Inspection on 02/05/06 for 17 Bowler Road

This inspection was carried out on 2nd May 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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Bowler Road 02/12/05

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 Key Unannounced Inspection 5th May 2006 10:00 17 Bowler Road DS0000016326.V291550.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 17 Bowler Road DS0000016326.V291550.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. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 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.V291550.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd December 2005 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.V291550.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 5th May 2006 over 5 hours. The inspector met with the acting manager, 1 member of the care staff and 1 service user. Records relating to staff training and recruitment, care planning and daily recording, medication, health and safety were examined. An inspection of the environment was also undertaken. This inspection looked at the designated core national minimum standards. What the service does well: What has improved since the last inspection? What they could do better: The home needs to have a period of staffing stability and consistency. The home needs to replace and repair the kitchen units. The home needs to register its new manager. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 6 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.V291550.R01.S.doc Version 5.1 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.V291550.R01.S.doc Version 5.1 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): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a Statement of Purpose that meets the required standard. The home has an admissions policy that complies with the regulations. EVIDENCE: The acting manager has updated the Statement of Purpose and Service User’s guide to ensure they include current and accurate information. Copies of these must be supplied to the Commission. The home has had no admissions for several years but there is an admissions procedure in place that meets the standard. This is a national policy and procedure provided by the organisation. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has care plans in place that reflect the assessed needs of the service users. The staff are committed to supporting and involving service users to be fully involved in planning their care and making decisions about their lives. EVIDENCE: All service users have detailed care plans in place that are being regularly reviewed. The home has taken steps to make the plans more person centred with service users fully involved in developing and preparing plans. The personal files also contain a record of the review meeting that has taken place. The inspector considered that the goals identified could in some cases have more definite timescales and more specific information about how targets or goals would be achieved. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 10 There have been several changes in the management of the home over the past 18 months and the acting manager has taken steps to improve the personal files and general record keeping. All the files contained updated information on families and friends contact arrangements. Risk assessments were up to date with review dates in place. Records from service user meetings also show how people are consulted about all decision relating to their care and future plans. All records seen were up to date and showed that the staff team operate a good system of recording that is up to date and accurate. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 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): 12,13,15,16&17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home supports people to lead individual lifestyles with a range of activities that are appropriate to service user needs, and driven by individual choice. Changes to the staffing rota have improved the opportunities for individual and group activities. EVIDENCE: The staffing rota within the home has been reorganised with the intention of providing more opportunities for individual activities and also for general activities in the evenings and at weekends. The records show that a greater number of different trips and activities have been taking place since the previous inspection. This has included a holiday to Dublin, outings to pubs, trips to local organised events and visits to relatives. On the day of the inspection one person left to attend a local food and drink festival. Individual files contain weekly activity timetables for each service user. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 12 The home has had two service user meetings in the past four months. These meetings are minuted and there was evidence that action had been taken forward by the various key-workers. The staff supports the service users to maintain family contacts, both through visits and telephone calls. These contacts are recorded in the personal files. Service users are encouraged to make decisions about their daily routines and can choose to spend time alone or in the communal areas of the home. Individual files contain details about contact arrangements with families. The kitchen was well stocked with fresh produce and the menu’s reflected personal tastes with an effort to provide a balanced and healthy diet. One service user was observed during the inspection being supported by a staff member on their key-working day. They appeared relaxed and were being encouraged to undertake activities and follow an established routine, as has been identified in the care plan. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 13 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, & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service user’s personal care and health needs are met through support from staff and outside professionals. Changing needs are assessed to ensure that appropriate action can be taken. EVIDENCE: The personal care required is detailed in the individual care plans and recent reassessments have taken place relating to physio and moving and handling. One service user has an on-suite bathroom that is designed to meet their individual needs. They are also getting a new wheelchair. The records show that service users have had regular health check ups and are supported to attend appointments. All medication was correctly stored and the records examined were accurate and up to date. A recent incident of medication error was dealt with appropriately by the home. A requirement has been made that one person’s medication, relating to a regular invasive procedure, is reviewed and the outcome recorded. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 14 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&23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are able to complain or express their dissatisfaction with the care and support they are provided with. Staff training helps to ensure that service users are protected from abuse. EVIDENCE: Service users are asked for their views on their care and support in the service user meetings and their responses recorded. There was evidence of service users expressing their opinions and this being respected by the staff. The home has posters in place advising people how they can complain about anything they are not happy about and there is also the organisation’s “postcard” scheme in place, which enables service users to send a pre-paid card to the organisation’s area office. These cards are coded so that the organisation can determine the source of the concern. At this and previous inspections service users were observed as being comfortable and relaxed in their home and able to interact positively with the staff on duty. Restraint is not used within the home and staff undertake some basic training on protection and abuse issues during their induction and foundation training that is provided by the organisation. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 15 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, 26, 27, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home provides a comfortable and homely setting that is well maintained and meets the needs of the service users. Improvements to the kitchen and stair way will further improve the environment for the service users. EVIDENCE: The home is generally maintained to a good standard and is bright and homely. The kitchen is in need of repair or replacement and the manager stated that this has been requested and agreed to. This will be done during the coming financial year and is included as requirement in the report. The stair carpet is badly stained and needs to be cleaned or replaced. All the bedrooms were well decorated, personalised and reflected the needs and interests of the individual service users. The garden has been worked on to improve the access for the service users and also to improve the appearance. This is now an attractive and comfortable area for the service users to use. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 16 The home was clean and hygienic throughout. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 17 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): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service user needs are met by an organised and motivated staff team. Staff training and supervision help provide staff with the required skills to support the service users. EVIDENCE: The home is now fully staffed apart from 1 vacancy for 15 hours per week. All staff undertake induction and foundation training which leads onto NVQ training. All staff are undertaking some form of training. The induction training has been altered to provide new staff with a mentor. All staff are up-to-date with the required statutory training. The manager is developing a matrix system for the monitoring and recording of staff training. The staff team, in conjunction with the manager, have been involved in reorganising the rota to help provide more flexible cover to meet the social needs of the service users. The home has regular staff meetings and records were seen of the minutes. Staff records show the correct procedures have been followed during recruitment and the correct information is contained on the files. One recent staff appointed was interviewed solely by the acting manager and the inspector 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 18 is of the view that this would be better practice for them to be supported through this process by another experienced staff member. Staff interviewed were positive about the care provided and the impact of having a permanent manager in post. Staff commented about the extra amount of individual attention service users can receive with the new rota, particularly in the evenings and at weekends. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 19 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): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Having a permanent manager is providing the home with more direction and ensuring that the administrative processes are effective. The home has some quality assurance systems in place but these could be expanded and improved. Effective health and safety monitoring helps to provide a safe environment. EVIDENCE: A new manager has been appointed since the previous inspection and is currently going through the registration process. They are qualified to NVQ 4 in Care and are now undertaking the Registered Managers Award. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 20 Since being appointed they have ensured that there have been regular staff meetings and also regular service user meetings. The rota has been reorganised to provide greater flexibility over staffing cover. Other action has been taken in relation to staff induction, medication training, care planning and risk assessing. Staff interviewed were positive about the benefits to the home of now having a permanent manager in post. This has been motivating to the staff team and provided some clear direction on a number of issues. The home has a development plan that has been worked out in conjunction with the staff team. Regulation 26 inspections have been completed and copies supplied to the home and to the Commission. The new manager has been receiving regular supervision from the organisation’s area manager. An annual questionnaire has been circulated and completed by the service users. This form of Quality Assurance could be extended by the home to include relatives and outside professionals. All Health and Safety testing and recording has been completed and recorded. The freezer in the utility room needs to be repaired or replaced, as the some of the produce on the lower shelves appeared not to be properly frozen. 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 21 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 3 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 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 2 X 3 X X 3 x 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 22 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. 1. 2. 3 4 5 Standard YA24 YA24 YA37 YA42 YA19 Regulation 23(2)(b) 23(2)(b) 8(1)(a) 23(2)9(c) 13(b) Requirement The home must repair or replace kitchen units The home must clean or replace stair carpet The home must register the manager The home must repair or replace freezer in the utility room. The home must ensure that the medication relating to one service user referred to in the text is reviewed and the outcome recorded. Timescale for action 31/03/07 31/07/06 30/06/06 30/06/06 30/06/06 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 YA6 Good Practice Recommendations The home should consider making goals and objectives in the care plans more specific and detailed 17 Bowler Road DS0000016326.V291550.R01.S.doc Version 5.1 Page 23 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.V291550.R01.S.doc Version 5.1 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. 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