CARE HOME ADULTS 18-65
1 Church Road Wembdon Bridgwater Somerset TA6 7RQ Lead Inspector
Ms Sue Hale Unannounced Inspection 15th February 2006 09:15 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 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 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 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. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service 1 Church Road Address Wembdon Bridgwater Somerset TA6 7RQ 01278 453635 01278 456656 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) Home First & Foremost Ltd Mr James Reginald Marchant Care Home 13 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th October 2005 Brief Description of the Service: No 1 Church Road is a large extended house providing a high standard of accommodation. The home is situated in a quiet residential area on the outskirts of Bridgwater. The property is surrounded by landscaped gardens. The home can accommodate up to thirteen people with a learning disability and additional physical impairments. All residents have their own bedrooms with en-suite facilities. The home is sufficiently spacious to allow the people who live here to be alone or mix with others according to their needs. Support is provided by the manager, James Marchant, and a small staff team throughout the 24 hr period. The people living here are supported to access a wide range of recreational activities within the home and the wider community. Contact with friends and families is promoted and supported according to individual needs and wishes. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of one day in February 2006. The inspector spoke to the manager and staff working in the home. Selected resident and staff files were checked and other records related to the running of the home. Thirteen residents were living at the home at the time of the inspection. None of the residents at home on the day of the inspection were able to communicate their views of the home to the inspector. This report should be read in conjunction with the previous report of 13th October 2005. What the service does well: What has improved since the last inspection? 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 6 The pre admission document has been revised to meet the national minimum standards. The staff sleepover room and bathroom area has been refurbished and facilities improved. A new male member of staff had joined the team and improved the gender balance to allow residents a greater choice of staff members for personal care and leisure activities. 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. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 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 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 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 the following standard(s): 1, 2, 4 & 5. Robust admission procedures are in place and all prospective residents would be able to spend time in the home and meet staff and existing residents before making a decision on residency. Standard 5 could not be assessed, as contracts were not kept on residents’ files at the home. The statement of purpose provided clear information about the philosophy of care and support at Voyage but did not include all the information required. EVIDENCE: The home statement of purpose was clearly written and detailed the philosophy of care and person centred value system in place at Voyage homes and focusing on residents’ rights. It did not however contain all the information in the Care Homes for Adults national minimum standards. The homes statement of purpose was currently being revised and updated so the current document is not commented on in this report. There have been no new admissions to the home since the previous inspection so this standard was evidenced by checking the admission and assessment polices and procedures and by discussion with the manager. The home would
1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 9 undertake a pre admission assessment and would obtain information from the funding authority from the care management assessment and proposed care plan. An individual care and support plan would be developed with the resident and discussion with their families and /or representatives would take place. Prospective residents would be invited to meet the staff and current residents informally and to spend time within the home including an overnight stay to assess their suitability and ascertain the view existing residents. All admissions would be on a trial basis and be reviewed formally after a settling in period. The home does not accept emergency admissions. Standard 5 could not be assessed, as residents contracts were not kept in the home so were not available for inspection. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 & 10. The care and support plans are individual, well organised and regularly reviewed and updated. Records were stored securely and staff was aware of confidentially issues. EVIDENCE: The inspector viewed one care and support plan, which was detailed and comprehensive and gave clear information to staff. Each resident has a nominated key worker. Risk assessments were in place, detailed and up-todate and were reviewed as necessary to ensure the safety of residents. Residents were supported by staff to access all necessary medical and health care and copies of medical and health care assessments were on file. Reviews occur on a monthly basis with summaries kept that detail the outcomes for individuals 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 11 The home has a robust confidentiality policy and the manager and staff spoken to was familiar with it and confident in how it worked in day to day practice. Records are stored securely in the office. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standard were assessed and met or exceeded at the last inspection. EVIDENCE: 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 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 the following standard(s): 18 & 20. There had been an increase of one male member of staff to improve the gender balance of the staff team. The home maintains good records in relation to the administration of medicines. EVIDENCE: One new male member of staff had transferred from another home within the organisation, which increased the number of male staff to enable residents to have a choice of a member of staff of the same gender for personal care and leisure activities. The inspector viewed the arrangements in relation to the storage and administration of medicines, and this was satisfactory to ensure the safety and well-being of residents. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. The complaints policy requires minor amendment to meet the national minimum standard. EVIDENCE: No complaints have been received by the home or the Commission for Social Care Inspection since the last inspection. The complaints policy should make clear that complainants are able to contact the Commission for Social Care Inspection at any stage of a complaint. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 30. The home was very clean and tidy on the day of the inspection. The laundry facilities were good and met resident needs. The staff facilities had improved and were of an acceptable standard. EVIDENCE: The home has a separate laundry with hand washing facilities, two washers and a dryer. Instructions on how to use the machines was available, the floor was impermeable and the walls easily washable. The home was very clean and tidy on the day of the inspection. The staff sleepover room had been redecorated and the bathroom area refurbished as required in the previous report. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 33. The number of qualified staff has increased but needs to continue to improve. Male residents have a greater choice of same gender staff. EVIDENCE: Seven staff is qualified to NVQ level 2 or above with a further twelve staff registered on NVQ level 2 training courses. This means that 30 of staff is qualified to provide a high standard of care. A male member of staff has joined the staff team which gives residents more choice of a member of staff of the same gender for personal care and leisure activities. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42. Internal quality assurance systems are in place to audit and review the quality of service provided by the home. The health and safety of residents is generally well promoted. EVIDENCE: The organisation undertakes yearly internal quality audits in which the views of some stakeholders and relatives of residents are sought about the services the home and provides. The homes policies and procedures are reviewed and updated by the organisation centrally and distributed to the home. They were not dated. Moving and handling Eight members of staff do not have a current moving and handling certificate. The manager stated that one member of staff had recently qualified to train other staff and that this would be arranged as a mater of urgency.
1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 18 Fire Safety Fire safety training is undertaken as part of the induction programme, all staff watch a fire safety video in the home. A fire risk assessment was in place and had been reviewed in February 2006.Evidence was seen that the fire alarm and extinguishers had been serviced. Health and safety All windows were fitted with restrictors. The home has COSHH policies and procedures and risk assessments for safe working practices. All cleaning products were stored correctly. The temperature of water outlets was checked weekly. A legionella risk assessment had been completed in December 2005. Evidence was seen that the hoist on the homes vehicle had been serviced in December 2005. Electrical Safety The portable electrical appliances were all checked in March 2005 and the hard wiring certificate is valid until August 2009. Gas Safety Evidence was seen of servicing of gas equipment in June 2005. Accident Book The home has an accident book that complies with the Data Protection Act 1998. It recorded if any treatment was given and was overseen by the manager. Food Hygiene Seventeen members of staff have current food hygiene certificates. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 19 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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 2 X X 2 X 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 20 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 1 Regulation Schedule 1 (1-9) (10-11) (15-17) 18 (1)(a) Requirement The registered person must ensure that the statement of purpose includes all the information required in the Care Homes for Younger Adults national minimum standards. The registered person should ensure that at least 50 of staff are qualified to NVQ level 2 or above by 31/12/05. Timescale for action 30/04/06 2 32 01/06/06 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 2 3 Refer to Standard YA5 YA22 YA33 Good Practice Recommendations A copy of the residents’ contracts should be kept on their personal file in the home and available for inspection. The complaints policy should make clear to complainants that they are able to contact the Commission for Social Care Inspection at any stage of a complaint. It is recommended that consideration be given to increasing the number of male members of the staff team. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 21 4 5 YA39 YA42 All policies and procedures should be dated and evidence of review noted. All members of staff should have a current food hygiene certificate. 1 Church Road DS0000039968.V283633.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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