Care Home: Hersham Road (20)

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What the care home does well All interactions observed between the residents, staff and the manager, evidenced that the home has a close and caring staff team. Residents are able to exercise choice in the daily lives, maintain bonds with family and friends, and take part in social, cultural, religious and recreational activities. The home provides a healthy and balanced diet. The resident`s physical, emotional and health care needs are monitored and met. Individual`s choice and dignity is promoted. The physical layout and indoor and outdoor communal areas of the home enable residents to live in a safe and well-maintained environment. Resident`s bedrooms, toilets, bathrooms and communal areas suit their needs and all areas of the home are clean and hygienic. Routine health and safety checks have been undertaken by the homes staff to ensure the safety and well being of residents. What has improved since the last inspection? Following the previous inspection in May 2007 the manager of the home had ensured that each resident had a completed `license agreement` (contract) which included a full breakdown of the total fee payable, in line with recent legislation. Whilst sampling the care plans the inspector noted that the home had complied with the previous requirement and had documented identified hazards in the form of risk assessments relating to the promotion of residents health, safety and welfare. What the care home could do better: It is recommended that the current skills and abilities of residents be further documented to include how the resident continues to achieve a goal or the stages at which the task is being completed. In order that proper provision for the health and welfare of resident`s care is monitored, and promoted a request must be made that the local authorities undertake a formal review of the care provided to residents by the homes staff. It is recommended that the current arrangements of report writing be reviewed to include a night-time risk assessment or the inclusion of a more holistic approach, which would be to report on the individual`s daily activities, theirinteractions, achievements and general demeanour throughout a 24- hour period. CARE HOME ADULTS 18-65 Hersham Road (20) 20 Hersham Road Walton-on-Thames Surrey KT12 1JZ Lead Inspector Suzanne Magnier Unannounced Inspection 27th May 2008 08:30 Hersham Road (20) DS0000013464.V363119.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 Hersham Road (20) DS0000013464.V363119.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. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hersham Road (20) Address 20 Hersham Road Walton-on-Thames Surrey KT12 1JZ 01932 269171 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) amanda.salih@nsurreypct.nhs.uk Welmede Housing Association Ltd Amanda Louise Salih Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2), Physical disability (1), of places Physical disability over 65 years of age (1) Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th May 2007 Brief Description of the Service: 20 Hersham Road is an adapted large house situated on a busy main road in a residential area, which is within walking distance of all community facilities of Walton On Thames. Service provision is for up to eight people with learning disabilities, some of who have physical disabilities in addition to their primary condition of a learning disability. The service affords all single bedroom accommodation on the ground and first floor with the third floor designated for staff use only. Wheelchair users are confined to the ground floor as provision of a lift is not available. There is a spacious combined lounge/dining room overlooking a furnished patio and a large, attractive well maintained enclosed garden. Residents have access to the home’s vehicle, which is equipped for transporting wheelchair users. The service is owned and staffed by Welmede Housing Association Limited. The weekly fees range from £1257.00 and £1,350.00 per week. This fee does not include holidays, hairdressing, personal items, toiletries, outings or aromatherapy. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Ms S Magnier Regulation Inspector carried out the inspection and the registered manager represented the service. For the purpose of the report the individuals using the service are referred to as residents. The inspector arrived at the service at 08.30 and was in the home for five and a half hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. A number of residents living at the home have communication difficulties, so their responses were assessed by observing facial expressions, body language, listening and requesting staff to interpret the individuals own way of communicating and observing staff interactions. Other residents were spoken with during the course of the inspection. The Commission received one written response from a resident and two written responses from health care professionals and five staff responses. All spoke favourably of the home and the comments received have been included within the report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes Statement of Purpose and Service User Guide, the terms and conditions of residency in the home, care plans, person centred plans, daily records and risk assessments, medication procedures, staff files, a variety of training records, health and safety records, and several of the homes policies and procedures. The commission have noted that the nine requirements made during the inspection, undertaken o the 8th May 2007 have been complied with. From the evidence seen by the inspector it is considered that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: It is recommended that the current skills and abilities of residents be further documented to include how the resident continues to achieve a goal or the stages at which the task is being completed. In order that proper provision for the health and welfare of resident’s care is monitored, and promoted a request must be made that the local authorities undertake a formal review of the care provided to residents by the homes staff. It is recommended that the current arrangements of report writing be reviewed to include a night-time risk assessment or the inclusion of a more holistic approach, which would be to report on the individual’s daily activities, their Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 7 interactions, achievements and general demeanour throughout a 24- hour period. 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. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 8 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 Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 9 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): 1, 2, 3, 4, 5. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Prospective residents and their representatives have accurate information about the home in order that they can make an informed choice about moving to the home. The homes admission and assessment procedures ensure that individual’s needs are appropriately identified and met. Terms and conditions/contracts of stay at the home are available to all individuals. The home does not provide intermediate care. EVIDENCE: The home has a statement of purpose and service user guide in place, which the manager advised were currently being updated and sampled by the inspector. All residents, their relatives, or representative have access to this information in order to provide them with sufficient information about the home. Two residents had been admitted to the home since the last inspection. Three resident files, which included the residents newly admitted to the home, were sampled and each contained evidence that a needs assessment for the individual had taken place prior to the person being admitted to the home. There was written evidence that the homes staff had visited individuals prior to Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 10 them moving to the home in order that the individual could get to know the staff and feel more comfortable when moving to the home. Visits prior to admission for some individuals had taken place, which had benefited them in settling into their new home. Whilst speaking with the manager and one resident it was evident that the home encourages other residents to help new residents to settle into the home by offering friendship and support. Following the previous inspection in May 2007 the manager of the home had ensured that each resident had a completed ‘license agreement’ (contract) which included a full breakdown of the total fee payable, in line with recent legislation. The home does not provide intermediate care, and this standard was not assessed. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The support and personal care that residents receive is based on their individual needs set out in their care plans. Arrangements for resident’s care plans reviews needs to be better managed. Monitoring of risk assessments is managed in a robust manner to ensure the safety of residents in the home. Resident’s dignity and respect is consistently promoted. EVIDENCE: Following the previous inspection it was noted and explained by the manager that the home had redeveloped the way in which care plans had been documented. These changes included clear evidence of reviews of the care provided by the individuals key worker and other staff to make sure the resident receives the care they require, and that their individual needs continue to be identified and met, and that residents are receiving care in the way they prefer. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 12 The manager had ensured that most of the care plans had been signed, where able, by the resident, or their representative and it was noted that some care plans included a statement that the resident was unable to sign their care plan. It was explained to the inspector that the home are continuing to work towards setting individual goals with residents and some of these aspirations were evident in the individuals person centred plans for example going on holidays and household activities. It is recommended that the current skills and abilities of residents be further documented. For example where residents are involved in daily living skills such as helping to lay the table, attending to their own personal care, dressing and undressing, doing household chores and gardening that these abilities and skills are more fully documented to demonstrate how the resident continues to achieve the goal or the stages at which the task is being completed. The manager described and it was documented how one resident, newly admitted to the home, had a variety of skills and abilities yet the detail of how the resident achieved and maintained these skills was not yet evident in any of the documentation and no progress and building upon this skill was documented to ensure that the resident maintained the level of skill and ability. Two residents had a person centred plan, which had been developed with the individual where able. The person centred plans were well documented and helped the reader to understand and get to know the individual and their life history, significant events in their life, their likes and dislikes, holiday memories, photographs, some goals and aspirations, meaningful activities, and people that are important to them in their lives. The care plans sampled were well documented to describe the resident’s individualised personal care needs and how care and support were provided taking into account the individuals preference on how they liked to receive care and support, the residents communication and sensory abilities and needs, and their mobility and assistance needed with moving and handling. The care plans also detailed the individuals likes and dislikes, their religion, next of kin or significant people in their life, and the individuals current medication. The commission has noted at the last inspections that there is a significant length of time since a formal review of some of the residents care plan/placement by the funding authority has been undertaken. This detail was discussed with the manager who confirmed that the staff at the home undertook any care plan reviews rather than formal reviews held with outside agencies for example care managers or the local authority. The inspector sampled that in house reviews had taken place to benefit the residents yet it Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 13 has been required that the home must request a local authority review regarding any resident’s care in order to promote and make proper provision for the health and welfare of residents. It was observed that events of note were recorded in individual books and the manager explained that entries are made in the book for events that are not routine. No records are routinely documented by the waking night staff and this was discussed with the manager and a recommendation made that the current arrangements of report writing be reviewed to include a night time risk assessment or the inclusion of a more holistic approach, which would be to report on the individual’s daily activities, their interactions, achievements and general demeanour throughout a 24 hour period. These changes would be viewed as positive in promoting residents care in a person centred way. During the inspection it was noted that there was a calm atmosphere throughout the home and individuals were observed to be comfortable moving freely around their home and working in the garden with support from staff. It was observed that staff addressed residents in a professional and caring manner and residents were addressed by their first or full name and where appropriate names of endearment were used to support trusting relationships. Staff were observed to preserve and maintain residents dignity and privacy by knocking on their room doors prior to entry and supporting resident’s discreetly to the bathroom. Whilst sampling the care plans the inspector noted that the home had complied with the previous requirement and had documented identified hazards in the form of risk assessments relating to a residents health and welfare. Several risk assessments were sampled and included documented hazards in residents daily living for example moving and handling, being present in the kitchen, using specific equipment such as wheelchairs, safety regarding eating and drinking, bathing, health care needs for example epilepsy, being safe in the community and using the homes transport with support. The risk assessments were well managed to demonstrate they had been regularly reviewed in order to promote the resident’s health, safety and welfare. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 14 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): 12, 13, 15, 16, 17. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Individuals are able to exercise choice in the daily lives, maintain bonds with family and friends, and take part in social, cultural, religious and recreational activities. The home provides a healthy and balanced diet. EVIDENCE: Two residents, supported by staff were on an overseas holiday and were due to return home during the afternoon on the day of the inspection. One resident showed the inspector their holiday photographs when she and another resident also went abroad for their holidays. In order to offer resident’s choice about where they wanted to go on holiday the homes staff, with residents had made a wall mounted collage of places and countries to visit which residents could choose and discuss with staff as potential places to visit. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 15 The manager explained that the homes staffing levels enable the home to offer a flexible structure, including a “floating” support worker provided by Welmede, to provide support for residents to have a chioce each day of what they might like to do if they are not attending their more structured activities which include visits to day centres. One resident was supported to the local shops in the morning and also told the inspector about having met members of the royal family in the past and about a planned visit to see the Queen which she was very excited about. Documentaion in the home including reisdent’s individual diaries confirmed that people are supported to take part in a range of activities and be members of their local community. Records stated that individuals participated in attending a local day services, visited the local Snoozelum, went out for meals in pubs and restaurants, participated in arts and crafts, had bingo sessions, enjoyed listening to music and watching television, enjoyed going for drives, took part in visits by a musician to the home, and had one to one sessions with the aroma therapist for aromatherapy at home, and enjoyed being in their garden and taking part in games. The Annual Quality Assurance Assessment (AQAA) states that the home had also researched and increased evening social activities in the community and reviewed meal times to suit the residents wishes, hobbies and activities. The manager advised that some residents have shown an interest in participating in attending places of worship and residents are supported to attend the church if they wish. The staff and residents confirmed that family members and friends visit the home from time to time and keep in contact. Links have also been maintained with other homes and during the inspection several people visited the home to have look in the garden and share ideas about growing vegetables. Some individuals have built up lasting friendships in the home and whilst sampling records and looking at individuals bedrooms the inspector noted that family and friends photos were in people’s bedrooms and in their person centred plans. Residents were seen to move around their home as they wished. The pace of the day was unhurried and staff undertook individual’s daily routines in a professional manner. The inspector noted that residents were given a choice of when they preferred to get up and have their breakfast. One resident told the inspector that they had helped with the cleaning of the lounge the day before which had been fun. During the course of the inspection the inspector observed the midday meal preparation and serving. The menu was seen to be varied and well balanced, and staff confirmed that advice is sought from a local dietician, for individual residents, as and when needed. The inspector was advised that residents plan Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 16 their meals, usually on a daily basis, with assistance and guidance from the staff where needed. The home have maintained methods of helping residents choose their meals through the use of photograph cards of different foods and also by promoting residents abilities in helping and being in the kitchen when food is being prepared. The lunchtime meal was observed during the inspection and it was noted that the food (sandwiches) were presented in an appetising manner and staff were at hand for residents in the dining room and there was a relaxed family atmosphere. Several resident had chosen to have their lunch in the garden and were seated having lunch on the new wooden garden furniture. It had been identified that following lunchtime one residents behaviour, newly admitted to the home, became testing to the service and the behaviour was communicated through self harming. The manager and staff confirmed that they were seeking to interpret what the behaviour meant in order to support the resident more fully. The manager advised that there was ongoing health care involvement regarding the resident and records evidenced confirmed that the concerns had been addressed with a variety of healthcare professionals. The homes fridges and pantry were well stocked with fresh fruit, vegetables, and dairy products. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The resident’s physical, emotional and health care needs are monitored and met. Individual’s choice and dignity is promoted. Medication procedures ensure that medication is administered to all individuals in a safe and appropriate way. EVIDENCE: The resident’s health care records are kept in a folder, which is called the Health Action Plans and the inspector sampled two. The files contained records of health care appointments that residents had attended and also visits of specialised health care professionals to the home and other venues. The health care professionals included the general practitioners (GP), chiropodists, dieticians, district nurses, dentist, psychiatrist and hospital specialists and speech and language therapists. For one resident newly admitted to the home progress reports had been developed which the manager explained were discussed in frequent reviews held with health care professionals. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 18 Records indicated ongoing support which included reviewing residents diet and monitoring individuals body weight records of, which were sampled by the inspector. Following the previous inspection the manager had met the requirement that requirement that risk assessments be carried out and documented, with reference to skin risk assessments, moving and handling risk assessment, nutritional risk assessments and a risk assessment for the use of bed rails. The inspector observed that staff supported residents in a sensitive way, ensuring their privacy was respected when providing assistance with personal care. The inspector sampled the secured medication cupboard in the home. The cupboard was orderly, clean and was well stocked. The local Pharmacist supplies the home’s medication and the inspector was advised that the home is not currently supporting any residents with the administration of controlled medicines. The administration of some medications was observed and the medication administration records (MAR), medication storage, policies and procedures were all sampled and found to be in good order. During the last inspection it was advised that the local chemist would soon be providing pre-printed MAR sheets yet the inspector observed that staff are continuing to hand write medication onto the medication administration sheets. The manager advised that the pre printed medication charts would be available to the home in July 2008. The stocktaking and returns of medication to the pharmacist are clearly documented in a logbook held in the home. The medication file contains a comprehensive list of the residents medication and what the medication is prescribed for, a photo of the resident and their known allergies. It was observed that there were no gaps in the medication administration sheets (MARS) and staff observed recording the administration of medication immediately after it was administered. Staff advised that no residents self medicate and recognised that the home supported resident’s rights not to take their medication and reassured the inspector that ongoing refusal to take medicines would be alerted to health care professionals. The manager advised the inspector that staff received medication training and records sampled during the inspection confirmed this information. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The homes complaints procedure is an accurate document for individuals to express any concerns or complaints. Residents are protected from abuse by the homes policies and procedures. EVIDENCE: The home has a current complaints procedure in place, which is also available in symbol format. The complaints procedure was available to all residents, their relatives and representatives and a copy kept on the resident’s individual files. A complaints log has been maintained and there have been no complaints since the last inspection. There is a safeguarding procedure in place called “dealing with abuse” and a current whistle blowing policy. This outlines in detail the step- by -step action to be taken in the event of a safeguarding issue. The home has a copy of the local authorities Multi Agency Policies and Procedures on Safeguarding Vulnerable Adults and records confirmed that all the staff in the home have undertaken safeguarding training with some staff booked to attend refresher training. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The physical layout and indoor and outdoor communal areas of the home enable residents to live in a safe and well-maintained environment. Resident’s bedrooms, toilets, bathrooms and lounge area suit their needs and all areas of the home are clean and hygienic. EVIDENCE: During the tour of premises the inspector observed that the home was well maintained and appropriate access was available to all residents in their home. The communal areas of the home were large spacious and clean. The manager advised that news sofas and chairs had been recently purchased, and additional furniture had been assessed and ordered for specfic residents to ensure their comfort. The inspector was also told that the homes kitchen is going to be refurbished. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 21 The garden area was spacious and it was evident that the residents and staff enjoy the gardenning activities and that the homes staff are committed to making the garden, with the help of residents a pleasurable place to be. New garden furniture had been purchased through local fundraising and the residents had spent time growing their own flowers for the garden which were in the greenhouse. Resident’s bedrooms were observed as spacious and comfortable and each had been personalised with the individual’s choice of colour and soft furnishings. The rooms were individualised and contained the resident’s own items of furniture, personal possessions, leisure items, framed photos and objects of reassurance. All the bedrooms were clean and orderly and were well decorated. The homes bathrooms and toilets were inspected and it was noted that each contained specialist equipment and specific aids to support people in their daily lives. The manager explained that there were plans to make one of the bathrooms into a ‘wet room,’ which would suit the resident’s needs more fully. The bathroom and toilets were clean and well decorated. Hand washing facilities were available throughout the home in order to promote safe practice in regard to infection control. The inspector viewed the home’s infection control policy and procedure. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Staff in the home are trained and in sufficient numbers to support the residents at all times. The home has a robust system for the induction, training and development of staff in order to ensure the safety and protection of residents in the home. Recruitment practices have been strengthened. EVIDENCE: The staff duty rota evidenced that there were sufficient staff on duty at any one time to meet the assessed needs of the residents. As previously documented the inspector was advised that the home has a flexible approach, which accommodates residents needs, preferences and activity. Written comments received by the commission from staff regarding the home included ‘ Our induction package was well planned and covered everything’, ‘All mandatory courses attended and policies and procedures are updated, read and signed.’ ‘ Support comes from other staff and a good team’, ‘I have regular supervisions’. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 23 Two staff files were sampled of staff recently employed by the home. One of file contained all the relevant information currently required by the Care Homes Regulation 2001 (as amended 2006). The other file did not contain the candidate’s full employment history and the file contained two written references from their last place of employment supplied by different people. It was noted that the staff member had also worked in another registered care home yet references had not been sought from this past employment. It was evident that the manager had taken time to access the files from the Human Resources Department yet had not checked the files for full compliance. The inspector spoke to the staff member concerned and was assured that the reference would be sought with immediate effect and the staff member would complete their full employment history onto the application form. Both files included a Criminal Record Bureau (CRB) disclosures check Following the inspection the commission were advised by telephone that the staff member had completed their full employment history on the application form and Welmede Housing had requested a written reference. Both files contained fully completed induction programmes and there was evidence that mandatory training in basic food hygiene, fire safety, moving and handling, first aid and health and safety had been attended or had been booked in order to ensure that residents are fully protected and their welfare and well being is promoted. Following the previous inspection requirement in May 2007 the manager and staff have devised a training matrix, which is easily accessible to determine the shortfalls and audit refresher training for staff. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The management and administration of the home is robust. The home is run in the best interests of the residents and their views and opinions and those of other associated are sought. Resident’s general safety and welfare is promoted. EVIDENCE: The registered manager who has been in post for several years manages the home efficiently. There is good line management structure in place to ensure that the home is well supported at all times. Written comments regarding the management of the home included ‘My manager will always give support and discuss any concerns I have’. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 25 Systems are in place to monitor quality assurance. House meetings take place to monitor services provided and residents are encouraged to meet with their key workers to talk about their views and the care they receive. Regulation 26 visits are undertaken monthly and the reports are retained in the home for information. Annual quality assurance surveys are given to residents and their representatives and people with an interest in the service, and results of these are sent to the home in a report. Resident’s financial interests are safeguarded and systems are in place for checking and recording all financial transactions, and all receipts retained for regular audits. The inspector sampled three residents finance records all of which were in good order. The health, safety, and welfare of the residents and staff are observed and promoted. There is a wide range of health and safety policies and procedures in place and staff were seen to adhere to these procedures during the inspection. Control of Substances Hazardous to Health (COSHH) procedures is maintained and risk assessments are in place for all identified risks and safe working practice. All staff undertakes training in fire safety and record indicated that fire alarm system is checked weekly and there is a contract in place for the maintenance of fire fighting equipment and emergency lighting. All accidents, injuries and incidents of illness or communicable disease are recorded and reported. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 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 Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 12. (1)(a) Requirement In order that proper provision for the health and welfare of resident’s care is monitored, and promoted a request must be made that the local authorities undertake a formal review of the care provided to residents by the homes staff. Timescale for action 27/08/08 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 YA6 Good Practice Recommendations It is recommended that the current skills and abilities of residents be further documented to include how the resident continues to achieve a goal or the stages at which the task is being completed. It is recommended that the current arrangements of report writing be reviewed to include a nighttime risk assessment or the inclusion of a more holistic approach, which would be to report on the individual’s daily activities, their interactions, achievements and general demeanour DS0000013464.V363119.R01.S.doc Version 5.2 Page 28 2 YA6 Hersham Road (20) throughout a 24- hour period. Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Hersham Road (20) DS0000013464.V363119.R01.S.doc Version 5.2 Page 30 - 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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