Inspection on 02/12/05 for 17 Bowler Road

This inspection was carried out on 2nd December 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Bowler Road 02/05/06

17 Bowler Road 30/03/05

17 Bowler Road 11/10/04

17 Bowler Road 18/03/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 17 Bowler Road 17 Bowler Road Northway Tewkesbury Glos GL20 8RZ Lead Inspector Mr Simon Massey Unannounced Inspection 2nd December 2005 5:00 17 Bowler Road DS0000016326.V270740.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 17 Bowler Road DS0000016326.V270740.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. 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 17 Bowler Road Address 17 Bowler Road Northway Tewkesbury Glos GL20 8RZ 01684 297699 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) www.mencap.org.uk Royal Mencap Society To be appointed Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/05/05 Brief Description of the Service: 17, Bowler Rd is a detached modern property located on a housing development on the outskirts of Tewkesbury. The home provides care and support for three adults with learning disabilities. The home is owned and maintained by New Era Housing Association and is staffed and run by the Royal Mencap Society. 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 2 hours in the early evening on Friday 2nd December 2005. The inspector met with two the service users, whilst another declined the opportunity. There was one staff member on duty, who helped with the inspection. Records were examined which included care plans, daily recording, medication records and health safety documentation. One service user showed the inspector their bedroom and a brief inspection was undertaken of the communal areas of the home. An immediate requirement was issued by the inspector in relation to the management arrangements for the home. What the service does well: What has improved since the last inspection? What they could do better: 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 6 The home needs to ensure that the Commission is fully and formally informed of the management arrangements in place in the home. The home needs to employ and register a manager. 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. 17 Bowler Road DS0000016326.V270740.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 17 Bowler Road DS0000016326.V270740.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): These standards were not inspected during this visit. EVIDENCE: There have been no admissions to the home for several years. 17 Bowler Road DS0000016326.V270740.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): 6,7,8,9 & 10 Care plans and risk assessments need to be correctly dated and reviewed at the correct intervals to ensure the home continues to meet the assessed needs of service users. EVIDENCE: All three care plans were examined and whilst these are detailed and person centred, some of the shortfalls identified at previous inspections were still evident. Not all paperwork is dated and it was unclear on some plans whether, as a result of reviews, any information had changed or not. All care plans are now overdue reviews. A number of risk assessments remain incomplete and some are past the intended review dates. One service user had an Individual Personal Planning meeting in March 2005 and there were notes form this that included goals and information about activities undertaken. Service users are consulted on the running of everyday activities within the home and are encouraged to participate in tasks and activities as far as their abilities allow. All records were securely stored and there was evidence that staff record regularly in the daily notes any events that occur. 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 10 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 11 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 &14 The home supports service users to lead a lifestyle that is settled and appropriate to their needs. EVIDENCE: Service users are supported to undertake a range of activities and the people spoken to expressed satisfaction with the trips out they had done. There is an activity-monitoring file in the home but entries ceased in May 2005. This is a useful record and it is recommended that it be restarted. The records show a limited number of social activities but service users spoken to stated they enjoyed spending time in the home together during the evenings. Service users have equipment in their rooms to watch television, videos and listen to music, apart from one person who prefers to have limited facilities in their room. 17 Bowler Road DS0000016326.V270740.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): 19 & 20 The home meets the emotional and physical needs of service users but steps must be taken to ensure that medication is correctly administered and that staff are aware that all medication errors should be reported to the Commission. EVIDENCE: The records detail visits to Doctors, Chiropody, Dentists, and Opticians, with details being entered into the appropriate files. One person, who is a wheelchair user, has no record of any recent physiotherapy assessment being completed. A requirement has been made that the home supply the date of the most recent assessment and make arrangements for this to be updated. The medication administration and storage were examined and two gaps were found in the recording of medication. These gaps related to the administration of medication on 25th & 26th November 2005 and the home are required to supply an explanation for these omissions. All medication errors should be reported to the Commission under the requirements of Regulation 37(1)(e) 17 Bowler Road DS0000016326.V270740.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): EVIDENCE: These standard were not inspected during this visit. 17 Bowler Road DS0000016326.V270740.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 &30 The environment is well maintained and decorated throughout and provides a comfortable and homely environment for the service users. EVIDENCE: A new carpet has been fitted in the living room, which has improved this area of the home. Two of the bedrooms were seen and these were arranged and decorated according to personal taste. Service users spoken to expressed satisfaction with their accommodation. The home was clean and hygienic throughout. 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 15 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): 33 & 35 The induction process for new staff needs to be structured and organised to ensure that staff are able to meet the needs of the service users before they work unsupervised. EVIDENCE: The home is fully staffed at present and the rotas showed that the agreed staffing levels are being maintained. The staff member on duty confirmed that they have been completing the homes induction programme since commencing employment three months previously. They have however not received any formal supervision during this period nor have been allocated a mentor during this period of induction. Despite working in the home unsupervised they have also not completed first aid, moving and handling or formal medication training. The medication training was provided in the form of being shown the procedure by other staff members. The staff member was administering medication, this being required, as they were the only staff on duty. Staff working through their induction period should be provided with formal support and supervision during their induction period. The staff member demonstrated a good understanding of the needs of the service users and was observed communicating in an appropriate and positive manner. The home has on-call arrangements in place for staff on duty. The home has been having regular staffing meetings. 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 16 17 Bowler Road DS0000016326.V270740.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 & 42 The Registered Provider must ensure that the Commission is notified in accordance with the regulations about the management arrangements for the home. EVIDENCE: The inspector was informed that the acting manager had left the home three weeks previously and was now working at another home run by Mencap. A registered manager from another home in Tewksbury was apparently overseeing the home until a new manager, who has been recently appointed, starts work in Januaryy2006. The Commission has not been formally informed of these changes and an immediate requirement was made in respect of this. All fire safety checks and servicing have been completed, and records of other health and safety checks are being recorded. 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 18 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 2 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X 3 x CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 17 Bowler Road Score x 3 2 X Standard No 37 38 39 40 41 42 43 Score 1 X X X X 3 x DS0000016326.V270740.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA6 YA9 Regulation 15(2)(b) Requirement Timescale for action 31/01/06 31/01/06 3 4 YA41 YA35 5 YA20 6 YA37 7 YA18 The home must review all care plans at least every 6 months 12(1)(a) The home must ensure that risk &13(4)(b) assessments are dated and reviewed within the designated timescale 17(3)(a) The home must ensure that all documentation is correctly dated and signed 18(1)(c)(i) The home must ensure that new staff are appropriately supervised and mentored during their induction period 37(1)&(2)& The home must ensure that 13(2) medication is correctly administered and that all errors are reported to the Commission & supply details of the recent errors referred to in the report 38(1)(b) The registered provider must inform the Commission of the current management arrangements for the home until the newly appointed manager starts employment at the home (Immediate requirement issued at inspection) 13(1)(b) The home must ensure that the service user identified in the report has an up to date DS0000016326.V270740.R01.S.doc 31/12/05 31/01/06 31/12/05 09/12/05 31/03/05 17 Bowler Road Version 5.0 Page 20 physiotherapy assessment 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 YA14 Good Practice Recommendations The home should continue the use of its “activity recording book” 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 17 Bowler Road DS0000016326.V270740.R01.S.doc Version 5.0 Page 22 - 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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