Inspection on 23/04/07 for The Chestnuts

This inspection was carried out on 23rd April 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

The Chestnuts 19/10/05

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 The Chestnuts 42-44 Chertsey Road Byfleet Surrey KT14 7AN Lead Inspector Susan McBriarty Unannounced Inspection 23rd April 2007 08:45 Chertsey Road (42-44) DS0000013500.V333222.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 Chertsey Road (42-44) DS0000013500.V333222.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. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Chestnuts Address 42-44 Chertsey Road Byfleet Surrey KT14 7AN 01932 336200 01932 347092 sue@downingcarehomes.co.uk 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 Mrs Susan Daphne Squires Care Home 20 Category(ies) of Learning disability (20), Learning disability over registration, with number 65 years of age (1), Physical disability (11), of places Sensory impairment (2) Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2005 Brief Description of the Service: The home is owned and managed by Downing (Chertsey Road) Limited. The home is registered to accommodate twenty 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 has three separate units. Each of the units has 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 is available in each unit. The home has a patio area and a well-maintained garden which are accessible to service users. Fee level for 2007/2008 starts at £1.250 per week. The maximum is dependent on the individual needs of the service user. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the first key inspection carried out by the commission. The inspection took place over seven and a half (7.5) hours, commencing at 8.45am and ending at 4:45pm. Ms Susan McBriarty, Regulation Inspector, carried out the visit. The manager was available throughout most of the inspection and the responsible individual (Director) and deputy manager also assisted the commission. The inspection took into account the pre-inspection questionnaire information and records held at the home including service users’ files, staff personnel files, supervision, training, medication administration and daily records. The inspector made observations of interactions between staff and service users during the visit and spoke with some of the service users and staff. Service user feedback was limited due to their communication needs. An oversight on the part of the commission delayed the sending of comment cards to the home. These were sent out the day following the visit and agreement made that any comments would be incorporated into the report if received before publication. The commission received thirteen (13) comments cards by the 10th May 2007 and the information received put into the report. What the service does well: What has improved since the last inspection? The requirements and recommendations made during the last inspection had generally been met. Where an issue seemed to be outstanding this related to an overall change in policies and procedures used by the home. The home has a new manager in place and whose application for registration was waiting for final written confirmation. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 6 The complaints procedure and documents to record a complaint had been improved and was in picture format. This would ensure that service users’ views were listened to and acted upon. 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 summary of this inspection report can be made available in other formats on request. Chertsey Road (42-44) DS0000013500.V333222.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 Chertsey Road (42-44) DS0000013500.V333222.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): Standards 1 and 2 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users and their relatives have the information they need about the home before they make a decision about moving in. Assessments are completed on prospective service users to ensure their individual needs and aspirations can be met. Some change regarding the storage of assessments documents would further confirm this. EVIDENCE: Thirteen (13) comment cards were received from friends, relatives and other professionals. Of the seven (7) relatives four (4) said the home always had enough information before a person moved in, two (2) usually and one did not answer. A draft of the revised Statement of Purpose and Service User Guide were available for relatives and visitors to see. The manager said that they were waiting for confirmation of their registration with the commission before making the document final. The Service User Guide was in easy read format with pictures to assist members of staff or relatives to tell the service users what it said. The documents set out what the home does and does not provide for the service users living there as part of their terms and conditions of placement. This ensures that prospective service users and their relatives have the information they need to make a decision about moving to the home. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 9 A number of service user files were sampled. One had the assessment completed prior to the service user’s admission to the home. The information provided included reports from a previous placement, health specialists and an assessment completed by the home. The manager told the commission that previous admission assessments for other service users had been archived. The management was advised that keeping the initial assessments on the service users’ files would assist in keeping clear records of progress or problems and suggested that these are re-introduced to the service user files. The information provided indicated that the home ensures that individual service users’ needs and preferences are assessed before they move into the home. Chertsey Road (42-44) DS0000013500.V333222.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): Standards 6,7 and 9 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments confirmed that the home could meet the individuals assessed and changing needs, some work was needed to confirm how this was achieved. Some improvement was needed to ensure that members of staff make clear how service users make choices and decisions about their lives. EVIDENCE: A number of care plans were sampled. The care plans had clear information about the service users including personal care and mobility needs. Each of the areas set out what the service users preferred and in some instances how they would tell staff what they preferred. A further section had been completed about the service user’s likes and dislikes. The care plans seen showed that they were being reviewed regularly and that dates of the last review were recorded. Some sections of the care plans although reviewed continued to show changes that took place some while ago and in discussion with the management of the home it was felt that the care plans would benefit Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 11 from minor changes in wording to confirm the current needs of the service user. The front of some of the care plans sampled showed that family members had been involved. One had a copy of the care plan with additional notes added by a relative for consideration of change or addition to the care plan. The management of the home were advised to add a section to the care plans that sets out who was involved in care planning and risk assessing confirming involvement in each review and space for a signature where it has been possible to gain one. It would also ensure that where service users are unable to take part in the review this is documented and recorded. Thirteen (13) comment cards were received and all stated that the people who use the service received the help and support they need. One respondent said that ‘I am pleased that she is treated like a young woman’ another noted that staff had gone to great length to find a particular religious tape which the resident enjoyed listening to. The service users in the home have a learning disability and including them in the care planning and risk assessment process would present members of staff with considerable communication challenges. However further training or information about how their likes and dislikes were found might assist the home in confirming how service users had been involved in gaining the information for care plans. See also the Staffing section of this report. Risk assessments had been completed for all areas of the service users’ lives and evidenced that they had been reviewed in February 2007. Daily records completed by members of staff confirmed that the care plans and risk assessments were being followed. However further work was needed to make sure that members of staff considered how they worded the records. For example, a number were seen that said ‘sent to’ or ‘refused to’ the records did not confirm that service users had a choice about what happened during the day. Observations made by the commission during the visit indicated that choices were made and staff responded to the preferences of the service users. Please also see the Staffing section of this report as a requirement was made for the home to carry out a review of training including record keeping. Chertsey Road (42-44) DS0000013500.V333222.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): Standards 12,13,15,16 and 17 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work was needed to ensure that all service users are able to take part in age, peer and culturally appropriate activities that include maintaining links with their family and access to the community. Service users were offered a varied and appropriate diet that met their needs. EVIDENCE: The care plans; daily records and discussion with a member of staff and the management team confirmed that a range of activities is available and provided or supported by the home. These include attending a day centre, going to church or to the pub. A number of the activity records held in the care plans had not been completed or not completed in full and all the activities scheduled by service users including spending time at their relatives’ homes had not been documented. In addition the management team of the home told the commission that staffing changes had taken place. The staffing changes were said to ensure Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 13 that more staff were available in the evening, however fewer staff were available between 10am and 4pm during the day. A number of service users do not attend any scheduled activity during the day and a reduction in staffing levels may have had an impact on what might be provided by the home. It could not be confirmed that all service users are able to take part in age, peer, culturally appropriate activities, maintain family links or be part of the local community. Please see the Staffing section of this report as a requirement was made to ensure that a review of the staffing levels takes place. A further requirement is made to ensure that information about the scheduled activities attended by service users is recorded in full including any activity provided in the home. Observations made by the commission during the visit over the breakfast, lunch and preparation of the evening meal confirmed the information provided in the home’s written menu. Members of staff freshly prepared the meals and the training records of the home evidenced that members of staff had received training in food hygiene. The menu provided covered a period of four weeks and showed a varied diet is offered. Outcomes from the quality assurance audit in 2006 said that of forty-seven responses five said that the quality and choice of food was poor. The remaining forty-two were satisfied. Chertsey Road (42-44) DS0000013500.V333222.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): Standards 18,19 and 20 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ physical and emotional health care needs are met by the home and personal care is provided in a way they prefer and require. Service users are protected by the policy and practices of the home regarding the administration of medication. EVIDENCE: A number of service user files were sampled. The information held in the files and observations made during the visit confirmed that service users’ preferences were taken into account. Specialist equipment is available for use throughout the home and assessments had been completed for manual handling needs on each of the files sampled. One service user admitted to the home had been referred to a number of health specialists for further tests to ensure that the home could be certain of their health needs and how they needed to be met. The service users and staff team are of mixed gender and ethnicity enabling choices to be made by service users, where possible, about who might provide their personal care. The pre-inspection questionnaire confirmed that the home Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 15 had policies and procedures in place regarding equal opportunities and racial harassment. The training programme seen by the commission did not include training for members of staff in these matters. A recommendation is made that the home provide training in equality and diversity to ensure that service users, where possible, their relatives and members of staff are aware of how equality and diversity are taken into account by the service. Records had been completed by members of staff setting out when individuals had attended a doctor, dentist, chiropodist or other health specialist appointment. The manager said that female service users had recently been offered mammograms, however it could not be confirmed whether male service users had also been offered specialist checks regarding their health needs including for example testicular checks. The management team were advised to discuss this matter with the doctor carrying out the annual health checks in order to confirm what checks were completed and consider seeking further advice and information if this is not the case. This would confirm that service users’ physical and emotional health care needs are being met. The records and documents for the administration of medication were sampled. No errors were found regarding the recording of administered medication. The commission raised some matters, for example, one liquid medication was being used out of date rotation, one handwritten instruction regarding medication said ‘as instructed by doctor’ and one entry completed by the pharmacist was incorrect. The pharmacist error was being dealt with by the home. The handwritten instruction was changed during the visit and confirmation given by the manager that the matter of rotation would be brought to the attention of the care staff team. The signatures of staff trained to carry out the administration of medication needed updating as some of the members of staff no longer worked at the home. Evidence was seen by the commission that confirmed that this matter was already in hand. Service users are protected by the policy and practice of the home regarding the administration of medication. The commission received thirteen comment cards. All stated that the health needs of the people who use the service were being met. One professional said ‘I am impressed by the charts kept by the home’ regarding seizures and medication and under what could improve said ‘keep up the excellent work’. Chertsey Road (42-44) DS0000013500.V333222.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): Standards 22 and 23 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some changes were needed to confirm that service users’ views were listened to and acted upon and that they are kept safe from abuse, neglect and selfharm. EVIDENCE: The management team of the home had brought in a range of new policies and procedures as part of the changes taking place within the home. The complaints procedure was viewed and a copy was seen having been placed in the entrance of the home, the process used by the home including a timescale was clearly given. An easy read version with picture faces for service users was also posted in the entrance. A picture format ‘speaking up’ form was available for staff to complete on behalf of service users. The form would assist members of staff to work with service users who said they were not happy and record information about why and what had happened. The easy read complaints format did not show a timescale for dealing with the complaint. The manager confirmed that it was difficult to keep the easy read format to one page and include all the information needed, in this instance the timescale. In discussion the manager said they would review the layout again and consider how they might ensure that the timescale in their easy read complaints procedure remains consistent whichever format is looked at. Two complaints had been received by the home in the last twelve months both matters had now been dealt with to the satisfaction of the complainants. Thirteen comment cards were received by the commission and all noted that Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 17 they had either not made a complaint, not received a complaint or were aware of how to make a complaint if needed. Policies and procedures were in place for safeguarding adults; whistle blowing, restraint, harassment and bullying. Previous requirements had been made regarding the home’s policies and procedures regarding bullying and restraint. As the home had brought in new policies and procedures these were reviewed again and similar issues raised. The new policy regarding bullying does not show the possible relationship with safeguarding matters and needs to be revised to ensure the link is clear. The prevention of abuse policy was seen and needed to set out the direct link with the home’s policy and procedure for referring safeguarding matters in order to confirm that any concern raised would be referred to the local authority for consideration under the multi-agency safeguarding adults procedures. A requirement is made to ensure that all policies and procedures that might link with safeguarding adults’ matters are revised to ensure that the link is made clear. One safeguarding referral has been made within the last twelve months and had been dealt with appropriately by the home. Discussion with the management team, training records and the pre-inspection questionnaire confirmed that care staff had received training in safeguarding adults and that further training had been booked for May 2007. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 18 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): Standards 24 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and hygienic in all those areas seen, some improvement was needed to make sure that all areas of the home were kept in good repair and decoration. EVIDENCE: All of the communal areas including the bathrooms and garden were seen and most of the bedrooms. Those bedrooms not seen were in use during the day and the privacy of service users would have been invaded had they been viewed. All the bedrooms seen had been personalised and where possible service users were asked by the commission if they had chosen the colours used, not all were able to confirm this clearly due to communication difficulties. A number of the bedrooms seen showed various levels of wheelchair damage to the walls and or doors and in one bedroom the paint on the walls had gone over the coving and door areas. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 19 The commission received thirteen comment cards. No issues were raised regarding the environment. One confirmed that bedrooms were personalised and where possible people who used the service were involved in the decision about colours. The commission spoke with the person carrying out the maintenance of the home. It was confirmed that the home did not have a plan of redecoration or refurbishment. However the person expected to decorate bedrooms every two years and the communal areas as necessary/requested. The management team said that one kitchen was due to be re-sited and replaced and that all the communal carpets were due for replacement. One kitchen area had already received work. The commission were told that the work should be completed by the end of the summer in 2007. A requirement was made that the home review the decoration of the home and carry out a plan to complete any redecoration or repair identified. The home was clean and hygienic throughout all those areas seen. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 20 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): Standards 32,33,34,35 and 36 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported and protected by the home’s policy and practice on recruitment of staff. The staff team have the qualifications, training and support needed to benefit the service users, further specialist training would improve some aspects of provision. Staffing levels required review to ensure service users’ assessed needs were met. EVIDENCE: The pre-inspection questionnaire confirmed that sixteen (16) of the thirty-two (32) care staff are qualified to National Vocational (NVQ) Level 2 or above and that twenty-seven have received training in first aid. One member of staff spoken with confirmed that they had completed and qualified at NVQ level 3 and that other refresher training was being provided. A number of staff personnel files were sampled, these contained all the information required including confirmation of identity, references and satisfactory Criminal Records Bureau (CRB) checks. The management team said that checks were made against the Protection of Vulnerable Adults list (PoVA) prior to any member of staff starting work. The confirmations from PoVA are then destroyed when a satisfactory CRB is received. One Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 21 confirmation was seen. The management team were advised that it might benefit the home to keep a record of the PoVA confirmations received as part of their central record regarding received CRB checks. The pre-inspection questionnaire, documents and records completed by the home confirmed that staff receive appropriate training including induction, manual handling, fire, first aid, epilepsy and that refresher training was taking place in all these areas. However no training regarding communication including Makaton and other methods of communicating with people who are non verbal or have limited verbal skills had been provided. A number of care staff speak English as a second language and this might mean that they have to consider both a second verbal language and a non verbal form of communication when speaking to service users. The training regarding epilepsy generally covered the administration of specified medication. It was recommended that a review of training takes place to ensure that all aspects of the service users’ needs are considered including communication and further in depth training regarding epilepsy. This will further ensure that an appropriately trained staff team can meet service users’ individual and joint needs. Records sampled, discussion with a member of staff and the management team confirmed that supervision took place; as yet this is not on a regular scheduled basis. The management team said that they expect all members of staff to have received the supervision they need during the course of the year. There has been a high turnover of staff since the last inspection, the preinspection questionnaire stated that at least twenty had left the home. The management team said that this had now slowed and that the staff team were more stable. Leaving dates to confirm this statement were not requested during this visit. The care staff team carried out the majority of the tasks within the home, including cooking and some cleaning as well as caring for the service users. As noted in the lifestyle section of this report changes had been made to the way members of staff worked, that was that staffing levels had been reduced at set times of the day. Members of staff were still expected to carry out personal care tasks, undertake escort duties, prepare meals and maintain good levels of personal care during that same time. The change indicated that members of staff would not have the time available to provide and support for example activities for those service users remaining at home. A requirement was made for the home to review staffing levels to ensure an effective staff team, with sufficient numbers and skills were able to meet service users’ assessed needs. The commission viewed the staff rota that had been prepared a month in advance and a second document detailing any changes in staffing and showing when one to one was support was needed. The shift plan in one kitchen did Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 22 not confirm the details held in the other documents and the manager was advised to ensure that members of staff completed the shift plan accurately to further confirm the staffing levels available. Thirteen comment cards were received, several made reference to the care staff stating that they ‘were friendly and helpful and others said that changes had taken place in the home and this had improved communication. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 23 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): Standards 37,39 and 42 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the leadership and management of the home including the quality assurance system and revision of policies and procedures. The service users might further benefit from a manager whose time was solely related to management matters. EVIDENCE: The home had a new manager in post that started working at the home in February 2006. During the visit the manager said that she received a telephone call from the registration team stating that her application had been successful. A revised Certificate of Registration would be forwarded from the registration team to complete the application. The manager had previously been registered with the commission having managed a smaller home for people with learning disabilities for the same Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 24 organisation. Observations made during the visit by the commission indicated that the manager was involved in meeting the needs of service users on a dayto-day basis. The manager said that she had been taking a very proactive review of the home, including relationships with relatives and professionals, and felt that these had improved since she had begun work at the home. A number of changes had taken place in the home since the last inspection. These included policies and procedures, detailed reviewing of care planning and risk assessment information and deployment of staff. During the visit the commission observed that the manager was also acting as part of the staff team, reducing the amount of time available for management tasks. Given the number of changes taking place within the home the management are advised to consider enabling the manager to have sufficient staff on duty to allow her to focus on those tasks required of a manager, ensuring that members of staff and service users benefit from the leadership and management approach of the home. A quality assurance system was in place and the outcomes for 2006 had been given to the commission. Forty-seven responses had been received indicating the home was well considered. The manager said that the next quality assurance audit would be carried out during either June or July of 2007. The quality assurance process ensures that the views of service users and their relatives underpin the self-monitoring and review of the home. The commission viewed the revised policies and procedures in use by the home including health and safety and restraint. The management team said that the home has a policy of no restraint, although a policy was in place that stated that restraint might be used but only by members of staff who had received training. None of the care staff had been trained in carrying out restraint. The manager removed the restraint policy immediately and confirmed to the commission that it would no longer be in use. The pre-inspection questionnaire received by the commission confirmed that a number of policies and procedures had been replaced or reviewed during 2007. These included continence promotion, pressure relief, risk assessment and management. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 25 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 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 2 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 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 26 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 YA12 Regulation 16(m) Requirement Timescale for action 29/06/07 2. YA23 13(6) 3. YA24 23(2)(d) 4. YA33 18(1)(a) A full and accurate record of activities attended, where and when must be kept by the home. This will ensure that service users’ social and leisure needs are met. Policies and procedures such as 29/06/07 the prevention of abuse and bullying must be reviewed and updated to include a statement that links those policies to the policy and procedure for safeguarding. This will ensure that service users are protected from abuse. A review of the decoration of the 29/06/07 home must take place in order to identify and plan the necessary redecoration or repair found. This will ensure that service users continue to live in a well maintained home. A review of staffing levels 29/06/07 throughout the day must take place and include the role of the manager. This will ensure that the social, personal and leisure needs of service users are met. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 27 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 YA18 YA33 Good Practice Recommendations It is recommended that a review of training take place to enable inclusion of the following: equal opportunities, communication skills, recording and further training regarding epilepsy. Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Chertsey Road (42-44) DS0000013500.V333222.R01.S.doc Version 5.2 Page 29 - 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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