Inspection on 25/01/07 for 1 Empire Road

This inspection was carried out on 25th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Empire Road 15/12/08

1 Empire Road 26/01/06

1 Empire Road 14/09/05

1 Empire Road 12/01/05

1 Empire Road 07/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 1 Empire Road Torquay Devon TQ1 4LA Lead Inspector Sam Sly Unannounced Inspection 25th January 2007 12:00 1 Empire Road DS0000018408.V314964.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 1 Empire Road DS0000018408.V314964.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. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Empire Road Address Torquay Devon TQ1 4LA 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) 01803 326215 Parkview Society Limited Mr Wayne Osbond Care Home 1 Category(ies) of Learning disability (1) registration, with number of places 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: 1 Empire Road was initially registered, and continues to provide care for one resident with a learning disability. The service is tailored to meet the specific needs of this resident and there is no further admissions planned. The home is situated in a residential area of Torquay, within walking distance of some shops, and within driving distance of the town centre. There is a double bedroom, a staff office/sleep-in room, a shower room, bathroom, lounge, quiet lounge, and kitchen. Outside is a small garden to the rear. The Owners are a local registered charity the Parkview Society that runs several care homes in the Devon area. The Statement of Purpose for the Home is not up-to-date. The fees for the service provided are £2,873.94 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was in two parts, the first was unannounced, and three and a half hours were spent with the resident and their carer on a weekday in January. Also a tour of the premises was made. The second part was announced on 30th January 2007, and one hour was spent with the registered manager examining records, giving feedback and discussing procedures. The resident who lives at 1 Empire Road was observed throughout the first visit and the Inspector accompanied the resident and their carer on the resident’s choice of a trip out; a local pub. To write this report all the records of contact the Commission has had with 1 Empire Road since the last inspection were looked at. The registered manager provided information too. All the standards that the Commission thinks are most important were looked at during the inspection process. A comment card was sent to the resident’s family but not returned. A comment card was sent and returned by the resident’s day service. Three staff comment cards were sent and returned to the Commission. What the service does well: What has improved since the last inspection? What they could do better: 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 6 The registered provider must make sure the systems for handling the resident’s finances are robust and records kept can be audited. The registered provider still needs to put together a system to monitor and improve the quality of service provided at 1 Empire Road so that the resident, their family and other stakeholders are assured of continual improvement. Other recommendations were made to improve the service provided. 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. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the service is not up-to-date, but the resident’s needs are well understood and regularly reviewed so staff know what support to provide. EVIDENCE: The Statement of Purpose and Service User Guide examined had not been reviewed and the resident did not have a current contract, which means the resident, their family and other stakeholders do not have up-to-date information about the service provided. The resident has lived at 1 Empire Road for over twelve years and the whole service has developed to meet their changing needs. These needs are well understood by the staff spoken with at the Inspection and are reviewed regularly within the care planning process. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident can be sure that staff are aware of their goals and care needs and are supporting them to be as independent as possible. The resident’s money looked after by the registered provider must be better accounted for. EVIDENCE: The care planning system held up-to-date information to tell staff about the support needs of the resident, and regular review meetings were held with all those involved in the resident’s life. However, the care-planning file also included out of date information and it was not always clear what the resident’s current needs were. Some of the file included symbolised information. Staff spoken with had a good knowledge of the resident’s needs, and worked with the resident at their own pace. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 10 There were records of the resident’s pocket money at 1 Empire Road on the day of Inspection, but no records of his Department of Work & Pensions benefits, or any savings. These records were requested at the second meeting on January 30th 2007. The records produced did not identify the Department of Work & Pensions benefits the resident received, and savings were kept in an account looked after by a temporary member of staff; these records were not available. The records produced did not give the registered manager the information required to audit and account for the resident’s finances handled by the Owners and staff and did not give clear information to the resident of what income they received. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The resident leads an active, interesting life with regular family contact, and the set up of the service means the resident can do what they want when they want to. EVIDENCE: The resident attends a Local Authority day service four days a week, and at present has one day a week and the weekends at home. A comment from the day service was that ‘effective communication was difficult now that the deputy manager had left – but a willingness to address this has been expressed’. Records showed that there had been a number of meetings recently to improve communication with the day service, and the registered manager said they were considering appointing another deputy manager due to the present longarm management of the home. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 12 The care plan and daily records showed that the staff were very aware of what the resident liked to do and have the flexibility to do activities chosen by the resident when the resident wanted to do them. On the day of the Inspection the resident got up in their own time, and was given choices of activities. The resident did not want to do any of the activities to start with, but after lunch chose to go to their favourite pub. Due to the one-to-one staffing at 1 Empire Road the staff member was able to quickly get the resident ready and go out as soon as this choice had been made. Records showed that the resident went out on trips, visited shops, pubs, had meals out and visited local attractions and visited their family on a regular basis. Staff demonstrated a keen interest trying new activities with the resident, and knew what activities they liked doing. The resident had access to a vehicle, and two of the staff could drive, so they could go out the majority of the time. The other staff member walked with the resident, which added some exercise. Meals that staff know the resident likes, as well as being healthy are prepared for the resident. Staff accompany the resident to buy small items of food from local shops to encourage community presence and exercise, and a main shop in done by staff as shopping for food is not the resident’s favourite occupation. All staff have undertaken food hygiene training as they all prepare the food the resident eats. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s healthcare and personal care needs are well understood and met. Medications practices and procedures protect the resident. EVIDENCE: It was clear from records within the care plan and daily recording that the resident’s health and personal care needs are well understood and closely monitored by staff. There were records of regular health checks, appointments for specialist input and medication reviews and staff spoke knowledgeably of the residents health and personal care needs. Medication is administered to the resident by staff and all staff have had training to do this. The medication procedures were examined and the resident’s medication was stored safely, receipts and records were kept accurately and training is provided to staff. There was some unused and discontinued medication that should have been returned promptly to the Pharmacist. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident can be confident that their views will be listened to and acted on, and that staff will be able to take the necessary steps to protect them from abuse. EVIDENCE: There was a complaints procedure within the Statement of Purpose and Service User Guide. Neither the registered person, nor the Commission had received any complaints about 1 Empire Road since the last Inspection. There was a copy of the Local Authority Alerter’s Guidance available and an adult protection procedure, and all staff had attended the Adult Protection training within the last two years. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The resident’s house is clean, comfortable, safe, homely and set out specifically for them. EVIDENCE: The premises were clean, well maintained and well decorated. As the resident is the only person living at 1 Empire Road the whole environment is tailored to their needs with a lounge and quiet room and a domestic kitchen, bathroom and shower room. This means the resident can be alone if they want or seek out the company of staff. The home is situated is a residential area of Torquay near local shops, bus routes and amenities, and cannot be distinguished from any of the other houses in it’s street. There has been no Environmental health department visit for several years as the home has been given a low risk priority. Staff and an 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 16 external provider carry out regular fire checks, as well as ensuring through training that the house is clean and hygienic. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident benefits from services provided by a fit, competent, trained staff team. EVIDENCE: There are three staff members and a bank worker supporting the resident, with occasional Agency staff. The team have attended a range of recent training with certificates kept on fire safety, food hygiene, health and safety, medication, breakaway, infection control, protection of vulnerable adults and one staff member is undertaking NVQ 3 (the nationally recognised training for care workers). Staff had not undertaken specialist training like person-centred planning, training on working with people with learning disabilities or total communication training and there was no information or training provided so that staff understood issues of equality and diversity that affected the resident’s life. The staff files were viewed on the second visit, but were not kept on the premises as required. The registered manager said this would now happen. Staff files held the required identification, fitness checks, application forms, 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 18 copies of training attended and some supervision information. There was no interview record, or record of decision making with regard to questions of fitness and staff did not undertake induction or foundation training. One staff member had received supervision and an annual appraisal recently, the other two had not. Two of the three-strong staff team were present for some part of the Inspection and with both staff the resident demonstrated a comfortable happy relationship with lots of smiles. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s health and welfare is protected through safe working practices, however the quality of the service could be better monitored. EVIDENCE: The registered manager also manages a service in Newton Abbot, with his main office there. Records showed that the registered manager and two other employees of the Company regularly visit and monitor the service. There is no longer a deputy manager at 1 Empire Road and this is something the registered manager said he was looking at changing. All three staff said they felt supported by the management and one staff member said ‘I receive great support from my colleagues and managers.’ 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 20 A Quality Assurance system was not being implemented, but on the second visit the registered manager showed a monitoring and review system that he said would be introduced at 1 Empire Road. The Commission is concerned that this was made a requirement at the Commission’s Inspection on 26th January 2006 and has not yet been met. The Company monitor all the mandatory health and safety training for staff, and all have attended First Aid, food hygiene and fire safety training. The fire book and fire checks were up to date. Accidents were recorded appropriately, and records were kept of electrical, gas and other health and safety checks. Water temperatures were restricted and checks carried out to control the risk of Legionella. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 21 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 X 5 X 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 22 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 YA7 Regulation 20 17 (2) Sch.4 (9) Requirement The Owners must make sure that money handled by staff and belonging to the resident is handled safely and records kept appropriately so that audit can take place. The Home must have a quality assurance system that is underpinned by the views of the resident, his representatives, and stakeholders. A report should be developed annually that is available for the Commission and other interested people that shows how the home has developed, and what still needs to be done to improve the quality of care (Timescale 15th March 2006 not met). Timescale for action 31/03/07 2. YA39 24 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000018408.V314964.R01.S.doc Version 5.2 Page 23 1 Empire Road 1. Standard YA1 The residents contract should be completed and signed, and copies of the revised Statement of Purpose and Service User Guide sent to the Commission. The care planning system should be reviewed to include only current information necessary to identify the resident’s needs, risks and the plan for how to meet these needs. . The use of multi-media formats (digital photos, symbols, line drawings) should be investigated to communicate currently written information to the resident. This would increase decision-making and choice. Staff should receive training in Total Communication and person centred planning. 2. YA6 3. 4. 5. YA20 YA34 YA35 Unused medication should be returned promptly to the Pharmacy. There should be a format for recording staff interviews and decision making about employment. There should be a training and development plan for the staff team, which includes specialist as well as mandatory training. Staff should have training on the promotion of equality and diversity and the Home should have a policy. 6. YA36 Regular supervision should take place. 1 Empire Road DS0000018408.V314964.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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