Inspection on 23/08/05 for Raleigh House

This inspection was carried out on 23rd August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Raleigh House 12/01/09

Raleigh House 17/01/07

Raleigh House 01/03/06

Raleigh House 01/03/05

Raleigh House 12/11/04

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 Raleigh House 9 Raleigh House Wallington Surrey SM6 8HE Lead Inspector Diane Thackrah Unannounced 23 August 2005 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. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Raleigh House Address 9 Raleigh Avenue, Wallington, Surrey, SM6 8HE 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) 020 8669 3691 Mrs Rose P Jesudasan Mr Davanthiran Jesudasan Care Home 3 Category(ies) of Learning Disability registration, with number of places Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 1 March 2005. Brief Description of the Service: Raleigh Avenue is a four bedroomed, semi detached house situated in a quite street in a suburb of Wallington. The home is approximatley one mile away from shops and bus routes to Croydon and Sutton. The Registered Provider is Mrs Jesudasan and the Registerd Manager is her husband, Mr Jesudasan. The home is registered to provide accommodation and care to three adults who have a learning disability. The owners hope to register a futher two single bedrooms in the home. The home has an extension on the ground floor, which includes a bedroom with en-suite shower facilities. There is a garden to rear of the building. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 23 August 2005 between 14.30 and 17.45. The standards of care were assessed through observation, examination of care records and discussion with the Registered Provider and Registered Manager. One staff member, and both service users were present during the last two hours of the inspection. What the service does well: What has improved since the last inspection? Since the last inspection the Registered Provider has completed training in management and now has a qualification in ‘Professional Development in Management Studies’ Both service users have been supported to have two holidays. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 6 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. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 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 standard(s) 1, 4 and 5. There is a Statement of Purpose and Service User Guide and contract. Also, service users have opportunities for visiting the home before agreeing to live there. Service users, their relatives or advocates, therefore have the information needed to make an informed choice about were to live. EVIDENCE: There is a Service User Guide and Statement of Purpose which is made available to prospective service users, their relatives or advocates. These documents are in written, and audiotape format. These documents have recently been reviewed. The Registered Manager said that no changes have been made to either document. The current service users have lived in this home for seventeen years. There have been no other service users living in the home. The Registered Provider said that any new prospective service user would be given the opportunity to visit the home and meet with current service users and staff members prior to moving in. There was a written contract in place for each service user. These detailed the terms and conditions of the placement. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 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 standard(s) 6, 7, 9 and 10. Service users’ assessed needs are recorded and reviewed, needs are therefore well met. EVIDENCE: A care plan was in place for each service user. Care plans detailed the individual care required by service users. Care plans also set out specialist requirements and one-to-one support required. There was documentation detailing the involvement of the social worker and other social care professionals in the care planning processes, including the review of care. Risk assessments are in place detailing why service users do not leave the home alone. The Registered Manager said that each service user is supported to make some decisions. This is detailed in care plans. A representative from the London Borough of Sutton is an appointee for each service user. The home operates a Risk Management Strategy. Service users have individual risk assessments depending on their needs and goals. Copies of individual risk assessments are kept on the service users file and cover a variety of situations. Risk assessments are reviewed regularly. There is also a missing person’s policy which gives staff clear guidance if a service user was to go Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 10 missing. There is a policy regarding confidentiality. Any new staff member must familiouraize himself or herself with this policy during their induction programme. Personal records are stored in a locked filing cabinet. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 and 17. Service users have opportunities for personal development and daily routines are flexible, this allows them to lead fulfilling lifestyles. Service users are consulted about meals and activities and therefore differing expectations and lifestyles are well catered for. EVIDENCE: Both service users attend a local daycentre each weekday. Activities at the day centre vary according to needs and abilities. The Registered Provider said that service users are involved in weekly shopping trips, and both attend local places of worship. The Registered Provider has a positive approach to supporting service users to maintain contact with family members and friends, all of whom are welcome to visit service users in the home. Individual choice is promoted and service users are encouraged to make decisions about daily living. Risk assessments are in place detailing the reasons why each service user does not have a front door key. There is generally one-to-one support for service users, as one staff member and the Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 12 Registered Provider, or Registered Manager are in the home at most times. Service users have unrestricted access to all areas in the house and the garden. There is a five-week rotational menu. Service users eat a main meal each lunchtime at the day centre they attend, and a light meal, such as soup or sandwiches is provided each evening. Drinks and snacks are available at any time. Menus observed detailed that a balanced and healthy diet was available. Service users are encouraged to participate in the selection of meals and, having lived with the Registered Providers for seventeen years, their preferences are well known. There is a pleasant dining area. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21. Appropriate personal and, in general, good healthcare support is provided. Ageing and death is dealt with sensitively. This ensures the well being of service users. However, there is a lack of training in the safe handling of medication for some staff members. This has the potential for placing service users at risk. EVIDENCE: There is an induction programme which covers ‘personal care’ and staff members must be competent in providing flexible care and in maximising the privacy, independence and dignity of service users, prior to working with them. Care plans detail how care is to be provided in a sensitive manor, and in a way that maximises independence. Staff members are available to provide support and guidance with personal care. Current service users do not require any technical aids or adaptations. Service users are registered with a local GP. Records detail that health care needs are addressed, and that service users have access to a range of health care professionals. Annual health checks occur for each service user. There is an accident/incident book in place and records are maintained of any accidents/incidents that occur to service users or staff members. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 14 There are policies and procedures in place regarding medication. All medication entering and leaving the home is recorded, and Medication Administration Records are in place. Medication currently in use was noted to be stored in a locked cabinet. Both the Registered Provider and Registered Manager have completed training in the safe handling of medication. However, other staff members, who have responsibility for administering medication, have not received such training. A Requirement is made that staff members who handle medication must receive accredited training in the safe handling of medication. There were records detailing that arrangements for the deaths of service users have been handled sensitively. This has evolved consultation with social care professionals. Records also detailed that attempts have been made to involve and independent advocate in this process. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 15 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. There is a system in place for the effective handling of complaints and service users and their relatives are encouraged to raise any concerns they have. Service users therefore know that their concerns will be acted upon. Not all staff members have received training in adult protection; this has the potential for service users not being fully protected. EVIDENCE: There are policies and procedures in place for dealing with complaints. Information is made available in the Service User Guide about how a compliant, concern or suggestion should be made, and how this will be handled. This information is available in symbol format. This information also includes details about how a complaint may be made to the Commission for Social Care Inspection. No complaints have been made since the last inspection of the home. The home has a copy of the London Borough of Sutton Adult Protection Policy in place. Both the Registered Provider and the Registered Manager have attended the Local Authorities vulnerable adults protection training. However, other staff members working in the home have not received this training. A Requirement is made that all staff members who work in the home must receive training in the protection of vulnerable adults. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 16 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, 28, 29 and 30. The home is, maintained, decorated and furnished to a good standard and facilities are clean and safe. This ensures that service users live in a pleasant, homely and comfortable environment. Specialist equipment provided throughout the home maximises the independence of service users. EVIDENCE: The home is situated on a residential street and cannot be distinguished from other properties. The house is domestic and homely in nature. There are four bedrooms, two of which are registered with the Commission for Social Care Inspection, a lounge, dining room, kitchen and utility room. Current service users share a bedroom on the ground floor which has en suite facilities. There is a bathroom, and staff sleep-in room/office on the first floor. There is also a large and well-maintained garden to the rear of the property. There were records detailing that the home was inspected by the local fire service in June 2004, and found to comply with their requirements. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 17 Only one bedroom is currently in use. This bedroom contained suitable furniture and fittings, in line with regulation. There is limited specialist equipment required by current service users. Handrails have been fitted on the stairway. The home was very clean, hygienic and free from offensive odours. There is a utility room, hand washing facilities and policies and procedures for the control of infection. Staff members are provided with protective clothing. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 18 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) 34, 35 and 36. The procedures for the recruitment of staff are not robust and therefore do not fully provide the safeguards to offer protection to people living in the home. There is a staff training, development and supervision programme that, in general, provides staff members with the skills necessary for meeting the needs of service users. EVIDENCE: There are currently six staff members, including the Registered Provider and Registered Manager, who work in the home. Criminal Records Bureau checks have been carried out for four of these workers. The Protection of vulnerable adults list has been checked for the two workers who have commenced work prior to satisfactory Criminal Records Bureau checks being made. There were records detailing that Criminal Records Bureau checks have been applied for regarding these workers, however, staff members must not work unsupervised with service users until a satisfactory Criminal Records Bureau check has been obtained. Written references were in place for all staff members. There were records detailing that each staff member has undergone induction training. Induction training covers principles of care, safe working practices and the experiences and needs of service users. One staff member has recently undertaken training in basic food hygiene. There is a need however, for all staff members to undertake this training. The Registered Provider and Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 19 Registered Manager have undertaken a wide range of training. This includes First Aid, Moving and Handling, Fire Safety, sexuality and Relationships and Risk Management. All staff members receive monthly supervision and a yearly appraisal. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 20 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) 42. The health and safety of service users is taken seriously, therefore their wellbeing is protected. EVIDENCE: There are good arrangements for ensuring safe working practices in the home. All staff members undergo training in safe working practices and safety. However, three Requirements have been made as a result of this inspection in relation to the need for staff training in the safe handling of medication, food hygiene and adult protection. Risk assessments of the premises and individuals are in place. All accidents and incidents are recorded. Portable appliances and electrical installations were tested in 2005. The gas system was serviced in 2004. There are good systems in place for fire safety including regular testing of the fire alarm and smoke alarms and regular fire drills. Water, fridge and freezer temperatures are tested regularly. Policies and procedures are in place for infection control and protective clothing is available. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 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 x x 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Raleigh House Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 22 NA 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 20 Regulation 13 (2) Requirement Timescale for action 01.11.05 2. 23 13 (6) 3. 34 19 (1) (a)(b)(i) 4. 35 13 (4) (c) The Registered Provider must ensure that all staff members, who are responsible for handling medication, have received accredited training in the safe handling of medication. The Registered Provider must 01.11.05 ensure that all staff members must receive training in the protection of vulnerable adults. The Registered Provider must 01.09.05 ensure that a satisfactory Criminal Records Bureau check is in place for all staff members prior to them comencing work in the home. The Registered Provider must 01.12.05 ensure that all staff members who are involved in the preparation and handling of food, have undertaken training in basic food hygiene. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 23 Raleigh House Standard 1. Raleigh House G53-G53 S7183 Raleigh V207785 120705 stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection CSCI 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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