Inspection on 26/05/05 for The Chestnuts

This inspection was carried out on 26th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Chestnuts 23/04/07

The Chestnuts 19/10/05

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 Mrs Sue McBriarty Unannounced 26th May 2005 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. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Downing Ltd David Horsgood Care Home 18 Category(ies) of LD - Learning Disability (18) registration, with number of places LD(E) - Learning Disability over 65 PD - Physical Disability (10) SI - Sensory Impairment (2) Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 6. The home may accommodate one named person over the age of 65 3. The age/age range of the persons to be accommodated will be : AGED 18 65 YEARS 5. The home may accommodate up to 10 residents within the category and 2 residents within SI category within the total number accommodated. Date of last inspection 12th April 2005 - Specialist Brief Description of the Service: The home is owned and managed by Downing (Chertsey Road) Limited. The home is registered to accommodate eighteen younger adults with learning disabilities. Within this, the service user categories are ten with a physical disability, two with sensory impairment and one with a learning disability over the age of sixty-five. 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) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first inspection for 2005 – 2006. The inspection started at 8am to enable the inspector to observe the morning routine. The service users at this home have complex needs and it was not possible to gain their views of their experience of living in the home. During this inspection it was possible to observe the support offered to all the service users and observations were made of two staff members in the course of their work. Documents including care plans, daily notes, night shift reports, staff rosters, and personnel files were sampled. A tour of the communal areas of the home took place and two bedrooms were seen. The focus of this inspection was the experience of the home by service users. Two complaints had been received by the CSCI since the last inspection and the CSCI Pharmacist had completed an inspection. Documented outcomes are available from the local Eashing CSCI office on request. What the service does well: What has improved since the last inspection? What they could do better: This inspection highlighted a number of areas where the home must improve. Documents that provide adequate details of the service provided were Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 6 available but were not used consistently by the staff team. In addition the need to maintain a good standard of repair and decoration was required. These have been noted in the requirement section of this report. 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) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 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 Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 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) These standards were not assessed during this inspection. EVIDENCE: Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 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, 7, 9, 10 The assessment, recording and documentation provided by the home required work in all the areas covered by Standards 6, 7, 8, and 9. The information provided was kept appropriately. EVIDENCE: Service user files were sampled in detail and were found to be confusing and the detail inconsistent. Two files were maintained on each service user and it was found that the information held on one file had not necessarily been transferred to the other. The files in use downstairs had the oldest care plan to the front of the file and the latest at the rear. The files contained very detailed information regarding the service users needs and what support was required to meet those needs. However staff had not completed the supporting documents and the inspector could not evidence that the support required had been provided. Some evidence was found in the second file kept (key worker file) but this was limited. One of the care plans sampled had not been reviewed since July 2004. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 10 The service users have complex needs, however there was no evidence of how the home might involve the service users to gain feedback about life in the home. Some risk assessments had been updated this year but not all. A number of risk assessments had dates from early 2004. Some updated risk assessments were found in the key worker file. The risk assessments had space for staff to sign that they had read and understood the needs of the service users. These had not been signed in the files sampled. The files are kept in lockable spaces and are available to staff to read and understand the needs of the service users. Requirements had been made by the CSCI previously and this is noted in the requirement section of this report. The files sampled did note the likes and dislikes of the service users. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16, 17 Further work is required by the home to be able to meet Standards 11, 12, 13, 14, 15, and 16. The menus seen on the day of this inspection met the needs of the service users. EVIDENCE: The files sampled had clear written activity plans for each service user. The inspector found it confusing as two different copies were found in the files and it was not clear until the entire file had been read as to which one was in operation. On sampling the supporting documents it could not be evidenced that the planned activities took place. Staff members are required to complete daily notes that ask them to complete an activities section. In the sampled files there was scant evidence to show the service users attended activities or if they did not attend why not. For example, the files sampled showed that one would wish to attend church. The recording documentation used by the staff was inconsistent and it was not possible to evidence that this person was supported to attend church on a regular basis. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 12 The files sampled detailed the person’s next of kin and family address however it was not possible to evidence the level of contacted wanted by the family members. Information regarding service users finances was held in the key worker file. Given the information available it was not possible to evidence that Standards 11, 13, 14, 15 and 16 were met. The menus seen on the day of the inspection showed a variety of food on offer. Observations were made that staff encouraged service users to make a choice about what they might prefer for breakfast. Staff also checked back with those service users to make sure that they had understood the request. The relationship between staff and service users was observed as being warm and friendly. The daily notes require staff to complete a section on what food was offered to the service user, when and whether it was eaten. The section on what food and when had been completed. The section that required staff to tick if eaten had not been completed consistently. It was therefore not possible to evidence that service users had eaten regularly. Weight charts were kept and were able to show that for those service users sampled there had been no weight loss. The kitchen area was inspected. Undated food was found in the fridge and a requirement made that all food opened must have the date or opening on the package. A requirement had been made previously by the CSCI and this is noted in the requirement section of this report. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Detailed plans were available in the home; however further work is required to meet Standards 18, 19 and 20. EVIDENCE: As noted the home had provided detailed care plans for service users. Those files sampled showed the depth of information known about the person and how their needs must be met. The daily notes and night shift reports did not record whether the actions required had been taken. Limited information had been recorded in the daily notes sampled. Some information regarding access to health professionals was found however the information was inconsistent. It was not possible to evidence that where health needs for example, regular turning and skin checks had been completed. One assessment was found in another file but was dated 23rd March 2004. The homes recording system including the receipt and administration of medication were adequate. Since the last inspection the CSCI pharmacist had inspected the home. The Deputy Manager on duty discussed the visit and noted that one of the recommendations made had not been put into place as the home felt their record system was acceptable. This recommendation was Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 14 about the service user records. The administration book did not contain photographs of the person and the information about each person was held at the front of the file and the medication administration record at the rear. Given the medication being administered each service user must be provided their own section in the file. The section must contain a photograph, medical details and current medication. One person was on medication that changed on a regular basis, the information supplied by the prescribing person was confusing. The Deputy Manager had spoken to that person to clarify; no record had been made of the conversation. It was required during the inspection that the prescribing person provide the home with clear instructions in writing and that the document be dated by them and a date added by the home to show when it was received. Previous requirements had been made and these are noted in the requirement section of this report. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Staff had received appropriate training in the protection of vulnerable adults. EVIDENCE: Evidence of staff training and their understanding of the protection of adults from abuse were recorded in their personnel files. The home had recently reported a vulnerable adult issue and this had been dealt with through their policy and procedure and in line with the local authority multi-agency procedures. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 There were a number of areas in the home, which require repair and attention, and more work must be done to make the home safe, homely and well presented for the people living there. EVIDENCE: The communal areas of the home offered a number of spaces where service users could meet others in private. Those bedrooms seen had been personalised and the equipment required by service users was available. At the last inspection a requirement had been made to repair and decorate the bathrooms and toilets, this requirement had not been met. For example one bathroom had missing tiles around the bath and water could make its way under the bath. In another there were holes in the walls where items had been removed or replaced elsewhere in the room. In the ground floor bathroom the bath had not been cleaned and unclean in the bottom of the bath. The communal areas were showing signs of wear. Doors and walls had been damaged by wheelchairs and required repair and decorating. The stair carpet was marked and required cleaning or replacement. Further requirements have been made to repair and decorate the home. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 17 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) 31, 32, 33, 34, 35 Further work is required to ensure the home meets Standard 33. Staff training and induction were adequate. EVIDENCE: Staff personnel files were sampled during this inspection. The standard of the contents varied. The applications forms had been completed and noted that prospective staff were required to provide two references. In one file only one reference was evident. None of the files sampled held a contract of employment or job description. Induction training and Criminal Record Bureau (CRB) checks had been completed and were open for inspection. The home must ensure that when employing overseas staff they obtain documentary evidence of their right to work in the United Kingdom. The personnel files, information held in the downstairs kitchen and medication administration information evidenced staff training including; the protection of adults, manual handling and administration of medication. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 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, 41, 42, Staff training information was recorded in full. Further progress is required with regard to maintaining service user records. Action is also required with regard to some parts of the home. EVIDENCE: This inspection focussed on the experience of service users and how their needs are met. Previous requirements had been made to ensure that the home were able to evidence the support provided. During this inspection it was not possible to evidence how the management and or staff team was meeting service users needs. As stated earlier the staff members were required to record what support was provided to each service user. These records had not been completed clearly and consistently. Staff personnel records were not complete and required further work to ensure they met the standard. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 19 The hot water temperatures within the home were fluctuating from area to area. In one bathroom the temperature was recorded at 45 degrees centigrade. In another it was not possible to be accurate, the thermostat provided was able to record temperatures up to 55 degrees centigrade the test showed the water to be at least up to the maximum able to be recorded. The inspector was informed that the thermostatic valves were last checked in February 2005. A number of requirements have been made based on this inspection. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 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 x x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 2 3 2 2 2 3 2 Standard No 31 32 33 34 35 36 Score 2 3 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chertsey Road (42-44) Score 2 2 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x 2 2 x H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YP6, 7 Regulation 15(1)(2)( a)(b)(c) (d) Requirement The registered person must ensure that the service users care plans are kept up to date, decisions and outcomes recorded and reviewed regularly. The reviews to be dated and documented. The registered person must ensure that all service users are provided with a full range of updated risk assessments taking into account their changing needs including short-term changes that may be identified. (Timescale of 29th April 2005 not met. This is the fourth inspection where this requirement has not been met. Enforcement action will be taken if this requirement is not met.) The registered person must ensure that all services provided, including health checks, to service users are documented and recorded in full on the service users files and in the documents required by the home. The registered person must ensure that activity provision is planned, documented including Timescale for action 30th June 2005 2. YP9 12(1)(a)( 3), 13(4)(b) (c) Immediate 26th May 2005 3. YP11 17 (1)(2)(3) (a)(b) Immediate 26th May 2005 4. YP13, 14, 15, 17, 16 (m)(n)(3) 30th June 2005 Page 22 Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 5. YP17 17, Schedule 3(m) , 13(4)(c ) 12(1)(a)( b)(2), 13(4)(c) 6. YP18,19 7. YP24 23(2)(b)( d) 8. YP24 23 (2) (b)(d) 9. YP24 23(2)(b)( d) 10. 31, 34 19(1)(a)( b)(c ) 11. 42 13(4)(a) (c ) actual activities provided. The information must be recorded and documented. (Timescale of 22nd April 2005 not met). The registered person must ensure that staff consistently complete documentation required by the home to indicate whether food has been eaten by the service user. The registered person must ensure that the actual support provided to service users to meet their personal care and health needs is documented and recorded consistently. The registered person must ensure that there is a programme for the home to maintain a good state of repair and decoration. The registered person must ensure that the bathrooms and toilets are repaired and redecorated. (Timescale of 31st November 2004 not met). The registered person must repair and decorate those areas of the home damaged by wheelchairs and the communal areas of the home. The registered person must review the recruitment policy and procedure within the home to ensure that all the required documentation is provided. The registered person must ensure that the thermostatic valves are working consistently and within required levels in all bathrooms, service users bedrooms and toilets within the home. 30th June 2005 30th June 2005 31st July 2005 immediate 26th May 2005 31st July 2005 31st July 2005 Immediate 26th May 2005 Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 23 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 YP20 Good Practice Recommendations It is strongly recommended that the registered person review the current filing provision for the filing of medication administration records. Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Chertsey Road (42-44) H58_s13500_Chertsey Road_v221220_260505_stage4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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