Inspection on 03/05/05 for 138 to 138a Mason Way

This inspection was carried out on 3rd May 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 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 5 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 02/11/05

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 03 May 2005 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service 138/138a Mason Way Address Waltham Abbey, Essex 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) 01992 769113 01992 769113 Redbridge Community Housing Limited Mrs Tina Tait Care Home 8 Category(ies) of LD Learning Disabilities registration, with number of places 138/138a Mason Way Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: No conditions of registration apply. Date of last inspection 9th February 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place on 3rd May 2005. Views were gathered from 7 people living at the home, the acting manager and deputy manager. 16 of the 43 National Minimum Standards were assessed with 10 being met. For the purpose of this report the individuals spoken with on the day stated that they prefer to be referred to as tenants. Overall the care and support afforded to tenants at 138 Mason Way is good and all tenants spoken with confirmed that they are very happy to be living there. What the service does well: What has improved since the last inspection? What they could do better: The approach to the home was marred by the fact that the front garden was overgrown with long grass and there were black garbage bags. The acting manager explained that there were problems with a contract gardener and a refuse collection was due on the day of the inspection. Issues with regard to bathroom and communal area floor coverings as identified at the previous Commission for Social Care inspection had not yet been addressed resulting in musty aromas and potential hygiene problems with the bathrooms and a general feeling of shabbiness in the communal living areas. New flooring had been selected and assurance was given that this would be in place as soon as practicable. 138/138a Mason Way Version 1.10 Page 6 Tenant’s medication records examined on the day of the inspection were generally good but some gaps in recording on the Medicine Administration Record sheet required an explanation. The acting manager needs to update and maintain the staff training matrix in order that it reflects the true position of the support worker training undertaken at 138 Mason Way. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 138/138a Mason Way Version 1.10 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 138/138a Mason Way Version 1.10 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) 1, 2 and 5 The home had appropriate admission assessment procedures and practices in place. These focussed on the needs of the tenants ensuring that prospective tenants were sure that their needs would be met. EVIDENCE: A file was sampled for the most recent tenant at 138, mason Way: Despite the fact that the tenant was referred by Social Services there was no assessment of needs provided before admission to the home. However, the home had completed the RCHL comprehensive assessment in order to develop a tailored plan of care to be delivered for the individual tenant. The assessment was made with input from the tenant, relevant family members and appropriate healthcare professionals. Risk assessments were present on all files sampled and corresponding reviews were documented incorporating any resulting changes to the individuals’ plan of care. Historically RCHL had not provided tenants with a seven day holiday outside the home as part of the basic contract price. This issue had been addressed by the organisation and the acting manager stated tenants would benefit from funding towards an annual 7 day break of their choice this summer. The tenants’ contracts had not been amended to reflect this situation at the time of inspection. 138/138a Mason Way Version 1.10 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 6 The health care needs of the tenants living at 138, Mason Way were identified, planned for and monitored in a way which ensured their continued physical well being. EVIDENCE: Two tenants’ personal files were scrutinised at this inspection and both contained clear detail and instruction for the delivery of personalised care developed from the admission assessment. The plans of care were under constant review and amendment enabling the support staff to ensure that the tenants’ individual and complex needs were fully met. The home operates a key worker system and the tenants spoke fondly of the commitment of the staff team. Conversations with tenants and information found on their personal files confirmed that personal goals and aspirations are recognised, encouraged and supported. 138/138a Mason Way Version 1.10 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) 15 and 17 Tenants at 138, Mason Way were provided with support to enjoy appropriate personal, family and sexual relationships. Tenant’s nutritional needs were assessed and monitored in a sensitive and appropriate manner ensuring that their health is maintained whilst enjoying a varied diet. EVIDENCE: Tenants spoke happily of time spent visiting with family members away from the home, regular church attendance, having guests for dinner at the home, and friends made at work or college. Two tenants residing at the home have developed a close personal relationship and receive support and counselling from support staff whilst the situation is monitored appropriately and sensitively. The four tenants in each house take turns to devise menus, shop for provisions and to cook for their 3 housemates for a week. Freezers and cupboard contents indicated that tenants had access to a good standard and quality of 138/138a Mason Way Version 1.10 Page 11 food. All tenants spoken with were very pleased with the food they had and one house was looking forward to a Pizza for evening meal. 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) 19 and 20 The physical and emotional health needs of the Tenants are met appropriately. Tenants are supported to self-administer medication safely where they are able. EVIDENCE: Records scrutinised at this inspection confirmed the positive remarks made by tenants at 138, mason Way with regard to the way they feel their emotional and physical health needs are met. During conversations with the acting manager and deputy manager it was evident that there is a deep understanding of each individual tenants’ condition and the relevant management strategies involved. Three tenants are supported to administer their own medication from a weekly cassette system; appropriate risk assessments had been taken. Other tenants are enabled to administer creams and ointments where appropriate with all documentation confirming this action. 138/138a Mason Way Version 1.10 Page 12 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 and 23 Tenants felt that they had a voice and were listened to. The management and staff team are committed to training and stringent recruitment practices, which ensure the tenants, are protected from abuse and harm. EVIDENCE: The home had RCHL complaints policies and procedures in place, a copy of which was included in the service user guide and each tenant had been given a copy. There were no documented complaints since December 2003. It was observed on the day of the inspection that all tenants were very comfortable with entering the manager’s office and discussing any issue with the acting manager or the deputy manager. The only complaints voiced by tenants were in regard to normal day-to-day family style tensions arising between fellow housemates. One tenant required support to deal with an external concern but at the time of the inspection that support had not been given. The acting manager demonstrated good knowledge of the Protection of Vulnerable Adults policies and procedures to be followed should an allegation or suspicion of abuse occur. All support staff members have undertaken training in the Protection of Adults from Abuse but the home has not yet scheduled refresher courses. All staff undertake an enhanced criminal Records Bureau Disclosure and do not commence employment until a satisfactory response has been received. 138/138a Mason Way Version 1.10 Page 13 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) 24,27and 30 There is a safe and homely environment but this would benefit from some refurbishment. There were sufficient bathing and showering facilities but new flooring was required. Overall the home presented clean and hygienic. EVIDENCE: There are requirements outstanding from the previous inspection relating to replacement of carpeting in communal areas, bathroom flooring in 138 and shower room flooring in 138. The acting manager has obtained some quotes but this work has not yet taken place. On the day of the inspection a carpet contractor visited the home to progress further with this issue. Tenants are actively involved in selecting new furnishings and choosing paint colours for the communal areas of the houses. Various ‘paint patches’ on some communal walls confirmed this. Tenants’ rooms were personalised and individual in nature. Each room was fitted with a lock and contained a lockable cabinet for storing personal and valuable items. Overall the home appeared to be clean and hygienic. 138/138a Mason Way Version 1.10 Page 14 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 standards 32,33 and 34 Tenants are supported by a committed staff team and protected by RCHL recruitment policies and procedures to ensure their safety and well-being. EVIDENCE: The home had a training matrix to identify training requirements within the staff team however this had not been maintained and updated. The acting manager stated that relevant training had taken place and was advised to have records of this available for scrutiny at future inspections. Staffing hours are adequate for the tenants’ assessed needs. The home abides by RCHL recruitment policies and procedures and new members of support staff do not start working at the home until two satisfactory references and an enhanced Criminal Records Bureau disclosure have been received. Tenants are actively involved in the home’s recruitment procedure and play a large part in the decision making process. New staff members undertake the RCHL induction procedure; this includes training in the Protection of Vulnerable Adults. During the induction process new staff ‘shadow’ experienced support staff and are under constant supervision. The home does not employ any support staff below the age of 21. 138/138a Mason Way Version 1.10 Page 15 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) None of these standards were assessed at this inspection. EVIDENCE: Whilst these standards were not specifically assessed the tenants spoke of their comfort with the staff and management of the unit. They stated that if they had any worries there was always someone to listen to them. It was observed throughout the inspection that management time was under pressure. This did not appear detrimental to the immediate needs of the tenants however, the home must be aware that staffing levels need to be kept under review in the light of tenants’ changing physical, social and emotional needs together with the administration tasks of the home. 138/138a Mason Way Version 1.10 Page 16 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 x x 2 Standard No 11 12 13 14 15 16 17 x x x x 3 x 3 Standard No 31 32 33 34 35 36 Score x 2 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x 138/138a Mason Way Version 1.10 Page 17 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 Reg 13 Requirement Timescale for action With immediate effect 2 YA24 Reg 23 3 YA27 Reg 16 (2) 4 YA30 Reg 16 (2) (k) 5 YA32 Reg 18 (i) The registered person must ensure that all staff comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. The registered person must ensure that carpets in communal areas are replaced. This is a repeat requirement exceeding the original timeframe of 30th April 2005. The registered person must ensure that flooring for the Bathroom and the Shower room in 138 is replaced. This is a repeat requirement exceeding the original timeframe of 30th April 2005. The registered person must take steps to ensure the home is kept clear from offensive odours and the tenants are kept safe from the spread of infection. (c) The registered must ensure that staff receive training appropriate to the work they are to perform and that a record of training must be made available to the Commission for Social Care Inspection for scrutiny. Version 1.10 30th July 2005 30th July 2005 30th July 2005 30th July 2005 138/138a Mason Way Page 18 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 YA5 Good Practice Recommendations The home should ensure that the tenants’ contracts are updated to include the funded 7 day annual holiday outside the home. 138/138a Mason Way Version 1.10 Page 19 Commission for Social Care Inspection Fairfax House Causton Road Colchester Essex C01 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 Version 1.10 Page 20 - 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. 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