Inspection on 29/03/07 for Newlands Cottages (8)

This inspection was carried out on 29th March 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newlands Cottages (8) 27/10/05

Newlands Cottages (8) 11/04/05

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 (8) 8 Newlands Cottages Fox Lane Coulsdon Common Coulsdon Surrey CR3 5QS Lead Inspector Lee Willis Key Unannounced Inspection 29th March 2007 10.40a Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 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 Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 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. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newlands Cottages (8) Address 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) 8 Newlands Cottages Fox Lane Coulsdon Common Coulsdon Surrey CR3 5QS 01883 349 507 01883 349 507 THF Care Estates Limited Dana Thompson Care Home 1 Category(ies) of Learning disability (1) registration, with number of places Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: 8 Newlands Cottage has recently been taken over by Consensus Care, but remains registered with the CSCI to provide personal support and accommodation for one younger adult with a moderate learning disability. The registered manager, Dana Thompson, continues to be responsible for the day to day running of this home in conjunction with no.10 Newlands cottages. Both the cottages share the same staff team and laundry facilities, which are located in the garage at the rear of the property. This older style semi-detached bungalow is situated on a small rural housing estate in between Coulsdon and Caterham. The home is within easy walking distance of a local parade of shops, a popular country pub, and is on a main line bus route, which has good links to Caterham and Croydon. The property comprises of a single occupancy bedroom with its own communal lounge, a small spare room, kitchen, and bathroom/WC. The rear garden has recently been cleared and now contains a vegetable patch and herb garden. The sole resident of the cottage has access to a copy of the homes most up to date Statement of Purpose, Guide, and CSCI report. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence gathered during the inspection process, which included a visit to the service, the Commission for Social Care Inspection (CSCI) has judged the scheme to have substantially more strengths than weaknesses as most of the key National Minimum Standards are met, although a potential risk to the service users safety was identified during the inspection. Nonetheless the Commission is confident that this matter is being managed. This unannounced site visit was carried out on a Thursday between 10.40am and 3.10pm. During the course of this four and a half hour inspection the homes sole resident, a senior support worker, and the homes registered manager were all spoken with at length. The remainder of the site visit was spent examining the homes records and touring the premises. The Commission received two comment cards in respect of this service from the service user and their relative. What the service does well: All the written and verbal feedback received from the service and their relative about the home was very complimentary. The individual who resided there said the best thing about living at the home “was having the freedom to choose when you spent time with others or in your own company”. The home is good at encouraging and supporting the service user to take responsible risks to ensure they maintain and develop their independent living skills. This individual said staff were very good at helping to prepare his own meals and keep his cottage clean and tidy. The home is also very good at helping the service user make ‘informed’ choices about their life. Records revealed that residents meetings are held on a regular basis in the neighbouring cottage and that the resident of No10 is always invited to attend them. The service user told us that he got on really well with all the staff who always took account of his point of view. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 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 Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 Quality in this outcome area is good. This judgement has been made using all the available evidence. People’s needs are fully assessed prior to admission so the individual and the home can be sure the placement is appropriate. Each service user is supplied with a written and costed contract so service users and their representatives know what their terms and conditions of occupancy are and how much they can expect to be charged for facilities and services provided. EVIDENCE: The manager confirmed that the service continues to be fully occupied and consequently the home was not receiving any new referrals. The manager told us that the service user has a written contract that sets out their terms and conditions of occupancy. The service user said they remembered signing their contract and believed a copy was held on their behalf in office of No 10 Newlands cottage. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using all the available evidence. The homes approach to developing care plans is sufficiently robust to ensure service users unique assessed needs and personal goals are reflected in each of their individual plans. The service user participates in all aspects of life in there home and the adjoining service, which is run by the same staff team. Staff ensure the service user is supported to take ‘responsible’ risks as part of a structured programme to promote their independent living skills and lifestyle. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 10 EVIDENCE: A care plan was made available in respect of the sole individual who resided at the cottage. Information contained in the plan had clearly been generated from the individual’s needs assessment. The inspector is aware that the homes new owners intend to introduce a far more person centred approach to developing care plans that places a greater emphasis on service users unique strengths and personal aspirations, as opposed to just their individual needs. Progress on the matter will be assessed at the homes next inspection. Minutes of residents meetings held at No 10 Newlands cottage on regular basis revealed that the sole occupant of No 8 is always invited to attend. A comprehensive set of assessments that set out all the action to be taken by staff to minimise identified risks contained in this individuals care plan were made available on request. The assessments included detailed guidance to help staff deal with behaviours that could potentially challenge the service. The manager and the senior member of staff in charge of the early shift both demonstrated a good understanding of how to carry out a thorough risk assessment and develop effective risk management strategies. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Opportunities for the service user to participate in social activities remain excellent and provide flexible choice in how he spends their day. Dietary needs and preferences are extremely well catered for and meals nutritionally well balanced, providing daily variety and interest for the service user. EVIDENCE: The occupant of No 8 Newlands cottage was spoken with at length and told us that he liked living there because he had his own front which he could choose to shut if he wanted to enjoy his own company. He went onto say that he also spent a lot of his time in the neighbouring cottage enjoying the odd meal and the company of the other service users. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 12 The home continues to have an open visitors policy and the service user told us that they were not aware of any restrictions on visiting times. The service user confirmed that staff actively encourage him to help the other residents plan weekly menus every Sunday afternoon. He also told us that he sometimes cooks his own meals and will often choose to eat alone in his cottage. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home has sufficiently robust arrangements in place to ensure the health care needs of the service user are continually recognised and met. The homes policies and procedures for dealing with medicines are sufficiently robust to safeguard the service user. EVIDENCE: The person living at the cottage said they had the freedom to choose what time they got up, went to bed; what activities they engaged in; and what they wore each day. Their individualised care plan contained all the detailed information about their specific health care needs, as well as all the medical appointments that he had each attended in the past year. No errors were noted on the individual’s medication administration records. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using all the available evidence. Sufficiently robust arrangements are in place to enable the service user to raise any concerns they may have about the homes operation. The homes vulnerable adult protection protocols minimise the risk of the service user being abused, harmed, or neglected. EVIDENCE: The service user said on the whole staff were good listeners and always took their viewpoint into account. The manager confirmed that there have been no allegations of abuse made within the home. Furthermore, the senior in charge of the early shift demonstrated a good understanding of the local authority’s vulnerable adult protection protocols and the providers own whistle blowing procedures. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 30 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a site visit to this service. The physical design and layout of the cottage suits the occupant’s lifestyle and ensures their privacy is respected. However, not all parts of the cottage are reasonably decorated and the providers will need to improve their routine maintenance programme. Furthermore, the homes faulty shower facility will either need to be repaired or removed to ensure the service user continues to live in a relatively safe environment. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 16 EVIDENCE: The service user invited us to go on a guided tour of his home. The cottage felt pleasantly warm throughout and was free of offensive odours. Since the last inspection a new carpet has been fitted in the lounge and a vegetable patch created in the rear garden. However, a large damp spot has formed on the bedroom ceiling because if a leaky roof and wall paper throughout the cottage has begun to peel. A time specific programme for the redecoration of the entire cottage needs to be established. Having tested the temperature of water emanating from the homes only bath it was found to be a safe 43 degrees Celsius at 12.30. The homes manager said the temperature of water emanating from the shower facility above the bath fluctuated. The service user said he rarely used the shower as he preferred t have a bath. The manager and service user agreed at the time of this inspection that until a decision about what to do with the faulty shower (i.e. repair or remove it) no one would be permitted to use it. Manager also agreed to replace the bath mat that had become covered in mould. The homes laundry facilities are located in the garage and its washing machine is capable of washing clothes at appropriate temperatures. No laundry has to be taken through areas where food is stored, prepared, or eaten. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of suitably competent staff are employed on a daily basis to ensure the individual needs of the service users are generally met. The homes recruitment procedures are sufficiently robust to protect the service users from avoidable harm. EVIDENCE: The service user told us that the homes staff team were very approachable and always treated him with the utmost respect. One service user said they got on extremely well with their allocated keyworker who was frequently on hand to offer them support and advice. On arrival a senior member of staff was the only person on duty in the neighbouring cottage. The shift leader explained that at least two staff would normally be on duty during the morning, but because one service user was out it was perfectly acceptable to have just the one member of staff on. The senior went onto explain that the homes manager was taking an exam that morning. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 18 The home has experienced a relatively high rate of staff turnover in the past year with three new members of staff recruited during this period to replace those that had left. The personal files for all three of the homes most recently employed staff were examined in depth and found to contain all the relevant recruitment checks, including completed job applications, two written references in respect of each of them, up to date Criminal Records Bureau and Protection of Vulnerable Adult checks, and proof of their identities. The manager has carried out a thorough assessment of her current staff teams skills and training needs. This assessment along with certificates of attendance of various training courses revealed that sufficient numbers of the homes current staff team had received training in fire safety, basic food hygiene, and handling medication in a residential care setting. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The service users benefit from living in a home that is run by an experienced and competent manager. The homes quality assurance system is not sufficiently robust to ensure service users and their representatives views about the standard of care provided underpins the services development. The homes health and safety arrangements are sufficiently robust to minimise the risk of service users, their guests, and staff being harmed. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 20 EVIDENCE: The homes manager is still studying for her Registered Managers Award, which she hopes to have completed by August 2007. The homes manager said she receives a lot of support from her line manager to carry out the duties of running a residential care home. Documentary evidence was made available on request to show that senior representatives of Consensus Care continue to carry out monthly-unannounced inspections of the home as part of the providers self-monitoring systems. However, it was disappointing to note that despite repeated requirements being made by the Commission the home had still not introduced an effective quality assurance system for ascertaining service users and their representatives views about the standard of care being provided at Newlands cottage. A letter as being issued by the Commission ‘warning’ the providers that continued failure to address this outstanding matter will result in enforcement action being considered to ensure compliance. The homes fire records revealed that its fire alarm system continues to be tested on a weekly basis, and fire evacuation drills are still being carried out at regular intervals. Up to date certificates of worthiness were made available on request to show that the homes fire alarm system, fire extinguishers, emergency lighting had all been tested in the past year by suitably qualified engineers in accordance with good health and safety guidelines. Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 1 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 1 X X 3 X Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 YA24 Regulation 23(d) Requirement A time specific rolling programme to redecorate the cottage interior, including the bedroom and spare room, must be established and a copy forwarded to the commission. Taking into account the service users wishes the faulty shower above the bath, which is deemed unsafe, must either be removed or repaired to ensure the water temperature never exceeds 43 degree s Celsius. The home must introduce an effective quality assurance system for ascertaining service users and their representative’s views about the standard of care provided and publish the results of their findings on an annual basis. Previous timescales for action of October 2004 and 31st December 2005 not met. Warning letter issued regarding this persistent breach of the Regulations. Timescale for action 01/07/07 2. YA27 12(3) & 23(2)(c) 01/05/07 3. YA39 24(2) 01/08/07 Newlands Cottages (8) DS0000025817.V331810.R01.S.doc Version 5.2 Page 23 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. Refer to Standard YA37 Good Practice Recommendations The homes manager should have completed her Registered Managers Award by August 2007. 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