Inspection on 26/09/05 for 121 Watley`s End

This inspection was carried out on 26th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

121 Watley`s End 14/05/07

121 Watley`s End 20/04/06

121 Watley`s End 05/05/05

121 Watley`s End 31/01/05

121 Watley`s End 11/08/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 121 Watleys End Road 121 Watley`s End Road Winterbourne South Glos BS36 1QG Lead Inspector Melanie Edwards Unannounced 26 September 2005 09:45 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 121 Watleys End Road Address 121 Watleys End Road Winterbourne South Glos BS36 1QG 01454 250232 01454 250994 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Aspects & Milestones Trust Mrs Carol Elizabeth Close Care Home for Younger Adults 14 Category(ies) of Care Home with nursing,14 registration, with number of places 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 14 persons aged 18 years and over with learning disability who may also have physical disability and who require nursing care.Staffing Notice dated 20/07/2001 applies.Manager must be a RN on part 5 or 14 of the NMC register. Date of last inspection 5-May-2005 Brief Description of the Service: Aspects and Milestones Trust operate 121 Watleys End Road, which is registered to provide nursing care to 14 adults with a learning disability and a physical disability. The property is located in a quiet residential area, close to local shops and amenities.There are 14 single bedrooms of various sizes, all of which have sinks.There are a parking spaces and grounds to the side and rear of the house. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Please note due to their disabilities, many residents are unable to express their views verbally about the Home. Because of this the inspector spent time talking to staff on duty about their roles and responsibilities. The inspector spoke to one registered nurse, three care staff, and the registered manager, about their roles and responsibilities, their training needs, and how they assist and support residents. Staff were also observed assisting residents with their needs. A range of records relating to the day-to-day running and management of the Home were inspected. A selection of resident’s care records and care plans were also inspected. What the service does well: What has improved since the last inspection? What they could do better: All residents would benefit if their care plans and assessments are formally reviewed and updated on a regular basis, indicating staff monitor residents changing care needs. It would protect and safeguard residents’ wellbeing if all serious allegations that may affect their well-being, were reported to the Commission for Social Care Inspection as is legally required. From information seen in records it is evident an allegation had been made in the Home in July 2005 that one resident had been placed at risk of harm by the actions of a member of staff. This allegation should have been reported under Care Home law to the Commission for Social Care Inspection, and it should also have been reported to the adult protection co-coordinator for South Gloucestershire Community Care Department who has a responsibility for Protection of vulnerable adults from abuse matters in the area. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 6 The reporting of such allegations that may put residents at risk also ensures that the Commission can make the Community Care Department protection officers aware if needed, in case there is a significant risk of harm to residents who due to profound disabilities are very vulnerable. The safety of everyone who is inside the Home at any time would be better protected if checks of the fire alarms were being carried out on a regular basis. It would be beneficial to the health and safety of residents if food that has been stored in the fridge and appropriately covered, was also dated so that food products are not kept and used past their use by date, and hence become a food safety risk. The health and well-being of residents would be better protected if bedrooms were kept satisfactorily clean. 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. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Residents’ assessed needs are met, however assessed needs are not being formally monitored and reviewed. EVIDENCE: To review how residents’ care needs are planned and assessed two residents assessment records were inspected. The assessments included a range of information, and detailed each resident’s range of complex care needs. However, the assessments had not been formally reviewed or updated for over nine months, meaning there is no evidence to demonstrate staff monitor residents’ changing needs. Staff on duty demonstrated a good understanding, and sensitivity about the complex needs of residents. Staff will rely on understanding a resident’s body language, gestures, and long-term knowledge of the resident to try and understand their needs. Staff communicated with residents in a warm manner, and used warm humour, and sensitive touch. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9. Resident’s assessed needs are met, however individual care plans do not reflect that needs are being monitored and reviewed. EVIDENCE: To review how care is provided two resident’s care plans were inspected. The care plans contained detailed information about how staff are to support the residents with physical, and mental, health and social care needs. Care plans had been written in a clear objective style, and were written from a resident centred perspective, which should help staff to provide care that meets residents’ individual needs. Care plans had not been formally reviewed or updated on a regular basis and this fails to demonstrate residents’ needs are being monitored and reviewed by staff. All the staff the inspector met are experienced in their work, and knowledgeable of the needs of residents in their care. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 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 standard(s) 12,13,16,17 Residents are provided with a healthy varied diet, and are supported to live a fulfilling life in the Home and in the community. EVIDENCE: 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 11 The menu record was inspected to find out if residents are being provided with a well balanced diet. There were choices of dishes for each day and the menu was nutritionally well balanced. Some residents like to eat a very repetitive diet, and staff work hard to ensure individual residents concerned are provided with a well balanced diet. The kitchen was inspected to see if food is stored and prepared in a safe environment. The kitchens were clean, tidy, and organised however food being stored in the fridge was not being labelled with the date that it had been cooked or in respect of a packet of cold meat, when it had been first opened. This is recommended in food safety guidelines as best practice for high risk foods stored in fridges. Staff work hard to support residents to go out for coffee, as well as to nearby pubs, and other social venues thereby helping to ensure a varied and fulfilling life. Residents access a range of community activities such as the shops, or the pub or local day care services. One resident went out with day care staff during the inspection for a drive into the community. The Home has recently purchased a karaoke machine and it was reported by staff that several residents enjoy the use of the karaoke machine as a social activity. One resident was having an aromatherapy massage with the aromatherapist. The resident looked to be enjoying this experience, and the aromatherapist regularly visits residents to provide them with aromatherapy treatments. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 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 standard(s) 18,20 Residents are well supported by staff to meet their needs, and there is a safe system in place for the handling, administration, storage, and disposal of resident’s medication. EVIDENCE: The staff who were on duty responded to residents in a sensitive, patient manner when they were assisting residents. The inspector also observed residents rising during the morning at their preferred time. The procedures for the administration, storage and disposal of medication were reviewed with one of the registered nurses, to monitor the systems in place for the handling of medication. The medication administration charts of three residents were inspected in detail. There was a photograph of the resident kept with their record, to ensure medication is dispensed to the correct person. The medication administration charts were legible, up to date, and contained the signature of the dispensing registered nurse, demonstrating resident’s medication is administered safely, the reasons for any omissions had also been written on the charts. Up to date records were also kept of medication being received into the Home, and medication sent back to the pharmacy, showing there are safe systems in place to monitor how much medication is held. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 13 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 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 standard(s) 22,23 The manager has failed to demonstrate that the protection of vulnerable adults from abuse procedure is protecting residents from abuse or harm, nor is the complaints procedure for representatives of residents to complain being followed correctly by management. EVIDENCE: 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 15 A copy of the complaints procedure for residents’ representatives to make a complaint on their behalf is on display in the entrance hall, this is a wellfrequented part of the Home. The procedure includes contact details for the Trust and the area office of the Commission for Social Care Inspection, if someone is not happy with the outcome of a complaint investigated by the Home. The complaints record book was viewed to find out how staff respond to complaints. There had been one new complaint recorded since before the last inspection, the record did not include the details of how the complaint was to be dealt with, or any written correspondence from the home to the person making a complaint, to demonstrate what actions were to be taken to investigate the allegation. There are policies and procedures in place relating to the issue of protection of vulnerable adults from abuse. The Trust does provide training to ensure staff are up to date in their understanding of the principle of the protection of vulnerable adults from abuse. However the Home had failed to report the allegation that had been made in the form of a written complaint, to the South Gloucestershire adult protection co coordinator. This is written in the Protection of vulnerable adults from abuse guidance policy that care homes inform The Community Care Department when an allegation has been made that may put vulnerable adults at risk. The Commission for Social Care Inspection were also not informed of this allegation, which may have meant a resident was at risk of harm. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24-30 The Home is generally safe and satisfactorily maintained however, it is not satisfactorily clean. EVIDENCE: 121 Watleys End Road is close to local shops and residents can easily access local amenities. It is a ‘purpose built’ bungalow style property in a quiet residential area. The entrance of the building provides very easy access for wheelchair users and there is similar access to all areas. There are grab rails positioned along the corridors and manual handling lifting aids in bathrooms and toilets. The bathrooms are spacious in size to provide easy access and the baths are specially adapted to assist residents. The standard of the decoration and the quality of fixtures and fittings was satisfactory. Rooms had been furnished and decorated to reflect resident’s different interests. There were visual stimulation aids as well as relaxation aids such as wall lights and mobiles seen in many rooms to provide additional stimulation and relaxation for residents. Bedrooms were decorated in different colours and this helped to create an individual feel to rooms. The environment was clean, tidy and satisfactorily maintained in communal areas. However, a significant number of bedrooms were not satisfactorily clean as they required further dusting, and polishing. It was reported that the domestic staff member had been on leave and there had been no additional domestic staff cover provided in her absence. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 17 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36 Residents are generally supported by skilled and well-qualified staff, with an understanding of their roles and responsibilities, in the Home. EVIDENCE: The staff duty record for shifts in September 2005 was inspected to review the number of staff on duty to support residents to meet their needs. There were a minimum of seven staff on duty for a morning shift, consisting of six care staff and one registered nurse, and five staff on an afternoon shift consisting of one registered nurse and four care staff, At night there are three staff who work a waking night staff consisting of one registered nurse and three care staff. The number of staff on duty for each shift met the minimum staffing numbers required by the Health Authority staffing notice under previous care homes legislation. However, there has been a significant amount of short-term staff sickness over the last two months. The home is also short of three full time staff, and as such is using `bank’ staff and agency staff, and the Homes own regular staff are doing extra shifts when they are able. The shortage of staff must not lead to a lack of consistent care for residents. Staff demonstrated that they communicate with and support residents in a sensitive manner, and work together well as a team. It was also reported by staff that a team ‘away day’ had recently taken place giving the staff team an opportunity to discuss and share a range of work and practice related issues. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Health and safety practices are only partly maintaining the health and safety of residents, staff and visitors. EVIDENCE: The environment looked to be satisfactorily maintained, and a maintenance worker visited the Home during the inspection to carry out routine repair work to the kitchen windows. The fire logbook record showed that the range of required fire safety checks were not being carried out regularly. Specifically weekly fire tests were not being carried out regularly, and the fire logbook showed there were ‘gaps’ of time when the test had not been carried out for over two weeks. There are also regular health and safety checks carried out of the environment, helping to ensure that the building is satisfactorily maintained. There are a range of policies and procedures in place that support and guide staff in their care practices, health and safety matters, employment issues, and the general running of the Home. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x x Standard No 22 23 ENVIRONMENT Score 1 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 121 Watleys End Road Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 1 x D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 21 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. 1. 2. Standard 6 23 Regulation 15(2)(b) 37,13,6 Requirement Residents care plans must be regularly reviewed and updated. All incidents that take place in the Home that may affect the wellbeing or safety of a resident must be reported to the Commission for Social Care Inspection in accordance with the regulation. The fire alarms must be tested on a weekly basis, and an up to date record of these tests maintained. Residents assessed needs must be regulalry reviewed and updated. Bedrooms must be kept satisfactorily clean. Complaints made about the Home must be investigated within 28 days, and a record of the outcome of a complaint must be maintained. Timescale for action 15/10/05 27/09/05 3. 42 23(4)c(v) 27/09/05 4. 5. 6. 2 30 22 14(2) 23(2)(d) 22(3),(4) 15/10/05 27/09/05 27/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 22 No. 1. Refer to Standard 17 Good Practice Recommendations The date that high risk foods are stored in fridges should be recorded. 121 Watleys End Road D56 D05 S20258 121 Watleys End Road V247523 260905 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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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