Inspection on 12/01/06 for 164 Coleshill Road

This inspection was carried out on 12th January 2006.

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

164 Coleshill Road 17/04/07

164 Coleshill Road 22/09/05

164 Coleshill Road 10/02/05

164 Coleshill Road 23/09/04

164 Coleshill Road 08/03/04

164 Coleshill Road 25/06/02

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

CARE HOME ADULTS 18-65 164 Coleshill Road 164 Coleshill Road Atherstone Warwickshire CV9 2AF Lead Inspector Justine Poulton Unannounced Inspection 12th January 2006 09:45 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 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 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 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. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 164 Coleshill Road Address 164 Coleshill Road Atherstone Warwickshire CV9 2AF 01827 718528 01827 718528 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) Mrs Anne Fretwell Mrs Anne Fretwell Care Home 7 Category(ies) of Dementia (7) registration, with number of places 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd September 2005 Brief Description of the Service: The home is in a residential area, a short walk away from Atherstone town centre. There is a bus stop just outside the home. In Atherstone there are facilities such as post office, banks, shops, cafes, pubs etc. There is also a small post office a very short distance from the home. There is on-street parking, and a car park for a few cars to the rear of the home. The home is a family house, which has been adapted to provide residential care for seven people. On the ground floor are a dining room, a lounge, and a conservatory, which overlooks the back garden. The kitchen, two bathrooms, and two single bedrooms are also on the ground floor. There is a stair lift to the first floor, where there are a further five bedrooms, and a small office. The rear garden is enclosed, and has been specially designed for the needs of people with dementia. The home is registered for seven adults under 65 with dementia. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday and was carried out from 9:45am until 12:00pm. Residents, staff and assistant manager cooperated fully with the inspection. A total of 6 standards were inspected on this occasion of which none had shortfalls. The majority of residents were at home for al or part of the inspection and were spoken with informally. Staff on duty were also spoken with informally. In addition to this records, files, policies and procedures were also inspected. It was advised during the inspection by the assistant manager that the home is beginning to pursue the idea of developing the service along the lines of a more rehabilitative service for younger adults with dementia, catering for conditions such as Korsakoffs Dementia. This is in the very early stages of planning however. The inspector would like to thank the residents, staff and assistant manager for their co-operation and hospitality during the inspection. What the service does well: What has improved since the last inspection? What they could do better: 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. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 6 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 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 7 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): 2 Pre admission documentation ensures that the home is able to meet prospective residents needs prior to them moving in. EVIDENCE: One resident has been referred to the home since the last inspection. Examination of the pre admission paperwork available confirmed that a completed social work assessment was available along with a ‘Working Age Dementia Service Specialist Assessment’ which had been completed by a Community Mental Health Nurse. A referral letter from the residents’ consultant had also been received. Alongside this information the homes own assessment documentation, personal profile documentation and rehabilitation plan have been completed for the resident. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 8 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): x EVIDENCE: Key standards 6, 7 and 9 were inspected at the last inspection of the home on 22 September 2005, when they were deemed to be met. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 9 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): 15, 16 and 17 People living in this home have opportunity to live ordinary and meaningful lives appropriate to their needs. They are supported and enabled to be part of the local community in which they live. A varied selection of food is available that meets residents dietary needs. EVIDENCE: Key standards 12 and 13 were inspected at the last inspection of the home on 22 September 2005, when they were deemed to be met. Standard 14 was also inspected at this time and was met. The home focuses on providing individualised support to residents, based on their identified needs. This includes ensuring that families and friends are as involved as they wish to be in line with the residents wishes. Evidence was available to demonstrate that five of the six residents have some level of family involvement either through visiting, being visited or telephone contact. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 10 The service is relatively small and domestic in nature. The staff team strive to ensure that it is completely user led. As such there are no set rules or routines in place other than those that form part of each residents support plan. This was clearly observed during the time spent in the home. Although the home is small, a cook is employed on a part time basis. It was stated during the inspection that the focus of support is being shifted towards supporting the residents in a more rehabilitative manner. As such they are beginning to get involved in planning and preparing their own meals. In order to ensure that this is managed safely it was stated that all of the residents are to attend a food hygiene course in the near future. It was observed during the inspection that each resident was offered a three course lunch, consisting of two choices per course. Where an alternative was requested this was also catered for. This information is then recorded. The home has a communal dining room for residents to eat in, however residents spoken with said that they can choose to eat elsewhere if they wish. The kitchen is small and domestic in nature, and on the day of the inspection was very well stocked with a variety of different foods, snacks, fruit and drinks that the residents are free to help themselves to. All of the necessary health and safety procedures such as fridge and freezer temperature recording, and the recording of core food temperatures, as applicable to food hygiene and safety were in place and undertaken as appropriate. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 11 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): x EVIDENCE: Key standards 18, 19 and 20 were inspected at the last inspection of the home on 22 September 2005, when they were deemed to be met. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23 The home has a satisfactory complaints system in place. There are policies and procedures in place for the protection of service users from harm. EVIDENCE: The home has a concerns and complaints policy in place, which was reviewed in June 2005. Residents spoken with said that they were comfortable with making complaints should they need to. Examination of the complaints log confirmed that there have been no complaints made since the last inspection. A comprehensive policy on Adult Protection and Prevention of Abuse is available in the home. The manager said that it is reviewed on a regular basis, with the last review being recorded for June 2005. The policy covers a number of stages that are to be undertaken should an allegation of abuse be made or received. Also included are the organisations policy on staff training and recruitment procedures in relation to protecting vulnerable adults. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 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 the following standard(s): x EVIDENCE: Key standards 24 and 30 were inspected at the last inspection of the home on 22 September 2005, when they were deemed to be met. Standards 25 and 28 were also inspected at this time and were met. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 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 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): x EVIDENCE: Key standards 32, 34 and 35 were inspected at the last inspection of the home on 22 September 2005, when they were deemed to be met. Standards 33 and 36 were also inspected at this time and were met. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 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 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): x EVIDENCE: Key standards 37 and 42 were inspected at the last inspection of the home on 22 September 2005, when they were deemed to be met. Standard 41 was also inspected at this time and was met. 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x x x x x x x x 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 17 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 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 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. Refer to Standard Good Practice Recommendations 164 Coleshill Road DS0000004312.V278091.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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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