands the complex needs of service users within the home. There is an open and inclusive management style within the home and staff seen during the inspection worked very much in partnership with the manager and service users. Regular staff meetings are held. The registered manager informed the inspector that service users hold a residents forum, which is facilitated by a resident on a regular basis. The committee feeds back any issues raised to the Head Office of the service. An Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 20 annual survey is sent to service users and their family with a follow up report. Quality assurance guidelines are in place. Policies and procedures are in place for the home and it is recommended that an index be inserted for ease of use. Health and safety policies are in place and a health and safety checklist for the home is completed on a monthly basis. The premises risk assessment has been updated and the fire risk assessment has been signed and dated. The electrical 5-year inspection was carried out on the 13th September with a satisfactory outcome to inspection. The Gas safety inspection is due in October 2005. Epsom and Ewell Borough Council conducted an inspection under the Food Safety Act 1990 on the 24th January 2005 and no contraventions to this act were found. Legionella testing has been carried out and the results found to be negative. Please see recommendations section of this report. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 2 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 2 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Manor Green Road (62) Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 X 3 X DS0000013524.V258388.R01.S.doc Version 5.0 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 (2) Requirement Each service user must have a current photograph affixed to medication records for identification purposes. Medicines received into and returned to pharmacy must be recorded and records made available for inspection. The temperatures of the fridge and freezer must be monitored and recorded. The hot water system must be maintained throughout the home. Where window restrictors are not used, risk assessments must be undertaken and action taken where risk is identified. Window dressings in the sleep in room must be affixed. Moss on the patio area of the rear garden and dead trees and bushes must be removed. The proposal regarding the staffing structure of the home must be forwarded to the Commission for Social Care Inspection. Staff records must be stored in the establishment for those staff DS0000013524.V258388.R01.S.doc Timescale for action 30/11/05 2 YA20 13 (2) 30/11/05 3 4 5 YA28 YA28 YA28 16 (2) (g) 23 (2) (j) 13 (4) (a) 30/11/05 30/11/05 30/11/05 6 7 8 YA28 YA28 YA33 23 (3) (a) (i) 23 (2) (b) 18 (1) (a) 30/11/05 31/12/05 30/11/05 9 YA33 17 (2) sched (4) 30/11/05 Manor Green Road (62) Version 5.0 Page 23 working in both homes and available for inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA34 YA40 Good Practice Recommendations It is recommended that staff recruitment records are checked for validity. It is recommended that an index be inserted into the policies and procedures manual for ease of use. Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Manor Green Road (62) DS0000013524.V258388.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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