Inspection on 01/08/05 for The Bungalow

This inspection was carried out on 1st 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

The Bungalow 25/04/07

The Bungalow 07/12/05

The Bungalow 09/11/04

The Bungalow 13/04/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 The Bungalow Beech Lane Normandy Surrey GU3 2JH Lead Inspector John Chivers Unannounced 1 August 2005 @ 11:00am st 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. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Bungalow Address Beech Lane Normandy Surrey GU3 2JH 01483 810115 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) Care Solutions Limited Ms Stella Nwaubani CRH - Care Home 5 Category(ies) of LD - Learning Disability (4) registration, with number LD(E) - Learning Disability over 65 (1) of places PD - Physical Disability (4) The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 - Within the category Learning Disability (LD), up to 4 may have an additional Physical Disability (PD) and 1 may be over 65 years LD(E). 2 - The age/age range of persons to be accommodated will be 35 - 64 years and 1 over 65 years of age. Date of last inspection 9 November 2004 Brief Description of the Service: The home is registered to Care UK Limited and is one of a number of Residential Care Homes administered by the company. The home is registered to accommodate a maximum of five residents, four of whom are aged between thirty five and sixty four years and one aged over sixty five years. The residents have learning and physical disabilities. The home is a detached single story building situated in a quiet road. Local facilities and amenities are closeby. THe home provides a caring and supportive service to people with profound disabilities and encourages its residents in adult education and independance training within the limitations of their disabilities. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was undertaken on 1st August 05. The duration of the inspection was 4.25 hours. As part of the inspection process two staff were formally interviewed and limited discussion/communication was held with three residents. In addition discussion was held with the home’s management and an informal discussion was held with one of the home’s neighbours. The inspection included examination of the home’s policies, procedures and statutory and none statutory records. The resident’s personal files and staff personnel files were also scrutinised. A tour of the premises was undertaken. The findings of the inspection were positive and it was encouraging to confirm that all of the requirements set at the previous inspection had been addressed. There was evidence of good management and care practice; however it is important that the company forward certain internal quality assurance information to the home following surveys and Regulation 26 inspections. Staff were observed to be appropriately deployed and attentive to the needs of the residents. Staff recruitment and vetting procedures were evidenced as sound and staff training had been enhanced covering a range of topics; however it would be beneficial for staff to receive ‘Equal Opportunities’ training as part of their training programme. The premises have recently been refurbished and present to a very good standard. One of the home’s neighbours thought that staff do a good job in caring for the residents and that the home’s operation does not have an adverse effect on the local community. Staff interviewed were supportive of the home’s management. Due to the residents profound learning and communication difficulties it was not possible to obtain their views and opinions with any accuracy. Residents were however observed to be well cared for, well presented and appeared of a contented disposition. One resident showed awareness via change of facial expression when a ‘stranger’ (the inspector) entered the room. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 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. The Bungalow H58 H09 S13581 Bungalow V242059 010805 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 The Bungalow H58 H09 S13581 Bungalow V242059 010805 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) 2 and 5. The home has regard for assessing residents individual needs prior to admission and ensures that this area is reviewed as necessary. The home ensures that written contracts/terms of residency are in place regarding the residents. EVIDENCE: Written needs assessments were held in the sample of residents files inspected. The assessments were comprehensive and informative. There was evidence that the assessments were scheduled for review in September 05. Due to the resident’s profound communication and learning disabilities it was not possible to accurately ascertain their opinion and views regarding their individual aspirations; however the residents were well presented, observed as settled and relaxed and staff attentive to their needs. Written contracts/terms of residency were available in the sample of residents files inspected. The Bungalow H58 H09 S13581 Bungalow V242059 010805 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 and 9. The home has regard for maintaining residents care plans and compiling risk assessments on individual residents; however it is important that such assessments are reviewed within time scales in all cases. EVIDENCE: Written care plans were available in the sample of resident’s files inspected. The care plans had been well prepared and covered many areas. There was evidence of care plans being reviewed and updated. Written risk assessments were held and are subject to regular review; however it was noted that one risk assessment scheduled for review in April 05 had not yet occurred. It is important that this is arranged. A requirement will be made regarding this. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 10 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 and 15. The home maintains residents in adult education and provides a range of activities within the home and local community. The home has regard for enabling residents to have an annual holiday and encourages them to have contact with their families and relatives. EVIDENCE: It was evidenced that residents attend adult education centres and their weekly activity programme offered a wide and stimulating range of pursuits. The home also offered a range of active and sedentary pastimes. Paintings and artwork completed by some of the more able residents were displayed in their bedrooms. Residents have contact in the community and events such as barbeques are organised by the home. Discussion was held with one of the home’s neighbours who was of the opinion that the home encourages the residents to live as “normally” as possible within the community and thought that the staff do a “good job” in looking after them. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 11 Annual holidays are taken and it was evidenced that the residents are to go to ‘Butlins’ at Bognor Regis in October 05. Resident’s maintain contact with family and relatives and visits are entered in the resident’s daily notes. The manager stated that all residents have advocates. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 12 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 and 19. The home has regard for meeting resident’s individual personal and health care needs and this activity is monitored, recorded and reviewed as appropriate. EVIDENCE: All residents have ‘key workers’. Staff that were interviewed were knowledgeable about their individual residents care plans, needs and levels of support. Health and medical details were held in the sample of resident’s files inspected. Such information was available in assessments and care plans and evidenced monitoring and review. Visits to the doctor and other health care professionals are clearly recorded. Resident’s weight is monitored and recorded. Other health care/medical related correspondence and reports were also held. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 13 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. The home has regard for the area of complaints; however the pictorial complaint procedure needs to be expanded to include the contact address and telephone number of the CSCI Surrey Local Office. The home takes steps to protect the residents from abuse and is diligent regarding their safety and welfare. EVIDENCE: The home has the company complaint procedure. Drawn from this is the home’s internal complaint procedure, which is also available in pictorial form for the residents. This procedure is detailed; however it is important that the contract address and telephone number of the CSCI Surrey Local Office is included in the pictorial procedure. A requirement will be made regarding this. It was evidenced that staff sign the home’s complaint procedure. Complaint forms were available. The manager stated that no complaints have been received. Staff interviewed were aware of the home’s complaint procedure. One of the home’s neighbours stated in discussion that they had no complaints about the activities of the home or its impact on the local community. The home has an internal policy and procedure regarding the Protection of Vulnerable Adults. In addition the home held the revised version of the Surrey County Council Multi-Agency Adult Protection procedures. There was evidence that some staff had attended training in the Protection of Vulnerable Adults on 18th February 05 and further training was evidenced on future dates via the home’s staff training matrix. Staff interviewed confirmed their attendance on such courses. The residents were observed to be cared for in a supportive and sensitive manner. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 14 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, 25, 26, 27, 28 and 30. The home has regard for maintaining the exterior and interior of the premises in good order and provides a safe, homely and comfortable environment for the residents. EVIDENCE: The home is a single story building situated in a quiet residential road. Local facilities and amenities are nearby. The exterior of the premises are in good order and are well maintained. The garden area is spacious and very well kept. No safety hazards were evident in the garden area. The interior of the building has recently been refurbished. Communal and private areas provide adequate space for the residents. Communal areas are decorated and furnished to a very good standard. A sample of resident’s bedrooms were inspected. The bedrooms were decorated and furnished to the same standard as communal areas and had been personalised to varying degrees by their occupants. Paintings and artwork completed by some of the residents were displayed in some rooms. Bathing and toilet facilities were of a very good standard and afforded privacy for the residents. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 15 The home has a comprehensive infection control policy and staff are due to attend training in the area of infection control. ‘COSHH’ substances are kept in a locked cupboard. Standards of cleanliness and hygiene were high throughout the home. No safety hazards were identified during the inspection. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 16 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 and 35. The home has regard for sound recruitment and vetting practices and is supportive at enabling staff to attend training courses. EVIDENCE: The home has a staff recruitment policy. It was also noted that the company has a written policy regarding the recruitment of ‘ex-offenders’. A sample of staff personnel files were inspected. The files were comprehensive and contained an abundance of information. Staff files held details such as: photographic and certificated identity, personal details, reviews, appraisals, probationary reports, supervision records, health questionnaires, job descriptions, induction details, training and development plan, contract, application form two references and clear Criminal Record Bureau checks. Home Office and Immigration correspondence was also held in appropriate staff members files. There was evidence that staff training had enhanced and covered a number of topics. Staff have individual training files, which evidence training activity and certificates obtained. The home also has a training ‘matrix’ that clearly sets out course dates and the staff to attend. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 17 The manager stated that she is currently undertaking the Registered Managers Award. One member of staff holds the NVQ level 2 qualification and all of the remaining 8 staff are currently undertaking the NVQ level 2 course. Staff interviewed confirmed their attendance on training courses and thought the home/company to be supportive in this area; however one member of staff was of the opinion that the staff team could benefit from Equal Opportunities training in order to increase awareness in this area. The inspector would concur with this and a requirement will be made regarding such training. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 18 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) 39 and 42. Whilst the home is managed to good standard, shortfalls in the forwarding of internal quality assurance information by the company to the home was evident. The home has regard for health and safety matters concerning the residents and staff. EVIDENCE: The manager stated that the home forwards service provision questionnaires for resident’s relatives to complete. However the questionnaires are returned and kept at the company’s head office and not copied to the home. It would be important for the company to send copies of the questionnaires to the home in order for them to be aware of relative’s views and to keep for them available for the purposes and evidence of internal audit The home had an annual development plan, which is due for updating in October 05. The home also held an ‘action plan’, which was introduced in March 05. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 19 The manager stated that Regulation 26 visits occur each month and are unannounced. Regulation 26 visit reports were available for the months of January 05 and February 05. The manager stated that it “appeared that the company had not yet forwarded copies of the reports to the home”. It is important that these reports are pursued and it must be ensured that copies of reports are sent to the home each month. A requirement will be made regarding this. The home has a ‘Health & Safety’ policy statement. The home’s Health & safety ‘Law’ poster was prominently displayed. The home had a current written fire risk assessment and evidenced that fire evacuation drills and fire alarm tests occur on a regular basis. A fire maintenance check was undertaken on 14th May 05. There were current certificates held for the testing of electrical and gas systems and ‘Legionella’. Hot water temperatures are taken and recorded on a regular basis. The Environmental Heath Officer (food Hygiene) visited the home on 7th February 05. A small number of requirements were made and have been addressed. Staff interviewed were supportive of the home’s management and were clear that the management were open and approachable. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 20 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 x 3 x x 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x x x 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Bungalow Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 9.2 22.3 Regulation 13, (4) (c ) 22, (7) (a) Requirement That the risk assessment regarding one of the residents is reviewed and updated. That the contact address and telephone number of the CSCI Surrey Local Office is included in the residents pictorial complaint procedure. That staff attend Equal Opportunities training. That copies of relatives questionnaires are forwarded to the home by the company, That Regulation 26 visit reports are forwarded to the home by the company. Timescale for action 15/9/05 15/9/05 3. 4. 5. 35.4 39.3 39.3 18, (1) (c ) (i) 24, (3) 26, (5) (b) 1/11/05 1/9/05 1/9/05 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 Good Practice Recommendations There are no recommendations at this inspection. The Bungalow H58 H09 S13581 Bungalow V242059 010805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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. 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