Inspection on 11/04/05 for Newlands Cottages (8)

This inspection was carried out on 11th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Newlands Cottages (8) 29/03/07

Newlands Cottages (8) 27/10/05

Newlands Cottages (8) 05/10/04

Newlands Cottages (8) 18/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Newlands Cottages 10 Newlands Cottages Fox Lane Coulsdon Common, Coulsdon CR3 5QS Lead Inspector Claire Taylor Announced 11 April 2005, 09:30 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 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 Stationary 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. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Newlands Cottages Address 10 Newlands Cottages, Fox Lane, Coulsdon Common, Coulsdon, Surrey, CR3 5QS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01883 349 507 01883 349 507 newlands@carecol.co.uk THF Care Estates Limited Dana Thompson Care Home 3 Category(ies) of Learning disability registration, with number of places Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th October 2004 Brief Description of the Service: 10 Newlands Cottages is owned by THF Care Estates Limited and is registered to provide residential care for up to three adults with moderate learning disabilities. An all male group of three service users currently resides at the home who are aged between their mid- twenties and thirties. The cottage is an older style detached property situated in a quiet rural area between Coulsdon and Caterham. The home is very close to a local bus route, country pub and a parade of local shops. 10 Newlands cottage is built over two-stories comprising of three good-sized bedrooms, two communal lounges, an open plan kitchen and dinning room area, an office, two WC’s and a bathroom. The cottage shares its laundry facilities, which are located in the garage, with no. 8 Newlands, also owned by THF Care Estates. The home has a garden, its own vehicle and ample space in the front drive for parking. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was arranged by advance notification and the service users, relatives and other professionals had been well informed about the visit. One service user, several relatives and two care managers completed Pre inspection comment cards. The inspector met with all three service users, three members of staff and the registered manager. The inspection took place over 8 hours and included a brief inspection of the neighbouring cottage, no.8 which is also owned by THF Care Estates Ltd. A separate report is available for this service although it should be acknowledged that the two cottages are run together and have the same registration category. A tour of the premises took place and records were examined including the service users plans of care, staff training / qualifications and other records related to the general management of the home. The inspector spoke with all three service users, one member of staff and the manager. One service user showed the inspector around the house and is thanked for taking the time to do so. What the service does well: This home provides good support for service users to live as independently as possible and improve their quality of life. Due to its small size and high staffing ratio, the service users benefit from a family type environment and one to one support and supervision. They are encouraged to take responsibility for running their home and learn, or further develop independent living skills such as cooking, domestic tasks and organising their personal leisure activities. Service users are treated with respect as individuals and offered choices. The home benefits from a well-experienced manager who has worked there for over seven years. Staff have a variety of skills and knowledge relevant to the setting and clearly understand the needs of the young adults living there. They are provided with appropriate training opportunities and benefit from regular supervision and guidance from the home manager. Service users spoke highly of the staff team and management and one described staff as “wonderful”. One relative described the home as always “clean and homely” and staff as “excellent and always trying to do different things, including outings with the clients”. Another commented, “We are happy with the care our son receives and feel he is in a very caring environment.” Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: It was disappointing to note that when service users went on an outing, leisure activity or holiday they were expected to pay for staff costs as well. I.e. when an outing is arranged service users would be expected to pay for staff admission fees, meals out, travel cards any other costs. With the exception of travelling to the farm, service users also contribute towards petrol expenses for the home’s own vehicle when going out socially. This can limit service users choice and cause significant difficulties given that service users need support from staff when accessing the community. Two of the service users care managers pay an annual sum towards their holiday costs but the contract to confirm this arrangement was not available in the home. The owners, THF Care Estates Ltd should consider alternative ways for funding the service users activities from their own budget. Some areas of the home still require redecoration or repair and this should be addressed. The paintwork needs redecorating in the hall, landing and staircase. Following the repair to the leak from the shower, the ceiling in the hall now needs repainting as it appears discoloured. A more suitable fitting is needed in the laundry area that provides adequate lighting. There was no hot water supply for the sink in the laundry as the tap was missing. This must be addressed to ensure that service users and staff have accessible hand washing facilities and thus minimise the risk of cross infection. The staff could benefit from further training that is more specific to the service users individual needs i.e. Asperger’s syndrome, autism and mental health conditions. The home manager has not received formal recorded supervision or an annual appraisal of job performance since September 2002 and the registered provider must address this. To maximise safety within the home, environmental risk assessments need to be updated and an electrical safety inspection must be carried out to ensure that the home complies with appropriate regulations. Although quality Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 7 assurance systems have been implemented, an annual development plan for the home needs to be put in place. This will demonstrate how the home regularly appraises its care practices through the views of service users, relatives and other relevant parties. To demonstrate financial viability, a business and financial plan for the home must be available. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 8 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 Standards Statutory Requirements Identified During the Inspection Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 9 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 standard(s) 1, 2 and 5 A well-written Service Users Guide gives prospective service users good information about the home and services provided. Detailed assessments are completed to ensure that the home can meet the needs of prospective service users. Service users contracts need improving to ensure that full terms and conditions of occupancy and the home’s duty of care are covered. EVIDENCE: Service users are given a copy of the home’s Service User Guide when they move into the home. The Guide is detailed and contains all of the information as required in the National Minimum Standards. It has been supplemented with photographs for the people who live at Newlands Cottages. The home undertakes its own assessment (meeting the prospective service users in their own living environment where possible in line with the homes admission policy), to ensure the home can fully meet the service users needs. A specific form is used on which to record an overall assessment of each service user once they have been admitted. This covers all aspects of the person’s life, including strengths, social and cultural needs and psychological needs. Copies of these assessments were on file for each service user as well Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 10 as detailed needs assessments completed by their placing authorities. I.e. undertaken by their care managers. There is a written contract between the home and the service user. Service users or their recognised representatives are provided with a signed and costed contract/statement of terms and conditions of occupancy. It specifies the room to be occupied; fees charged, including the cost of extras and periods of notice. Copies of the contracts sampled are in a suitable format and signed by the service user and the registered manager. The manager explained that the registered providers, THF CARE ESTATES LTD, hold a separate contract between the service user and placing authority at their central offices. Copies of these must be made available to service users in the home as they outline other terms of occupancy including arrangements for holiday costs for two service users. Further shortfalls related to contracts have been discussed further on in this report under “Lifestyle”. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 11 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 standard(s) 6, 7 and 9 The care planning process is managed to a very good standard. Individual plans of care are reviewed and revised regularly and service users are fully involved. Service users are provided with the necessary support to take risks so that independence is maximised as far as possible. EVIDENCE: Records for all three service users were examined in some depth. Each service user has a written plan of care that describes what service users can do independently and when they need support from staff. Plans are reviewed six monthly with service users, their families and other relevant professionals. As part of the review process, each service user has a key worker who is responsible for updating their key service users monthly ‘progress sheets’ which form part of their care plan. Discussion with two staff members identified that they were clear about their roles in regards to being a keyworker and assisting service users to make decisions. Informative action plans outline how staff support those service users who may become anxious or physically aggressive towards others. Known as a “non Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 12 crisis intervention” plan, it provides staff with clear guidelines on how to diffuse potential incidents of physical aggression. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 13 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 standard(s) 12, 14, 15, 16 and 17 The home positively encourages activities that match service users needs / preferences and actively explore options that will enhance each individual’s quality of life. Improvements could be made to funding social activities for service users as they have to pay for staff expenses as well as their own. Appropriate contact between service users and their families and friends is encouraged to help them maintain relationships. Independence is encouraged by flexible daily routines and service user involvement in the running of the home. Food provided represents a range of nutritional and cultural preferences to ensure that service users choices are met and a healthy diet is promoted. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 14 EVIDENCE: The home is well placed for accessing a local parade of convenient stores and a local pub. Daily diary notes showed that service users are very active in the local community and enjoy a wide range of activities. E.g. cinema, bowling, restaurants, swimming, Bingo and going out in the evenings to a variety of social clubs. Social needs are clearly described within individual care plans that take account of service users preferences and enable them to have the opportunity to take part in worthwhile and meaningful activities. Service users have the freedom to come and go as they wish and are offered keys to their own bedroom and the front door. The home supports service users to be flexible about when they choose to get up, go to bed, have a bath, and eat. All three service users attend Tandridge Hill Farm five days a week, which provides service users with a wide variety of opportunities to develop their educational, vocational, and practical life skills through animal care, gardening, horticulture, and art and crafts. The registered provider for the home also owns the farm and working at the farm forms part of the service users contract / fees. One service user attends a local college to learn how to speak French and also does cookery classes at a second further education facility. The home keeps a social activity diary of all activities undertaken by service users. This includes going out on a monthly social event that is chosen by each service user. E.g. visit to the theatre or leisure park. Good entertainment facilities are available within the home including TV, music system, videos, computer and a “Playstation” console for one service user. It was disappointing to note that when service users went on an outing, leisure activity or holiday they were expected to pay for staff costs as well. I.e. when an outing is arranged service users would be expected to pay for staff admission fees, meals out, travel cards any other costs. With the exception of travelling to the farm, service users also contribute towards petrol expenses for the home’s own vehicle when going out socially. This can limit service users choice and cause significant difficulties given that service users need constant support from staff when accessing the community. Two of the service users care managers pay an annual sum towards their holiday costs but the contract to confirm this arrangement was not available in the home. The registered providers, THF Estates should consider alternative ways of funding service users activities i.e. pay towards staff expenses and/ or provide a budget for social activities. Menus showed a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of meals. Service users confirmed that they are asked to choose the meals they want to eat and shop for their selected foods. The menu option is displayed in the kitchen and if not desired on the day, alternatives are provided as service users wish. The service users and staff are thanked for inviting the inspector to join them for a very appetising lunch. Mealtimes are relaxed and arranged flexibly to suit individual work and activity schedules. Service users are encouraged to maintain contact with friends and relatives and to develop links Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 15 with the local community. Comments from service users indicated that visitors are made welcome at the home and that maintaining contact with friends and relatives is encouraged wherever possible. One service user said that he sees his parents most weekends. Minutes of regular service users’ meetings were available. These detailed that service users are consulted about a number of aspects of life in the home, including food and activities. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 16 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 standard(s) 18, 19 and 20 Promotion of health is well observed. Service users welfare is closely monitored and suitable arrangements are in place to ensure that their physical and emotional needs are met. Medication is well managed to maintain maximised good health. EVIDENCE: The current service users at the home are very independent and require little or no assistance with personal care (e.g. washing/bathing, dressing/undressing and eating meals). Where needed staff offer service users guidance about personal care/hygiene and seemed to be mindful of the need to respect service users’ rights to privacy and dignity at all times. Records concerning healthcare needs were in very good order. Service users are registered with a local GP practice and have access to other NHS facilities as necessary. E.g. dentist, optician, Consultant, chiropodist, and community psychiatric nurse. Potential complications and problems are identified and dealt with through prompt referrals to the appropriate health professional. All service users are offered annual health checks and care plans contained such details. Each service user has a written profile to specify what medication is required. As good practice, the home should obtain the service users consent to take their medication and record this in the care plans. Medication records checked, including medicines received, administered and returned were all being maintained to a high standard. All staff currently registered to administer medication have completed accredited training in the safe administration of medication. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 17 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 standard(s) 22 and 23 Arrangements for complaints and protection from abuse are well managed and ensure that service users feel listened to and safe. EVIDENCE: Comments received from both service users and relatives showed confidence that the home deals with complaints seriously and that staff are approachable and receptive to any concerns raised. Service users are aware of who to go to if they are unhappy and are provided with a summary complaints procedure. A record of any complaints made about the operation of the home is appropriately maintained and includes details of any investigations, its outcome and any action taken within an appropriate timescale (i.e. 28 days.) An Adult Protection policy is in place that is in line with Croydon Local Authorities procedures. There are adequate systems in place regarding the protection of vulnerable adults. I.e. legislative checks, such as CRB disclosures completed on new and current staff; induction training on the prevention of abuse and numerous policies to safeguard the service users welfare e.g. management of their finances, dealing with aggression and conflict and a whistle blowing policy to state what action to take should staff suspect anything untoward. All staff at the home have attended an Adult Protection course facilitated by Croydon social services. There have not been any adult protection concerns raised. Service users spoken to expressed the view that they felt they were living in a safe environment and that their welfare and rights are respected. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 18 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 standard(s) 24, 26, 27 and 30 Newlands Cottages is homely and comfortable and promotes a family-like atmosphere that further enhances the service users emotional well-being. Bedrooms are designed and furnished to meet the personal preferences and individual lifestyles of the service users. The home is clean, hygienic and in a fairly good state of repair although some repairs are needed in the laundry area to ensure a safe environment. EVIDENCE: Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 19 Situated in a quiet rural area of Coulsdon the home is within easy walking distance of local shops and amenities, including public transport links. The home appeared to be in good condition externally and is decorated in a homely and modern fashion inside. On the whole furnishings, fittings, adaptations and equipment are of good quality, domestic in scale and suitable for the people who live there. The home has a detailed planned programme of maintenance for the redecoration of the home. The carpet was loose in the office and needs to be made secure or replaced as it could present as a potential trip hazard. The paintwork needs redecorating in the hall, landing and staircase. Following the repair to the leak from the shower, the ceiling in the hall now needs repainting, as it appears discoloured. Two service users showed the inspector their bedrooms and commented that they were happy with them. Service users are encouraged to personalise their bedrooms with their chosen possessions and furniture as appropriate. Individual rooms are lockable and service users are provided with a key unless indicated in their individual care plans. All bedrooms have been fitted with suitable locks that can be overridden by staff in an emergency. Laundry facilities are in a separate garage area and are shared by the neighbouring cottage; no.8 Newlands. Two areas of concern were identified in the garage. Firstly there is only one light bulb suspended from a roof beam that provides limited light. A more suitable light fitting is needed such as a fluorescent strip light. The other requirement is that there was no hot water supply for the sink as the tap was missing. This must be addressed to ensure that service users and staff have accessible hand washing facilities and thus minimise the risk of cross infection. To enhance independence, service users are encouraged to participate in household cleaning tasks on a daily basis. The home appeared clean, tidy and free from offensive odours. Good hygiene practices are in place and systems to control the spread of infection. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35 and 36 The home has a staff team who have had relevant training enabling them to meet the needs of the service users living at the home although staff could benefit from further training specific to individual needs. There is a range of experiences, and an understanding of the needs of people with learning disabilities. Recruitment practices are securely managed to maximise protection for the service users. Service users are benefiting from having a well-supported staff team who receive supervision with their manager at regular intervals. EVIDENCE: Due to the home’s small size and high staffing ratio, the service users benefit from a family type environment and one to one support and supervision from staff. All new members of staff employed on a permanent basis receive a structured induction as part of their probationary period of employment, which is signed and dated on completion. A simplified version of the induction checklist that covers health, fire, emergency procedures and safe working practices has been made available for bank/agency staff. All the staff files were examined; including the manager’s, and records confirmed that all staff have undergone appropriate checks including an up to date CRB check. A wide range of training opportunities are available to staff at all levels and individual training needs are addressed through supervision and appraisal. The home keeps records which show what training courses staff Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 21 have done, and when they did them. Extensive in-house training has been achieved in all key areas and further training is planned for the forthcoming year. Examples include crisis intervention, equal opportunities awareness, fire safety, food hygiene and first aid. Further training is recommended that is specific to the needs of the service users. i.e. for staff to develop a better understanding of Asperger’s syndrome, autism and mental health conditions. Regular staff meetings are held which provide frequent opportunities for staff to share their views, develop teamwork and improve upon care practices for the service users. Support and supervision for staff is good and well organised by the manager. One member of staff spoken to confirmed this practice. The home manager however had not received formal recorded supervision or annual appraisal since September 2002 and the registered provider must address this. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 42 and 43 A long established manager runs the home efficiently and it provides a safe and stable environment for the people living there. Progress has been made by the home to establish a quality assurance system, which now needs to be further developed to ensure that quality of care is regularly appraised and the home is meeting its objectives. The health, safety and welfare of service users is overall promoted and protected. Some improvements are needed with the home’s record keeping to ensure that service users’ safety is not compromised. EVIDENCE: The manager has good experience and professional qualifications relevant to managing the home. The last inspection required for the home to implement a quality assurance system and an annual development plan, with both involving the service users. Some quality monitoring tools are in place to measure the success of how the home is achieving its aims and serve the best interests of the people who live there. Examples include care plan reviews, service users Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 23 meetings and monthly visits from the registered provider. In addition, satisfaction questionnaires are provided for service users and most recent ones all indicated positive feedback. Likewise, the Commission received favourable comments from relatives, two care managers and a general practitioner prior to the inspection. As a quality annual plan has yet to be developed, the previous requirement remains in force. The home has designed questionnaires and sent these to relatives of the service users. Findings from these should also be included in the home’s annual development plan. The home was found to be well maintained and, generally, to promote a safe environment. Two minor shortfalls were identified with record keeping. Environmental hazards have been risk assessed to safeguard the welfare of the service users but assessments need up dating, as they had not been reviewed for over a year. A report was seen concerning a recent fault with the emergency lighting. The contractor stated that “the electrical safety report does not match to installation”. The registered provider is therefore required to arrange another electrical safety inspection for the home to demonstrate that the system complies with current legislation. Staff were fully up to date in key areas of health and safety training i.e. moving and handling, food hygiene, fire safety and first aid. Fire drills, fire equipment and hot water temperature checks are carried out at appropriate intervals. Cleaning products are stored safely and staff have received training on infection control as previously required. Accurate records are kept for accident and incident reporting and the home keeps the Commission well informed of any incidents that affect the service users well being. A business and financial plan to confirm financial viability of the home was not available as it is held at the central headquarters of the registered owners THF Care Estates Limited. Outstanding from the last inspection, a copy must be sent to the Commission local office. Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 3 3 x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 x x 2 Standard No 11 12 13 14 15 16 17 x 3 x 2 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Newlands Cottages Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 2 2 G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 25 Yes 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. 2. 3. 4. 5. Standard 24 24 30 36 24 Regulation 23(2)(b) 12(1)(a) 23(2)(p) 23(2)(j) 18(2) 23(2)(b) Requirement The loose carpet in the office needs to be made secure or replaced The light fitting in the garage must be replaced to ensure that adequate lighting is provided. A supply of hot water must be available at all times in the laundry area (garage) The registered manager must have an annual appraisal and regular documented supervision The registered person must ensure the hallway, staircase and landing are redecorated (Timescale of 31.12.04 not met). The registered person must not pass on staff costs for outings and holidays to service users unless clearly stated in the contract and agreed by care management. The registered provider must ensure an annual quality assurance development plan is implemented for the home. A copy of which must be sent to the local office of the CSCI.(Timescale of 31.12.04 not met The registered Person must send Timescale for action 31.8.05 31.8.05 31.8.05 30.8.05 and henceforth 31.7.05 6. 14 5(1)(b) 17(2) sch.4 (8) 31.7.05 7. 39 24(2) 31.8.05 8. 43 25(2)(a & 31.8.05 Page 26 Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 c) 9. 42 13(4) 10. 11. 42 5 13(4) 5(1)(b & c) 17(2)sch. 48 to the CSCI, local office a current business and financial plan and a copy of the annual accounts (Timescale of 31.12.04 not met). The registered provider is must 31.7.05 arrange another electrical safety inspection for the home to demonstrate that the system complies with current legislation. Risk assessments need to be 31.7.05 reviewed for all safe working practices within the home. Contracts between the service 31.7.05 user and their placing authority must be made available to them in the home. 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 20 14 Good Practice Recommendations Service users consent to take medication should be recorded in their care plans. The registered providers, THF Estates should consider alternative ways of funding service users activities i.e. pay towards staff expenses and/ or provide a budget for social activities. Further training should be organised that is specific to the needs of the service users. i.e. for staff to develop a better understanding of Asperger’s syndrome, autism and mental health conditions. Following the repair to the leak from the shower, the ceiling in the hall now needs repainting, as it appears discoloured. 3. 35 4. 5. 24 Newlands Cottages G53 S25818 newlanscottages10 V189094 110405 stage 0.doc Version 1.20 Page 27 Commission for Social Care Inspection 8th Floor, Grosvenor House 125 High Street Croydon CR0 9XP 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. 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