Inspection on 19/10/05 for The Chestnuts

This inspection was carried out on 19th October 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 Chestnuts 23/04/07

The Chestnuts 26/05/05

The Chestnuts 08/12/04

The Chestnuts 02/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Chertsey Road (42-44) 42-44 Chertsey Road Byfleet Surrey KT14 7AN Lead Inspector Susan McBriarty Unannounced Inspection 19th October 2005 10:00 Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 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 Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 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. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chertsey Road (42-44) Address 42-44 Chertsey Road Byfleet Surrey KT14 7AN 01932 336200 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) Downing (Chertsey Road) Limited David Horsgood Care Home 19 Category(ies) of Learning disability (19), Learning disability over registration, with number 65 years of age (1), Physical disability (11), of places Sensory impairment (2) Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate one named person over the age of 65 The age/age range of the persons to be accommodated will be: AGED 18 - 65 YEARS The home may accommodate up to 10 residents within the PD category and 2 residents within SI category within the total number accommodated. 26th May 2005 Date of last inspection Brief Description of the Service: The home is owned and managed by Downing (Chertsey Road) Limited. The home is registered to accommodate nineteen younger adults with learning disabilities. The home is located in a residential area of Byfleet in Surrey. There is access to public transport and the home also has transport available to service users.The home is made up of three separate units. The units have their own living, dining and kitchen areas.Service users are provided with single bedroom accommodation and all the rooms are fitted with overhead hoist equipment. A good range of bathroom, toilet and washing facilities are available in each unit. The home has a patio area and a well maintained garden, which are accessible for service users. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection the second for 2005 – 2006. Previous reports are available on request. A number of documents were sampled as part of the inspection including care plans, risk assessments, daily diaries, staff supervision reports and health and safety records. The residents of the home have complex needs and limited verbal skills and it is not possible to gain their views without planning and support. 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. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 6 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 Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 7 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): 1,2,3,4,5 Prospective residents and their relatives or representatives are provided with the information they need to assist in making a decision about moving to the home. The organisation is able to provide residents with a statement of terms and conditions. EVIDENCE: The home has recently reviewed and updated the statement of purpose; the document contains all the information required. An assessment is undertaken by the home as part of the referral process, trial visits to the home are offered. However as the residents of the home have complex needs overnight stays or similar lengthy stays may be confusing for them. Residents usually attend the home for light meals and a moving in date agreed with relatives and purchasers. A number of residents do not have individual contracts regarding their placement. The manager informed the Inspector that requests have been made for contracts to be provided by specified purchasers as yet these have not been provided. The organisation has its own contract and it was recommended that the home consider using those in order to ensure that those parties without a contract from the purchasing authority are clear about what the home offers including any services that are directly charged to the resident. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 8 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): 8 The majority of residents have complex needs and limited verbal skills restricting their ability to make choices. EVIDENCE: The home provides for residents with complex needs including limited verbal skills. Choices are often made through non-verbal communication, non verbal communication method were included in the individual care plans sampled. The residents are encouraged are far as possible to make choices and decisions. The home now has a quality audit process in place please also see standard 39. This process will assist the home to enable residents and relatives to provide feedback regarding how the home works. The requirements made at the inspection on the 26th May 2005 had been met. The Inspector sampled the homes revised care plans which evidenced improvement. The care plans sampled had been signed and dated by staff members confirming that they had been read and understood. The revised care plans were clear and easy to read and understand. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 9 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): EVIDENCE: These standards were assessed during the inspection of 26th May 2005. The requirements made at the inspection on the 26th May had been met. The home had employed an activities co-ordinator and the documents sampled by the inspector on the 19th October reflected improvement. The information regarding who took part in what activity and when was clear and evidenced that planning took place. The daily reports sampled also evidenced improvement in consistency regarding staff members completing the information required. During the inspection it was noted that staff were playing live music and records with the residents. All were making a great deal of noise and being encouraged to take part. In touring parts of the home the Inspector observed a specified resident relaxing in a quieter area of the home. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 10 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): 21 The home has a policy and procedure in place to support those who are ill or dying. EVIDENCE: Policies and procedures were in place providing staff with clear guidelines to support those residents who may be ill or dying. The senior staff and manager informed the Inspector of the difficulties they were having in maintaining regular dental checks for residents. The dental practice usually accessed is only available one day a month for the community. Staff members are concerned should emergency treatment be required. Other options are being sought urgently and the home will keep the CSCI informed of progress. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 11 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 The home has a policy and procedure in place for dealing with complaints. EVIDENCE: The Inspector sampled the homes complaint procedure and found that it met the standard. The home has not received any complaints since the inspection on the 26th May 2005. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were assessed during the inspection on the 26th May 2005, noted in this report is the progress made regarding the requirements made. The requirements regarding the bathroom and thermostatic valve checks are in the process of being met. During the inspection of the 19th October 2005 the inspector toured the bathrooms and other washing areas with the manager. The home is having two shower areas fitted and the bathrooms fully refurbished. The washing areas completed or nearing completion show improvement. The home is not able to fully regulate the hot water although thermostatic valves are in use. The new washing areas are having new mixer taps fitted and the system should improve the consistency of the temperature of the hot water. In the interim staff have been made fully aware that they must check the temperature each time the hot water is used in those specified areas. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 13 Further refurbishment is planned by the home including re-fitting the kitchen areas and extending the building to increase the space available for use by the residents. The communal areas had been redecorated and new pictures placed on the walls. In addition the home had introduced a pictoral display of those staff on duty each day. The hallway and corridors were bright, airy and clean on the day of the inspection. The manager informed the Inspector that the carpets would be replaced once the building work has been completed. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 14 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, 36 The home has a good regard for the supervision needs of staff. EVIDENCE: Standards 31 through to 35 were assessed during the inspection of the 26th April 2005. However it is worth noting improvements within the home since the last inspection. The home plans supervision dates with staff. The inspector was able to evidence documents informing staff members of the dates of their supervision, sample supervision agreements signed by staff and completed supervision reports. A supervision year varies for staff members, as it is dependent on the month of their starting work at the home. For example a new member of staff starting in September will continue a supervision year of September to September. During the inspection the Inspector was asked to confirm the receipt of Criminal Record Bureau (CRB) checks for staff. The documents were found to be in good order and the relevant information being kept in a clear format for the homes records. The home has 31 staff in total with three current staff vacancies. Two of the vacancies have been filled and start dates are awaited. The ability to offer a Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 15 more consistent staff team will benefit the residents of the home. Due to the changing staff team the home are unlikely to be able to ensure the numbers of staff required to meet the target of 50 of staff trained to National Vocational Qualification (NVQ) Level 2 by 2005. The senior care staff are taking an NVQ in team leading to increase their skills and knowledge in that area. Five staff members have applied for the NVQ Level 2 in care. All the staff team are expected to complete an induction and the Learning Disability Award Framework (LDAF). A requirement was made that the home provide the CSCI with an action plan setting out how they intend to meet the 50 of qualified staff by 2005. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 16 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): 37,38,40,41,43 The home has a good regard for the management of the home and for safeguarding residents and staff. EVIDENCE: The manager is social work qualified and has worked with people with a learning disability for some years and will have completed the Diploma in Management by December 2005. It was recommended that the manager confirm that the qualifications are equivalent to those required by The National Minimum Standards Younger People. The Inspector noted a change within the home since the last inspection, staff members were more willing to acknowledge the inspector and continue their work with the residents. Staff members were also observed approaching the senior staff and manager with queries during the day. A formal quality assurance audit has not been in place until recently. The manager plans to undertake the first formal audit during 2006. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 17 The Inspector sampled a number of policies and procedures including; medication administration, equal opportunities, admission and evaluation, the protection of vulnerable adults, complaints and bullying. It was recommended that the bullying policy and procedure be reviewed to ensure that it is clear when bullying may become a protection of vulnerable adult issue. It was also recommended that the home consider the restraint policy. The manager informed the Inspector that the home has a policy of non-restraint; this is not clearly identified within the policy. The Inspector found improvements across a range of documents and records within the home specifically those identified at the last inspection. On this occasion there were very few gaps in recording how the daily living needs of residents were met. Records within the home were held securely in lockable cabinets or offices. The home had compiled an emergency (crisis) plan that included provision for full evacuation of the home in an emergency. An agreement had been confirmed in writing with a local day centre for the residents to be placed there until they could return home or be found a short-term alternative. The Inspector sampled a number of documents confirming that health and safety checks had been carried out by the home. These include electrical testing, legionella, hoist installation and following safety checks, heating service and lift service. All had been completed during 2005. Chertsey Road (42-44) DS0000013500.V259823.R01.S.doc Version 5.0 Page 18 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 3 3 3 2 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chertsey Road (42-44) Score X X X 3 Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 2 X 3 DS0000013500.V259823.R01.S.doc Version 5.0 Page 19 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 Standard 32 Regulation 18(1)(a) Requirement The registered person must provide the CSCI with an action plan showing how they intend to meet the target of 50 of staff being NVQ Level 2 qualified. The registered person must review and update the homes policy and procedure regarding restraint in order to clearly identify the homes policy of nonrestraint. The registered person must review and update the homes bullying policy and procedure in order to identify possible links with the protection of vulnerable adults. Timescale for action 25/11/05 2 41 13(6) 25/11/05 3 41 13(6) 25/11/05 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 5 Good Practice Recommendations It is strongly recommended that where purchasing authorities have not provided individual contracts for DS0000013500.V259823.R01.S.doc Version 5.0 Page 20 Chertsey Road (42-44) 2 3 19 9(b)(i) service users the home introduce their own in order to ensure that service users, where possible, and their relatives or representatives are clear about the services to be provided and any associated costs. It is recommended that the home ensure that the CSCI are updated regarding access to dental treatment. It is strongly recommended that the manager seek written confirmation from an appropriate body that the qualifications attained meet The National Minimum Standards Younger People. 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