Inspection on 22/09/05 for 164 Coleshill Road

This inspection was carried out on 22nd September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

164 Coleshill Road 17/04/07

164 Coleshill Road 12/01/06

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 Announced Inspection 22nd September 2005 09:30 164 Coleshill Road DS0000004312.V255119.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 164 Coleshill Road DS0000004312.V255119.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. 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 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.V255119.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 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.V255119.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on a weekday and was carried out from 9:30am until 16:30pm. The manager, assistant manager, residents and staff co-operated fully with the inspection. A total of 21 standards were inspected on this occasion of which none had shortfalls. Six of the residents were at home for all or part of the day and were spoken with informally. Staff on duty were also spoken with. In addition to this, records, files and policies and procedures were also inspected. The inspector would like to thank the manager, assistant manager, residents and staff 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.V255119.R01.S.doc Version 5.0 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.V255119.R01.S.doc Version 5.0 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): x EVIDENCE: No new residents have been admitted to the home since the last inspection, which took place on 10th February 2005, therefore standards 1 to 4 are deemed to be not applicable at this inspection. Standard 5 was not inspected on this occasion. 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 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): 6, 7 and 9 There is a clear, consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet resident’s needs. Residents are supported to take responsible risks based on effective risk management strategies that are agreed and recorded on the individuals care plan. EVIDENCE: Two residents plans were looked at during this inspection. These were detailed and informative and covered numerous areas of daily living such as personal care and support needs, personal development (daily living skills), leisure, religion and culture, and finance and budgeting amongst others. All care plan documentation was found to be dated and signed by the staff member who had compiled it and the resident (where able). Evidence that they are reviewed regularly was also in place. Residents spoken with said that they are involved in the compiling of their care plans. Two of the care plans in the files looked at were concerned with acknowledging civil rights and education and employment. 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 Page 9 The home places great importance on ensuring that the residents are able to make decisions about their lives, which is reflected within these particular areas. The assistant manager said that residents are actively encouraged to participate in their reviews to ensure that their views are listened to and their wishes acted on within the framework of assessed risk. Risk assessments were available within the plans looked at. These were also dated, signed and contained evidence of being reviewed regularly. 164 Coleshill Road DS0000004312.V255119.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 and 14 Residents have the 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. EVIDENCE: Evidence was available to confirm that residents are offered opportunities to participate in appropriate activities and leisure pursuits and are encouraged to make use of the local and wider community. On the day of the inspection five residents went out with staff as a group ten-pin bowling, and two went for a walk to a local shop to buy milk and a newspaper. Residents also said that they were going to call at a cinema to see what was showing, so they could decide what to go and see on another occasion. The assistant manager and staff said that all of the residents were going on a weekend break the next day to Centre Parks, which residents spoken with said they were looking forward to. Two residents did not go on the bowling trip. Staff were observed to offer activities such as massages and foot spa’s, looking through their photographic life stories, and watching DVD’s throughout the morning, as well as making use of the garden for short walks, sitting in the sun and playing with a ball. 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 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): 18, 19 and 20 Personal support is offered in such a way as to promote resident’s privacy, dignity and independence. Residents physical and mental healthcare needs are identified and met. Routine and specialist appointments are arranged as necessary. Residents are protected by the homes policies, procedures and recording of medication, therefore reducing the risk of harm. EVIDENCE: Information regarding personal care and support was fully detailed within residents support plans. Staff on duty were observed to be discreet when supporting residents with meeting these needs. Support is provided to residents to ensure that they are offered opportunities to attend routine healthcare appointments at the recommended intervals. Support to attend appointments with healthcare specialists such as Psychology and Psychiatry is also provided as necessary. Information was recorded within a healthcare summary within the support plans looked at, which detailed the health issue, any action taken and the outcome of the action. Medication is stored in a locked cabinet within the small office in the home. Boots supplies medication in a monitored dosage system. Medication administration record sheets accompany this system. Examination of the medication procedures undertaken within the home provided no cause for concern on this occasion. 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 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): x EVIDENCE: No standards in this section were inspected on this occasion. Standards 22 and 23 will be looked at, at the next inspection of this home later in the 2005/06 inspection year. 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 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): 24, 25, 28 and 30 The appearance of this home creates a comfortable and homely environment for the residents. The environment is appropriate for resident’s particular lifestyles and needs and accessible to community facilities and services. EVIDENCE: The home is a domestic 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 décor throughout the house was in good condition, and the fixtures, fittings, soft furnishings and furniture was of good quality. Since the previous inspection a new kitchen had been fitted. Residents have single bedroom accommodation appropriate to their needs, which are personalised to their taste. A large lounge and separate dining room are available for shared use, as well as the garden. On the day of the inspection the home was clean and tidy with a pleasant, relaxed atmosphere. 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 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): 32, 33, 34, 35 and 36 Residents benefit from a well-trained, and enthusiastic staff team who work towards common goals. The recruitment policy and procedure ensures that residents are supported and protected from harm by the people caring for them. EVIDENCE: Observations made during the inspection demonstrated that staff are competent and effective within their role. Support was provided discreetly to residents. Residents appeared comfortable and relaxed with staff members, and there was plenty of jovial banter and laughter. Staff files are stored at another home that is owned and managed by the provider, as there is little space within the Coleshill Road home for storage of anything other than resident related information. Four staff files were looked at on this occasion. All contained a current Criminal Records Bureau certificate. Three also contained satisfactory POVA First checks, as they were new members of staff. All other documentation required to ensure the protection of the residents was in place, thus confirming that the homes recruitment procedures are satisfactory and in line with current good practice. Staff training records confirmed that all new staff undertake the TOPPS induction upon commencing work. More specialised training in dementia care, the needs of the service user, the role of the care worker and death and dying is also provided for staff. 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 Page 15 Evidence was also available to confirm that residents are offered the opportunity to undertake training with the staff if they wish in areas such as food hygiene and customer relations. Supervision is carried out by the personnel manager. Staff have a three monthly formal appraisal, of which records were available, and signed by the staff member and the personnel manager. As well as this informal supervision is undertaken through observation by the manager and personnel manager, which is recorded in a book and discussed with the staff member. 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 41 and 42 The leadership, guidance and direction to staff by the management team ensure residents receive consistent quality care. The policies and procedures for safe working practices ensure that health, safety and welfare is promoted and protected. EVIDENCE: Observations made in the home during the inspection confirmed that it runs smoothly and consistently, successfully balancing the individual needs of the residents within a group living setting. Residents support plans and records are stored securely, however residents have access to them should they wish. The residents keep their photographic life histories in their bedrooms, so that they are readily available for them to look at when they choose. The health safety and welfare of both residents and staff is maintained as far as is practicable. Documentation to confirm that all routine checks such as portable electrical appliance testing and a landlords gas safety certificate were available. Fire alarm points are tested weekly on a rotational basis by a member of staff that has been designated as the person responsible for health and safety within the home. 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x 3 x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 164 Coleshill Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x 3 3 x DS0000004312.V255119.R01.S.doc Version 5.0 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 164 Coleshill Road DS0000004312.V255119.R01.S.doc Version 5.0 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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