Inspection on 05/10/07 for St Matthews Avenue, 1

This inspection was carried out on 5th October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Matthews Avenue, 1 20/06/06

St Matthews Avenue, 1 10/11/05

St Matthews Avenue, 1 19/07/05

St Matthews Avenue, 1 05/10/04

St Matthews Avenue, 1 11/05/04

St Matthews Avenue, 1 29/12/03

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 St Matthews Avenue, 1 Surbiton Surrey KT6 6JJ Lead Inspector Adrian Gordon Key Unannounced Inspection 5th October 2007 10:00 St Matthews Avenue, 1 DS0000013389.V352565.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 St Matthews Avenue, 1 DS0000013389.V352565.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. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Matthews Avenue, 1 Address Surbiton Surrey KT6 6JJ 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) 020 8390 3734 020 8390 3734 www.hft.org.uk Home Farm Trust Mr Stuart Mark Noble Care Home 8 Category(ies) of Learning disability (8) registration, with number of places St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 2006 Brief Description of the Service: 1, St Matthews Avenue is a registered care home for eight adults with learning disabilities. The home is owned and managed by Home Farm Trust Limited. The home is residential road in Surbiton, close to local shops and amenities with good transport links. The home is not identifiable as a care home and is in keeping with neighbouring houses. Information about the service is available in the Statement of Purpose and Service User Guide. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over the course of one day by one inspector. It consisted of a tour of the premises, examination of records and observation of care practice. We met with four people who use the service and four members of staff. Easy read questionnaires were given to all the people who live at the home. Three were returned. An Annual Quality Assurance Assessment was also received from the home. What the service does well: What has improved since the last inspection? What they could do better: Necessary training in core skills has not been provided to all staff over the past year. A training plan is now in place and gaps in training identified. More care must be taken in monitoring hot water temperatures to ensure they are within the accepted range. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 6 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. St Matthews Avenue, 1 DS0000013389.V352565.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 St Matthews Avenue, 1 DS0000013389.V352565.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): 2, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Easy to understand information is available for people who are thinking of using the service. However, not all the people that currently live there see the home as the right place for them. EVIDENCE: All the current people who use the service have been living there for about five years so there have been no recent admissions. When they first come to live at the home, people are given a Service User Guide, Contract and Service Agreement. The information includes ‘what I need to know’, how to complain, individual rights and fees. People who use the service are assessed before coming to live there. The assessment information is currently being rewritten using a new format called the Support Planning and Recording System. An example of this was seen which gives a great deal of information about individual needs and how these will be met. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 9 The majority of people are happy at the home and it is a suitable place for them. However, not everyone wants to live there. The organisation is working with the placing authority so that alternative placements are found if possible. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 10 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, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The support plans in place contain good information which enables staff to meet the individual needs of people who use the service. There are good arrangements for ensuring that the people living at the home are consulted. EVIDENCE: Support plans are in place for each person that uses the service. These give good information on individual needs such as communication, personal care and activities. A new Support Planning and Recording (SPAR) system is being introduced. These forms will give a very detailed picture of each person, their individual needs and how they must be met by the service. A completed plan for one person held good information about behaviour, encouraging choice, culture and employment. However, the staff group need to consider how to develop information on sexuality and relationships. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 11 People who use the service are encouraged to make decisions for themselves. Evidence was seen of this in practice and in written guidance. One care plan stated that staff must explain the weather each morning to a particular person individual, so that they can make an informed choice about what to wear. Staff were seen to explain things carefully to people, giving them the information they needed to make a choice. For example, deciding what to do in the evening. Resident meetings take place every month and are well recorded. A recent meeting in September 2007 included a discussion about changes to the home and activities. People who use the service are also able to put their views forward to an annual conference held by the Home Farm Trust. This gives them a chance to contribute to the development and improvement of the provider. Risk assessments are put in place to make sure that individuals are encouraged to be independent whilst remaining as safe as possible. The new SPAR system includes information about any risks attached to each area of need. For example being aware of road safety when out in the community. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 12 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): 11, 12, 13 , 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to enjoy a good range of activities of their own choosing. EVIDENCE: Person who live at the home enjoy a good range of activities and outings. These include day centres, outings to shops and cafes, table tennis, swimming and the cinema. One person said that they enjoy going to Scouts. A vehicle is available to assist with outings if needed. People have regular ‘home skills’ days where they will do an activity with a member of staff. During the inspection, one person went into London for their ‘home skills’ day which they clearly enjoyed. An accessible, colourful folder has recently been created which contains information on lots of ideas for local activities which individuals can enjoy. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 13 Holidays are planned around what individual people want to do. Some residents had recently been to Greece while others chose to go to Butlins. One person was on a holiday in France, which was set up for wheelchair users. People who use the service are able to have visitors to their home when they like and are encouraged to maintain relationships with family and friends. However, there is little information regarding sexuality and sexual needs. Staff should consider ways to make sure individuals have the opportunity to discuss these issues and consider how to meet any identified needs with sensitivity and respect. The majority of people eat together at mealtimes. There are eating guidelines for each person and pictures of foods to help them choose what they want on the menu. It is generally decided what meals people want on the day. However a member of staff said that a better menu planning system will be in place soon. This will help to decide menus in advance and allow them to plan what to buy when shopping. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 14 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, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good support is in place from staff and specialists to make sure the health needs of people who use the service are met. EVIDENCE: Information on health needs is detailed in support plans and each person has a Health Passport which gives specific information about their needs. Evidence was seen of contact with specialist support outside the home, for example, GPs, hospitals and the Community Learning Disability Team. Keyworkers make sure that the staff team is aware of each individuals support needs and how they choose to receive that support. Each person has also been helped to complete a ‘My wishes’ form which includes information on what support they would like in the event of a serious illness or if they were dying. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 15 Medication profiles are in place which include a photo of each person, guidance on medication and possible side effects. Medication Administration Record (MAR) sheets include details of allergies. No gaps were seen on the MAR sheets. Controlled medication is monitored correctly and there is appropriate storage. However, blister packs for the current week which contain controlled medication must be stored more securely. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 16 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 available evidence including a visit to this service. People who use the service know how to complain and their views are listened to. EVIDENCE: There is a good complaints procedure which uses pictures to help make it understandable. Information on how to complain was seen on the notice board in the lounge, and is included in the contract information given to people when they move in. If individuals wanted there is a form for them to use when they complain. This is in an easy to use format. The service has a copy of the local adult abuse procedures for the Royal Borough of Kingston. Staff were aware of the action to take in the event of any concerns. Training records showed that not all staff have received recent training in the Protection of Vulnerable Adults (POVA), however the person in charge said that this training has been planned. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 17 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, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home benefit from living in the clean, homely and spacious environment. EVIDENCE: 1 St Matthews Avenue is a large house set over three floors. Communal areas are located on the ground floor. These include a large, well furnished and comfortable lounge and separate dining room with laminate flooring. The kitchen is well equipped and has a section of lowered work surface for wheelchair users. There are pictures on the cupboards to help people understand what is in them. Bedrooms are located on the ground and first floors. There are two bathrooms, one of which has a chair hoist to help individuals in and out of the bath. The other bathroom had lino flooring which was uneven and stained in places. The downstairs shower room had recently been St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 18 redecorated but had signs of small mould patches on the ceiling. This needs to be put right. All parts of the home were clean and well maintained, although the carpet in the first floor hallway was stained in places. The person in charge said that it was due to be cleaned. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 19 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, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The competent and experienced staff team ensure that people who use the service are well supported. EVIDENCE: During the inspection staff showed a good knowledge and understanding of the people who lived there. Staff were seen to get on well with the residents and the atmosphere was light hearted and relaxed. A large board by the front door showed photos of staff so that people knew who was going to be on duty. Staff levels were appropriate on the day of inspection. However one staff member commented that staffing levels are not sufficient if an individual needs extra support when going out. Recruitment records are well maintained and show that staff have all the necessary checks before they start work. These include suitable references, proof of identification and a Criminal records Bureau check. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 20 New staff now receive induction in line with the Common Induction Standards. A training plan for the next year shows that a number of core training skills need to be updated. These include food hygiene, fire safety, manual handling and health and safety. There is generally a good range of training available which more recently includes the Mental Capacity Act and Makaton. Regular supervisions take place every one or two months. Records of supervision are signed and dated and include any action required. Staff who are supervised are able to write their own comments about what has been discussed. Appraisals are currently being completed. These include a self assessment by each member of staff and will be used to review progress and discuss development needs in the future. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 21 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 available evidence including a visit to this service. There are good management and monitoring systems in place which ensures that the service runs effectively. EVIDENCE: The registered manager is currently on secondment to another project. In his absence, the home is being managed by two senior support staff. This arrangement has been agreed with the CSCI. There are good systems for making sure the home is run effectively and it the seniors are maintaining good standards. Both are committed to running a service which is centred around the people that live there. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 22 Resident meetings are held every month and give people an opportunity to say how they are feeling and to discuss changes to the home. A Business Plan is in place for 2007 which uses the same outcome areas as the National Minimum Standards. It includes a section on how the service can be improved and there is a list of goals to be achieved for the year. Health and safety checks are up to date and include a gas safety check and portable appliance test. Hot water temperatures are checked every week. The available records showed that temperatures were in the range 18°C to 32°C which is too cold. We tested the temperature on the day of inspection and it was around 43°C which is acceptable. Problems with water temperatures were also noted in a previous audit. The senior agreed to call out the engineer to check the water system, but it should have been picked up that there was a problem when low temperatures were recorded. A fire risk assessment is in place and regular fire drills are carried out. There are weekly tests of the alarm system but it is not recorded which fire point is being tested. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 23 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 3 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 X X 2 X St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 Standard YA20 YA23 Regulation 13(2) 13(6) Requirement To ensure the safekeeping of medication all controlled drugs must be stored appropriately. To further protect people who use the service all staff must have regular training in the protection of vulnerable adults. To ensure staff are fully equipped to carry out their roles, training in core skills must be provided regularly. For the benefit of people who use the service hot water temperatures must be maintained at around 43°C and action taken if there is a variation is recorded. Timescale for action 01/11/07 01/01/08 3 YA35 18(c) 01/02/08 4 YA42 13(4)(c) 01/12/07 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 YA15 Good Practice Recommendations In order to make sure all the needs of each person are considered, information on sexuality and relationships DS0000013389.V352565.R01.S.doc Version 5.2 Page 25 St Matthews Avenue, 1 2 YA27 should be more detailed. To improve the environment the lino flooring in the upstairs bathroom should be replaced and the damp areas in the downstairs shower room rectified. St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 St Matthews Avenue, 1 DS0000013389.V352565.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!