Inspection on 02/11/05 for 138 to 138a Mason Way

This inspection was carried out on 2nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

138 to 138a Mason Way 28/06/07

138 to 138a Mason Way 12/06/06

138 to 138a Mason Way 03/05/05

138 to 138a Mason Way 09/02/05

138 to 138a Mason Way 24/09/04

138 to 138a Mason Way 11/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 138/138a Mason Way Waltham Abbey Essex EN9 3EJ Lead Inspector Jane Greaves Unannounced Inspection 2nd November 2005 1245 138/138a Mason Way DS0000017721.V262554.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 138/138a Mason Way DS0000017721.V262554.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. 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 138/138a Mason Way Address Waltham Abbey Essex EN9 3EJ 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) 01992 769113 01992 769113 Redbridge Community Housing Limited [RCHL] Mrs Tina Tait Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: 138/138a Mason Way is a residential care home for people with learning disabilities located in a residential area of Waltham Abbey. There are eight tenants living in this home. The primary aim for this home is to support the tenants to lead independent lives. The accomodation comprises two semi detached houses that provide 4 single bedrooms and communal space in each house. The tenants of the two houses share a rear garden. There is a local bus service to the nearby town of Waltham Abbey and a parade of neighbourhood shops is available close by. 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place one day in November 2005. 19 of the 43 National Minimum Standards were assessed at this inspection with 11 being met. Views were gathered from 2 of the people living at the home, the registered manager and the deputy manager. For the purpose of this inspection the people living at 138 Mason Way prefer to be referred to as ‘tenants’. The registered manager for this service is a Mrs Tina Tait however for the past fifteen months Mrs Tait had been seconded to another position within the Organisation and taken a further 6-month sabbatical. The service had been managed in the interim by an acting Manager who had made an application to the Commission for Social Care Inspection to be registered as manager for the service. On arrival at the home the inspector was informed that the acting manager was no longer in post. Mrs. Tina Tait was present at the home on the day of the inspection but was leaving the Organisation within days. Overall the care and support offered to the tenants at Mason Way was good and tenants confirmed they were happy to be living there. The inspector appreciated the assistance and co-operation received with the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Tenants would benefit from the décor and cleanliness of the home being improved. Some communal areas were dirty, carpeting in the hallway of 138a was stained and marked, there was a smell of cat in the hallway, thick dust on radiators, lampshades were missing, tatty and torn net curtains at the windows and a sofa in need of cleaning. 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 Page 6 A suitably qualified and trained staff team would better protect tenants’ health and safety. There were a number of gaps in the mandatory training provided for staff members, refresher courses had not been attended. Tenants’ health, safety and welfare would be better protected if the home’s medicine procedures were in line with the medication policy. 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. 138/138a Mason Way DS0000017721.V262554.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 138/138a Mason Way DS0000017721.V262554.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): 3 and 4 Prospective tenants could be confident that the home would meet their needs and aspirations and were encouraged to visit and to ‘test drive’ the home before making the decision to move in permanently. EVIDENCE: When a prospective tenant was considering making 138 Mason Way their permanent home an initial assessment of the their identified needs was sent to the home by the relevant placing authority. From this basic assessment the manager, once assured the tenant’s needs could be met by the service, would invite the prospective tenant for a series of visits to the home. The first visit to the home would be just a couple of hours; subsequent visits increasing to a trial weekend. The established tenants at 138 Mason Way were involved in the admission processes and no tenant would be admitted into the home without the agreement of all tenants. 138/138a Mason Way DS0000017721.V262554.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): 7 and 9 Tenants were encouraged to make decisions about their lives with support if needed and to take risks as part of an independent lifestyle. EVIDENCE: The staff team provided tenants with the information, assistance and communication support they needed to make decisions about their own lives. Redbridge Community Housing Limited provided a budget for each individual home to be able to access advocacy services for tenants as required. An independent advocacy service had been secured for one tenant since the previous inspection. The staff team enabled tenants to take responsible risks ensuring they had good information on which to base their decisions. These were detailed in the tenants’ individual care plans and infringement of rights notices were present. 138/138a Mason Way DS0000017721.V262554.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): 12,13,14 and 16 Tenants were supported to take part in age, peer and culturally appropriate activities both within the home and as part of the local community. Tenants were supported to engage in appropriate leisure activities. Tenants’ rights were respected and responsibilities recognised in their daily lives. EVIDENCE: Varied jobs were undertaken by the tenants at Mason Way from working in a pub and garden centre to a charity shop. Most tenants at the home attended college. The registered manager reported that tenants were regularly consulted at their reviews regarding work outside the home. The tenants that worked did so in the local community. Some tenants participated in religious observance at the local community church and were often accompanied there by community members. The community local to the home holds an annual ‘Cavalcade of Light’ in which the tenants participate; it was reported that last year the tenants won. 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 Page 11 There was good access to local transport; staff cars were used on occasion depending on the activity/weather. Tenants were supported and encouraged to exercise their political votes. The registered manager reported that tenants were asked if they wished to have a postal vote or attend the voting station in person. The reasons for voting were explained to the tenants and they were reminded on the day. Redbridge Community Housing Limited had agreed to contribute £125 towards the cost of an annual break away from the home for each tenant. Subsequent to the inspection site visit the inspector was furnished with a list of holidays taken by the tenants at Mason Way this year. This provided evidence that 5 of the 8 tenants at mason Way had received the agreed contribution from RCHL for their annual break. Instances where the holiday had been arranged prior to the RCHL agreement to financially contribute or where the tenant incurred no direct cost because they holidayed with family were not contributed to by RCHL. The daily routines of the houses promoted independence and individual choice. All tenants had keys to their personal rooms, a lockable space within their rooms and the front door of their house. A mini-safe had been provided for each individual tenant. Staff and management were observed to interact with the tenants in an appropriate manner. All tenants living at 138 Mason Way had responsibilities for housekeeping tasks. 138/138a Mason Way DS0000017721.V262554.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): 18 and 20 Tenants received personal support in the way they preferred and required. Tenants were not protected by the home’s medications procedures. EVIDENCE: Personal support was provided for tenants in private as observed during the course of this inspection. Staff members enabled and encouraged tenants to choose their own clothes, hairstyles and make-up. Each tenant had key workers; these were selected by the process of observing dynamics between tenants and staff members and with input from the tenants. Specialist support and advice was secured as required, an occupational therapist had attended the home recently to risk assess for one tenant. The Medication Administration Records contained a number of ‘gaps’ where it was not possible to ascertain whether the tenant had taken their medication or refused it. This issue had been mentioned at the previous inspection. There was confusion on the day of the inspection regarding some tenants’ medicines being returned to the Pharmacy, appropriate recording procedures had not been followed. A training course had been arranged via an external provider for later this month in the Safer Handling and Administration of Medicines. 138/138a Mason Way DS0000017721.V262554.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): 22 and 23 Tenants could be confident their views were listened to and acted upon. Tenants were not adequately protected from abuse and harm. EVIDENCE: There had been no complaints received at the home or by the Commission for Social Care Inspection since the previous inspection visit. Redbridge Community Housing Limited had a robust complaints policy and procedure in place throughout the organisation. All policies and procedures received an annual review. Redbridge Community Housing Limited had identified the need for Protection of Vulnerable Adults from abuse training for support staff members. An internal facilitator had been secured and the training courses were due to be rolled out in the near future. At the point of this inspection not all staff members had received up to date training in Protection of Vulnerable Adults from abuse however the subject was ‘visited’ in the Learning Disability Award Framework training provided for by all staff on commencement of their duties at the home. 138/138a Mason Way DS0000017721.V262554.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): 24,27 and 30 The accommodation provided for the tenants did not meet acceptable standards of cleanliness. EVIDENCE: Previous inspections had raised requirements for replacement carpeting and bathroom flooring in both houses. Carpeting had been replaced in most of the communal areas of both houses however the flooring in the hallway of 138a remained marked and stained giving off an unpleasant odour. The upstairs bathroom in 138a smelt very musty and damp as highlighted at previous inspections. Flooring had been replaced in some bathing facilities. At the previous inspection the inspector was informed that paint patches on the kitchen wall in 138 was evidence that the tenants were choosing colours prior to decoration taking place. The paint patches were still present at this inspection. The kitchen walls were shabby with grease on the walls, cupboard doors were flaking, shelving in cupboards was damaged, the oven was extremely soiled and the kettle contained heavy deposits of lime scale. 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 Page 15 Both houses had torn and tired net curtains at the windows, dust was thick on the radiators in the hallway of 138a and there were no lampshades for the ceiling lights in the hall. The sofa in the lounge of 138 was domestic in character and appeared comfortable but needed cleaning. The inspector was not invited to view the personal rooms of tenants at this inspection. Two tenants consulted were happy with their personal space and confirmed they could personalise their rooms as they wished. One tenant reported to the inspector that they were all involved in the household chores with the help and support of the staff team. The home offered good access to the local community with a doctor’s surgery and shops close by. 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 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 and 35 Tenants’ individual and joint needs were met by a staff team that had not received all training appropriate to the work they performed. EVIDENCE: Only one staff member at Mason way had achieved NVQ2 in care. It was reported that Redbridge Community Housing Limited were not currently supporting the NVQ 2 training programme. 3 staff members had undertaken Learning Disability Framework Award induction foundation training. The remaining established staff team members were scheduled to undertake this training imminently. The registered manager had been overhauling the training and development plans of the service at the point of this inspection. The training and development files contained good information; the matrix identifying staff training needs showed many areas of mandatory training where staff had not attended courses or annual refresher courses had not been attended. 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 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): 37 and 39 Tenants would benefit if the home had a registered manager in post. Tenants could be confident that their views underpinned all self-monitoring reviews of the home. EVIDENCE: The service had not had a registered manager in post at the home for almost 2 years. The acting manager had applied to the Commission for Social Care Inspection to become a registered manager for this service but had left this post during the registration process. The home operated under the organisations corporate quality assurance policies and procedures. There was an annual internal audit taken of each service. Monthly ‘person in control’ visits took place and a resulting regulation 26 report was sent to the Commission for Social Care Inspection. Tenants, their families/representatives and other stakeholders were surveyed as part of this quality assurance process. 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 Page 18 The tenants had been actively supported to be individuals. It was observed at this inspection how independent and comfortable the tenants were being able to state opinions and feelings regarding their lives and the care provided at Mason Way. 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 3 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X 2 X X 1 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 138/138a Mason Way Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X X X DS0000017721.V262554.R01.S.doc Version 5.0 Page 20 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 YA20 Regulation 13(2) Timescale for action The registered person shall make 02/11/05 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. This is a repeat requirement with an original agreed timescale of 03/05/05 The registered person shall make 31/12/05 arrangements by training staff or by other measures to prevent service users from being harmed, suffering abuse or being placed at risk of harm or abuse. The registered person shall, 31/12/05 having regards to the numbers and needs of service users, ensure that all parts of the care home are kept clean and reasonably decorated. This specifically relates to carpets, lampshades and curtains. The registered person shall, 31/12/05 having regards to the numbers and needs of service users keep the care home free from offensive odours. The registered person shall, 31/12/05 DS0000017721.V262554.R01.S.doc Version 5.0 Page 21 Requirement 2 YA23 13(6) 3 YA24 23(2)(d) 4 YA27 16(2)(k) 5 YA30 23(2)(d) 138/138a Mason Way 6 YA32 18(1)(b) 7 YA35 18(1)(c) 8 YA37 8 9 YA43 39 having regards to the numbers and needs of service users, ensure that all parts of the care home are kept clean and reasonably decorated. This specifically refers to the kitchen facilities. The registered person shall having regard to the size of the care home, the statement of purpose and the numbers and needs of the service users ensure that suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The registered person shall, having regard to the size of the care home, the statement of purpose and numbers and needs of service users ensure that persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. The registered provider shall appoint an individual to manage the care home where there is no manager in respect of the care home and the registered provider is an organisation or partnership. The registered person shall give notice to the Commission for Social Care Inspection as soon as it is practicable to do so if a person ceases to carry on or manager the care home. 31/03/06 31/03/06 31/12/05 02/11/05 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 Page 22 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 Standard Good Practice Recommendations 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. Extracts may not be used or reproduced without the express permission of CSCI 138/138a Mason Way DS0000017721.V262554.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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