Inspection on 05/12/05 for 12 Downview

This inspection was carried out on 5th December 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

12 Downview 02/10/08

12 Downview 04/10/06

12 Downview 19/07/05

12 Downview 01/03/05

12 Downview 01/03/05

12 Downview 01/03/05

12 Downview 01/03/05

12 Downview 25/08/04

12 Downview 25/08/04

12 Downview 25/08/04

12 Downview 25/08/04

12 Downview 02/03/04

12 Downview 02/03/04

12 Downview 02/03/04

12 Downview 02/03/04

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Treloar College

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

CARE HOME ADULTS 18-65 12 Downview The Cottage Hungerford Berkshire RG17 0ED Lead Inspector Tracy McGuire Brown Announced Inspection 5th December 2005 10:00 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 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 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 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. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 12 Downview Address The Cottage Hungerford Berkshire RG17 0ED 01488 683087 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) Mr Terry Shoesmith Mrs Susan Shoesmith Mrs Elizabeth Juggins Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: 12, Downview and The Cottage provide accommodation for up to 7 Service users of either sex, aged between 18 and 65, who have a learning disability. The Home is situated Hungerford within easy reach of all local amenities. The Objective of the home is offer encouragement, instruction and stimulation whilst encouraging independence. The home offers a mix of single or double rooms for Service Users and there is a Cottage offering additional accommodation within the grounds. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection, which was announced so the Inspector could involve the home in a consultation project. The Inspection took place over a 4-hour period. Time was spent talking to the residents, Manager, Proprietor and staff. Samples of various records were examined. There was also a brief tour of the premises and garden. Some residents invited the Inspector to view their bedrooms. In addition the home has worked with the Inspector and took part in a service user consultation project. This involved feeding back the previous inspection report to service users recording method, interest and providing comments. The Inspector would like to thank all those involved for their assistance in this project. What the service does well: What has improved since the last inspection? What they could do better: 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 6 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. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 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 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 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): These Standards not inspected on this occasion. EVIDENCE: 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Service users current and changing needs are assessed and detailed in their individual records. EVIDENCE: Samples of Service User records were examined. Since the previous inspection the Manager and staff have worked hard to develop further Essential Lifestyle Plans. These plans are comprehensive and detail individual needs and goals. The Inspector noted that supporting risk assessments had also been developed and updated. Service users spoken to advised the Inspector of some of the goals of their care plans. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 10 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): 16 and 17 Service users rights are important and respected. Service users have a healthy varied diet. EVIDENCE: Service users informed the Inspector that they will always knock on each other doors and this practice was seen during the inspection. Service Users told the Inspector that the post is bought into the conservatory where they collect their own mail, staff are available to assist “with reading or explaining post” if required. Service users were seen chatting to each other or having time alone if they chose. Service users have a good relationship with staff and were seen interacting in a positive and professional and consistent manner which was supported by care plan records. Service users informed the Inspector of their responsibilities in the house and cottage, they have allotted tasks such as “dusting the dining room and my bedroom” and “I hoover and polish in the cottage”. Menus are on display in the cottage and house. These menus reflect the choices of Service users and are varied and balanced. The Inspector was offered lunch which was freshly prepared and well presented. Service users were proud to inform me that “I cook on Friday” and “I cook tomorrow but 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 11 sometimes we go out for dinner”. Since the previous inspection the home has also improved the recording and meals consumed are now recorded. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 12 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): 20 Medication procedures are satisfactory. EVIDENCE: Medication policies and procedures were seen for storage, administration, selfadministering and refusal. Staff undertake “shadow” style training in the home. Medication records seen were accurate and up to date. The home operates the blister pack system. Medication is stored securely in a locked cabinet inside a cupboard. Service Users who spoke to the Inspector had detailed knowledge of medication safety. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 13 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): 23 EVIDENCE: The home has a copy of the most recent local authority interagency vulnerable adults procedures. Staff in the home have sound working knowledge of vulnerable adults issues and have improved their awareness and developed more efficient record keeping. The home has a whistle blowing policy in place Where required the Inspector saw detailed guidelines in place to protect vulnerable persons. Evidence was seen on service users files of the involvement of other professionals if required to advise on vulnerable adults issues. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 14 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): 24, 25 and 26. Service users benefit from a comfortable warm and well maintained home that promotes independence. EVIDENCE: The home is warm, comfortable and well maintained. Service users told the Inspector “I am very happy living here.” Service users told the inspector that they have had new sofas since the inspection and these were seen. A review of the use of the cellar has been completed, the risk assessment is in place and strictly staff only access the cellar, food is also no longer stored in the cellar to reduce the usage. Some Service users invited the Inspector to see their rooms, the rooms were nicely decorated and were well personalised. Service users are proud of their rooms which are well equipped Service users informed the Inspector they choose the colour and decoration. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 15 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): 32,34 and 35. There is and effective staff team that undertakes training and recruitment procedures are robust. EVIDENCE: The home is currently fully staffed and there are satisfactory numbers of staff on duty. The home has a minimum of 2 on duty and tries to ensure 3 during some hours to give support to the house, cottage and offer varied day activities. At weekends there are 2 staff on duty. There is always 1 sleeping in staff member. Staff in the home have a good rapport with the service users. The staff in the home have varied qualifications, skills and experience relevant to the current service users. The home has recently recruited to a vacant position, recruitment records were seen and a detailed application form was completed. 2 references were completed and relevant checks have been processed. Staff undertake training and the Manager has recently developed a form to identify training needs, this was discussed and would benefit from more detail. Accessing training and the costs associated were discussed with the Manager and Proprietor. The home is looking into various ways of accessing training and showed the Inspector some external course information, internal video and refresher training. Most staff have completed or are completing the NVQ level 2. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 16 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): 37, 39 and 42 The home is organised and well. Service users views are considered and health and safety is promoted. EVIDENCE: The home has a registered Manager who has been in post since May 2005.The Manager has good relevant experience and is undertaking the Registered Managers award. The Manager works closely with the Proprietors and has improved and developed further the good practice in the home. Staff and Service users are complementary about the Manager. The home has undertaken a satisfactory annual Quality Assurance survey .The results of these surveys have been retained and assist in the development of the home. Health and safety records were viewed, all relevant checks were in place and up to date. There is a fire risk assessment in place and additional risk assessments are developed and reviewed. In addition the Proprietor spent some time discussing with the Inspector and the Manager some financial issues in the home. The needs of some service users have changed requiring more intensive staffing. One placement in a 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 17 shared room has been relinquished and the home is now providing day opportunities after the local authority reduced this service, plus the employment of a Manager have placed greater pressure on the finances. The Proprietor and Manager are looking at these issues but raised concern about this. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 12 Downview Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000011202.V264341.R01.S.doc Version 5.0 Page 19 NO 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. Standard Regulation Requirement Timescale for action 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 YA35 Good Practice Recommendations Ensure there training needs list is detailed. 12 Downview DS0000011202.V264341.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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