Inspection on 15/08/06 for Robinsfield

This inspection was carried out on 15th August 2006.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Robinsfield 11/11/08

Robinsfield 19/11/07

Robinsfield 23/01/06

Robinsfield 25/10/05

Robinsfield 31/08/04

Robinsfield 15/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Robinsfield Robinsfield 35 Whyteleafe Road Caterham Surrey CR3 5EJ Lead Inspector Vera Bulbeck Unannounced Inspection 15th August 2006 10:35 Robinsfield DS0000013766.V302563.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 Robinsfield DS0000013766.V302563.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. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Robinsfield Address Robinsfield 35 Whyteleafe Road Caterham Surrey CR3 5EJ 01883 330070 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) Welmede Housing Association Ltd Ms Jacky Barker Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: Up to 5 persons 21-55 YEARS WITH ONE NAMED PERSON BEING IN THE AGE RANGE 17-21 YEARS Persons with learning disabilities accommodated at the home may also have an additional physical disability 23rd January 2006 Date of last inspection Brief Description of the Service: Robinsfield is a large property located in Caterham within walking distance of local shops and bus routes. The home is located on the ground floor of the property, with the first floor being occupied by tenants of supported living flats, run separately to the home. The main entrance to the property is shared with the supported living tenants and the laundry and staff sleep-in room is located in the entrance hall. The main door to the home is kept locked at all times to ensure the safety and security of the tenants. The home is owned and managed by Welmede Housing Association and provides accommodation and care to six tenants who have a learning disability and also physical disabilities. The accommodation comprises of six single occupancy bedrooms, a large kitchen/diner, a comfortable lounge, two bathrooms and a shower room. There is a good range of adaptations and facilities fitted throughout the home to enable the home to meet the needs of the tenants. There is a well-kept garden to the rear of the property, shared with the supported living tenants, and parking for several cars to the front. The home has recently been provided with a new vehicle, which is used by tenants for various activities including days out. Tenants are picked up and dropped off by the transport of the various Day Centres they attend. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced site visit to be undertaken by the Commission for Social Care Inspection year April 2006 to March 2007. Mrs Vera Bulbeck, Regulation Inspector, carried out the inspection. Ms Jacky Barker the registered manager for the home was present. The inspection was undertaken over 6 hours and 30 minutes. There are currently six tenants living in the home, and the majority have lived in the home for some considerable time. All the tenants were out at day centres on the day of the site visit; and the inspector was able to speak with the tenants in the afternoon before suppertime. A number of staff was spoken to and one commented the home is operating on an open management style and the staff team feel supported and work together as a stable team. A full tour of the premises was undertaken. Two care plans and two staff files were inspected. The inspector received comment cards from four relatives, overall the comments made were very positive. There were some comments made in relation to staffing levels at times not always sufficient and not being aware of the homes complaints procedure. It was also mentioned they did not have access to the inspection report. It was disappointing to note that one of the requirements from the previous inspection had not been met. The registered manager stated this is because an Occupational Therapist had undertaken an assessment on the bath and it was being dealt with. As a matter of priority the home needs to introduce an emergency contingency plan in the event of a major incident. The inspector would like to thank the tenants, registered manager and staff members for their time, assistance and hospitality during the inspection. The range of fees for the service is £1.100 per week. The Tenants living in the home wish to be called tenants, therefore Tenants will be referred to as tenants throughout the report. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 6 What the service does well: 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. Robinsfield DS0000013766.V302563.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 Robinsfield DS0000013766.V302563.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A tenant’s (Service User) guide is available but needs to be reviewed. It was clear the management of the home is aware of the need for pre assessments. EVIDENCE: The needs of prospective tenants are assessed, but the management has not completed a needs assessment on the current tenants as they have lived in the home for over five years. The policy and procedure in place is clear on information of admission criteria. Robinsfield DS0000013766.V302563.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The tenants’ individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences and choices, and include risk assessments. The staff is in the process of updating the care plans and changing from care plans to Person Centred Planning. EVIDENCE: The tenant’s individual plans have been updated and more input from the tenant’s. However, the tenants are unable to be involved with their care planning as there is limited communication and staff is aware of the tenants moods and reactions. There is only one tenant who is able to make any decisions; all tenants are involved with their reviews. Clear and comprehensive details of needs and goals were identified in their care plan. Risk assessments have been undertaken on all the tenants. It was noted in one of the tenant’s files that a licence agreement has been completed in picture form. The inspector was informed that none of the tenants have a care manager involved. However, if necessary a duty care manager would be allocated. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 10 Staff was seen to knock before entering tenant’s bedrooms. Tenants who are able to communicate were observed that they are supported to make decisions, such as choosing holidays and days out. Robinsfield DS0000013766.V302563.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The tenants have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that tenants’ rights are respected. EVIDENCE: The registered manager and staff team are committed to providing a safe and homely environment for tenants. Tenants are encouraged to engage in the daily running of the home and their views are continually sought to improve the service the home provides. This is maintained by the use of listening, sign and body language. The registered manager informed the inspector that questionnaires have been implemented and sent out to families on a yearly basis. There is a plan to send out questionnaires once again to families and friends. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 12 Staff stated that they actively encourage and support tenants to be independent, to make their own choices and to live their lives as they wish, as far as they are able. It was pleasing to note that tenants and staff have a good rapport, tenants were engaging with staff and it was very clear that staff have a good understanding of the tenants needs. Household routines are kept to a minimum and are only in place to enable tenants to share their home’s facilities and to maintain harmony within the household. It was observed, that staff knock before entering tenant’s bedrooms and that personal care is offered discreetly. Tenants are addressed in the way that they prefer and this is recorded in their individual plan. The registered manager informed the inspector that the two weekly menus works well for the home and all staff have completed a food hygiene course. A dietician is involved and can be contacted when necessary. It was noted that the meat probe recording has not been undertaken on a regular basis. All tenants go out to the day centre daily and therefore the main meal is suppertime. The registered manager informed the inspector that an activity organiser visits the home weekly and various trips are organised, these include rambling, bowling, going to the cinema, Christmas pantomimes, hydrotherapy sessions, trips to garden centres and a trip on the Wey River Canal. Holidays are arranged for those tenants who wish to go, three tenants went to Butlin’s in April and May and another tenant is going to Centre Parks in September. Tenants are able to choose a holiday or days out. A new mini bus was purchased for the home in May 2006, which has six seats, therefore is able to take three tenants at a time with three staff including the driver. Three members of staff are qualified to drive the mini bus. Robinsfield DS0000013766.V302563.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Personal support is provided appropriately and ’s healthcare needs are well met. EVIDENCE: From the tour of the premises, it was clear that tenants are provided with a variety of aids and equipment to assist with their independence, including tracking hoists, electrically operated beds and wheelchairs specifically designed for individuals. The inspector was informed tenants are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. The registered manager stated that the administration of medication is carried out by A nominated, “key holder”, member of staff. These members of staff are detailed on a daily handover sheet, which specifies the staffing arrangements for each shift. From the individual plans and speaking to tenants, it was evident that a number of healthcare professionals are involved in the support of the tenants. These include general practitioners (G.P.), chiropodists, opticians, dentists and hospital specialists. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 14 Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 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 the following standard(s): 22 and 23. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Policies are in place to protect tenants from abuse and neglect. EVIDENCE: All staff has attended the safeguarding of vulnerable adults training and when spoken to by the inspector it was clear that staff are aware of the whistle blowing policy. Tenants and relatives should be provided with a copy of the complaints procedure. To enable tenants to be clear of the procedure the complaints procedure is available in picture form. The current complaints procedure on tenant’s files needs updating, it is dated 1990. There were no recorded complaints records available; the registered manager informed the inspector the home has not received any complaints for some considerable time. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 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 the following standard(s): 24 and 30. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose EVIDENCE: The home is accessible, safe and generally well maintained. The home was found to meet tenants’ individual and collective needs in a comfortable and homely way. However, the kitchen is a number of years old and looking very tired and needs replacing. A drawer was seen to be broken. The kitchen is spacious and also used as a dining area. The lounge is a good size and adequate for the tenants to enjoy the surroundings, including a large tropical fish tank. A tenant pays for a company to maintain the tank on a regular basis. The garden is nicely laid out and tenants are able to enjoy the garden by the use of a ramp. A fluorescent light in the laundry needs a cover; this is a health and safety hazard. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 17 Paper hand towels need to be available in all communal areas. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All interactions observed between staff and tenants evidenced a high degree of respect and skill in working with the individual tenants at the home. EVIDENCE: The Registered manager stated and staff confirmed, that supervision of staff has taken place. On the day of the site visit one of the staff files checked was without a criminal record bureau check (CRB). Recruitment procedures need to be followed at all times as detailed in Schedule 2 of the Care Homes Regulations 2001. Staff spoken to on the day of the inspection had a good understanding of their job descriptions and their responsibilities and they were able to identify the roles of other members of staff in the hierarchy. Verbal and written communication between staff was good and evidence was found in the handover book, cleaning rotas and communication book. All members of staff receive supervision on a regular basis. The information received in the preinspection questionnaire indicates that the home has 80 of staff with a National Vocational Qualification. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 19 The home has a very comprehensive induction package that must be completed within six months of starting work for the organisation and further training is provided following this which is also very comprehensive and focuses on the Tenant’s needs and disabilities and incorporates the mandatory training such as fire awareness, health & safety, moving & handling, food hygiene and first aid. Staff training certificates should be available for inspection and copies should be kept on file. The inspector was informed that a member of staff had her certificates at home. All staff should receive a copy of the General Social Council of Care, code of conduct document. The current staffing levels are three staff on duty throughout the day staff undertakes the cleaning, shopping, cooking and laundry duties. One member of staff is undertaking NVQ Level 3 at Godalming College. One member of staff informed the inspector she does not wish to undertake any qualifications. The registered manager has produced a comprehensive training programme. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems in place for tenant’s consultation are varied and have been devised specifically to enable the tenants to make their views known in a manner of ways. EVIDENCE: The registered manager is in the process of completing the Registered Managers Award; she has already completed NVQ levels 2 & 3. A number of records were checked and it was noted the majority are well documented and kept up to date. However, the electrical certificate was dated 05/06/01; this needs to be updated as a matter of priority. On the day of the site visit the testing of portable appliances certificate was not available. The registered manager stated they had recently been checked, it was noted on an electrical plug a check had been undertaken in May 06. An up to date certificate for the testing of Legionella was also not available, the last recorded certificate was dated 23/11/04. Management of the home needs to implement Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 21 an emergency contingency plan and a copy to be held in the fire/health and safety folder Relevant policies and procedures for health, safety and welfare of tenants were in place and the information obtained from the pre-inspection questionnaire is that these are updated regularly and adhere to relevant legislation. Systems existed to demonstrate these had been communicated to staff. Also those of relevance to tenants had been shared with them. Staff was trained in First Aid, Food Hygiene and other aspects of Health and Safety. Tenants finances were checked and these were found to be well-documented and clear, receipts and cash corresponded with the written records. The petty cash money is counted and signed for at each shift change. All money held in the home is audited on a monthly basis. The service manager undertakes monthly audits and copies of the report were seen on file. Copies of these reports need to be sent to the Commission for Social Care Inspection (CSCI) on a monthly basis. The last recorded copy was received on 27/04/06. Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 22 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 3 2 X 3 X 4 X 5 X 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 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 X LIFESTYLES3 Standard No 3Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 3 X X 2 X Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 23 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 Standard YA27 Regulation 23 Requirement The scratched enamel on the bath in the main bathroom must be repaired or replaced. (Timescale 28/02/06 not met). The recording of the meat probe must be undertaken on a regular basis. The kitchen must be replaced or repaired and updated. The fluorescent light must receive a cover. Full recruitment details must be followed at all times. All relevant up to date health and safety certificates must be available. All communal areas must have paper hand towels available. To implement an emergency plan for any unforeseen problems. Timescale for action 24/11/06 2 3 4 5 6 7 8 YA17 YA24 YA24 YA34 YA42 YA42 YA42 13 23 23 19 13 13 13 16/08/06 24/12/06 15/09/06 16/08/06 15/09/06 15/09/06 22/09/06 Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 24 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 YA40 Good Practice Recommendations It is strongly recommended that the manager review the organisation policies and procedures to reflect the individual circumstances in the home. (Carried forward from the previous inspection) The complaints procedure on tenant’s files needs updating. 2 YA22 Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Robinsfield DS0000013766.V302563.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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