Inspection on 16/08/05 for 224 Glenfrome Road

This inspection was carried out on 16th August 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 but made no statutory requirements on the home.

Other inspections for this house

224 Glenfrome Road 31/08/07

224 Glenfrome Road 13/09/06

224 Glenfrome Road 04/02/06

224 Glenfrome Road 27/02/05

224 Glenfrome Road 28/09/04

224 Glenfrome Road 28/01/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 224 Glenfrome Road Eastville Bristol BS5 6TR Lead Inspector Paula Cordell Announced 16 August 2005 09:30 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 Stationary 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. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 224 Glenfrome Road Address Eastville Bristol BS5 6TR 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) 0117 9392192 01454 372151 info@freewaystrust.co.uk Freeways Trust Ltd Miss Claire Anne Hayward Care Home for Younger Adults 3 Category(ies) of LD Learning disability (3) registration, with number of places 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 3 persons aged 18 - 64 years of age Date of last inspection 27 February 2005 Unannounced Brief Description of the Service: 224 Glenfrome Road is a care home that is registered with the Commission for Social Care Inspection to provide personal care and accomodation to three persons with a learning disability aged between 18 and 64 years. Freeways Trust Limited, a non profit making organisation that has a number of care homes within the Avon area, operates the home. There is a care home for twelve persons at Underhay House that is close to 224 Glenfrome Road, which is registered with the Commission for Social Care Inspection. Miss Claire Hayward manages both homes. The accomodation comprises a semi-detached house based over two floors. Access to the upper floor is by means of stairs only. The home is situated in a residential suburb of Bristol on a busy main road. Public transport is available close to the home and there are local shops opposite as well as a large supermarket within a quarter of a mile of 224 Glenfrome Road. The home is within a quarter mile of the M32 an urban motorway that links to Britains motorway system. 224 Glenfrome Road also accomodates two pet cats belong to two of the residents. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection. The purpose of the visit was to review the progress to the requirements and recommendations from the unannounced visit in February 2005. The home has demonstrated compliance to all but one of the requirements from the previous inspection. The outstanding requirement relates to the removal of the garage in the back garden, which should have been removed by May 2005. There have been no additional visits during this period. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals living at Glenfrome Road and the provider has sent monthly appraisals of the service. This information was used to plan the inspection process. The inspection was conducted over 4.5 hours. The inspector had an opportunity to meet with two of the three residents, one member of staff and the manager. The methodology used during this inspection included viewing care records and other relevant documents required of a care home and a tour of the home. Residents were actively encouraged to participate in the process by the staff on duty. The inspector would like to take this opportunity to thank the team and the residents for their welcome and their assistance in the inspection progress. What the service does well: Glenfrome Road provides individualised packages of care to three people in a small, homely environment. Two of the residents stated that they enjoyed living at Glenfrome Road and the support offered to them. Staffing was evidently flexible to meet the care needs of the individuals maximising their independence. There was a strong commitment to empowering individuals and supporting them in their chosen lifestyle promoting independence and community participation. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 6 The home liaises with other professionals to provide a quality service complimenting the skills of the staff team. There is a strong commitment to having a trained staff team. There is an ongoing package of training from the commencement of employment which, includes a comprehensive induction and the Learning Disability Award Framework and then staff progress on to complete a National Vocational Qualification Award. Training was based on the care needs of the individuals living in the home. What has improved since the last inspection? The home has demonstrated compliance to the requirements and recommendations from the last inspection in all but one area. Residents have information to enable them to make a choice on whether to move to the home in the form of statement of purpose and a service user guide. This has recently been updated to reflect changes in staffing and the hours that are provided to the home. Residents now have access to their plans of care and medication is now administered in the home rather than previously from Underhay House which is less than a five minute walk on Muller Road. Risk assessments and strategies were put in place as discussed at the last inspection where the risk was still evident. However, the home must ensure that there are risk assessments in place demonstrating the level of independence and where residents are left in the home without staff. Residents were keen to share the record of complaints and the complaint policy that was displayed on the notice board. This was in response to a requirement from the inspection in February 2005. All staff have now received training in the protection of vulnerable adults further protecting the residents living in Glenfrome Road from abuse. All records relating to the running of the home are now kept in Glenfrome Road except the staffing records. These were inspected during the inspection at Underhay House. Glenfrome Road and Underhay House share the same staff team. However the manager stated that since the last inspection there is a consistent staff team supporting the residents at Glenfrome Road. Residents confirmed this by telling the inspector what staff worked on what particular day. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 7 Residents are now protected by regular checks on the fire equipment and regular fire drills, which is evidenced by records. These are now kept in the home along with the fire risk assessment. Since the last inspection the home is fully staffed and additional staff are employed which are above the minimum staffing to provide opportunities for individuals to access the community and meet their support needs. Residents and staff saw this as positive. Staff stated that this ensures that care is consistent and delivered by familiar staff and residents stated that there have been more opportunities to go out. What they could do better: There are a number of requirements and recommendations but this should not detract from the high level of satisfaction expressed by the residents or the commitment and the dedication of the staff team. Residents would benefit from the home devising a home’s care plan, which clearly describes how the staff should support them based on the Social Service’s plan of care. In addition residents should be given an opportunity to formally review their plan of care with relatives and other professionals where appropriate as stated in the statement of purpose on a six to twelve monthly basis. Risk assessment topics must be expanded to include all activities undertaken where there is a potential risk. Thus demonstrating that residents are supported to lead full and independent lifestyles minimising risks whilst maximising independence and ensuring the safety of the individual. The home must expand on the record of food offered to individuals living in the home. This would further evidence that residents are having a nutritious and varied diet offering individuals choice. The home must have a staff rota, which includes evidence of how each of the individual’s hours as agreed by Social Services is being provided. The reduced hours for one of the individuals must be supported by a care plan drawn up by Social Services. The manager stated that the placement for the individual who requires 24-hour care is under review so as not to reduce the independence of the other two individuals. Residents and significant others including relatives would benefit from being involved in a quality audit initiative which would inform the business plan of the home. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 8 A resident must be provided with a new carpet and another carpet would benefit from a deep clean. Residents could be more protected by the maintenance of a visitors record and a repair book. The garage must be removed within the extended timescale ensuring the safety of residents, visitors and staff. This is an outstanding requirement. 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. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 9 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 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 10 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) 1,2,3,4,5, Residents have sufficient information to enable them to make a decision to move to the home. However, there was insufficient evidence in the form of an agreement from the placing authority sanctioning the reduced staffing input for one of the individuals thus there was uncertainty whether the home was meeting the needs of one of the individuals. EVIDENCE: The home has a statement of purpose and a service user guide. The information was accessible written in plain English and included pictures. Copies had been made available to staff and residents. Further evidence had been seen that the statement of purpose had been discussed at a recent staff meeting. The manager stated that a copy has been made available to the three residents in the lounge area of the home. The inspector saw many examples of the staff team demonstrating the capacity to meet the residents’ specialised needs. Glenfrome Road is registered to accommodate and provide personal care for three adults with a learning disability. It was evident from care records, discussions with the manager and residents that individuals also have physical, psychological and communication needs. There was evidence that the Community Learning Disability Team including the consultant psychiatrist and psychology was supporting the home, staff and the individuals. This is seen as good practice and demonstrated a multi-disciplinary approach to the care of the individuals. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 11 Training will be discussed later. However, it was evident that the training was planned around the care needs of the individuals living in the home. The inspector was informed that one individual uses British Sign Language. Training was planned for later in the year for a number of staff to attend a course to improve communication. However, it was evident from talking with staff that the individual could make themselves fully understood. Evidence was provided that a translator had been used when the individual had attended appointments where technical jargon was used and where the staff did not have the expertise in the signs for this particular activity. This is seen as good practice. One of the residents stated that they were learning sign language to improve communication and that the individual who used signing as their main form of communication was keen to share this with staff and residents. The manager stated that one of the residents living in the home is being reassessed by a Social Worker, as they require more support than the other two residents. This is seen as good practice where the home ensures that they can continue to meet the needs of the individuals and their aspirations and promote independence Prior to this person moving to the home the home was staffed for a total of 49 hours over a seven day week but not at night. The manager was aware that there was a risk that two of the residents could become reliant on the sleep in cover thus reducing their independence. The inspector was concerned that there was no plan of care from Social Services agreeing to this reduced support when the norm is 24-hour care when living in a registered care home. There was evidence that residents are assessed prior to moving to the home within an individual plan of care drawn up by the social worker for two of the three residents. However, the home must be able to demonstrate that where residents receive less than 24 hours care that the placing authority has agreed this. Contracts were seen on individuals’ files and met with the legislation. These were updated annually to include the changes to the fees. This is good practice. These clearly stated what was not included in the fee and any additional costs. Residents contribute part of their disability living allowance to the running costs of the vehicle. Residents (where able) had signed the contracts. The inspector reviewed five standards and the home has demonstrated a good understanding of the legislation. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 12 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(s) 6,7,8,9,10 Residents are actively involved in the planning of their care on a monthly basis, however, the home must develop their own plan of care expanding that of the placing authority involving relatives and other professionals based on the wishes of the individual. Residents would benefit from more documentation supporting the level of independence whilst demonstrating the home is ensuring the safety of the individual. Residents are actively encouraged to participate in the running of the home and making decisions that affect their life. EVIDENCE: The inspector reviewed three individuals’ plans of care. For two of the three care plans seen there was a lack of information to determine how the home was meeting the assessed care needs and the plan of care drawn up by the placing authority. The home works from the plan of care drawn up by the Social Worker, which lacks any real measurable outcomes on how the plan is to be implemented by the home or by whom. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 13 For example the Social Worker’s plan states to offer the individual opportunities to use the community- there was evidence that the home was working towards this goal via the monthly key worker reviews but a full review would have been difficult as the information was too broad to determine whether the home was meeting the specific individual’s needs. One of the individuals did not have a plan of care drawn up by the placing authority as already discussed. Residents confirmed their involvement in the planning of care via the monthly key worker meetings. These reviews included a review of the activities that had been undertaken and discussing future plans for the forthcoming month, a review of health and discussions on general well being and a health and safety check of the individual’s bedroom. These were positively written and evidenced that the individual was the focus of the care delivery. One individual had a plan of care on their bedroom wall identifying goals for the next six months this included planning of an annual holiday and the decoration of their bedroom. The manager stated that the home is planning to develop the system to use more resident focused models including PATH, MAP and essential lifestyle planning. Whilst the monthly reviews were taking place, two residents had not had a review involving relatives and other professionals where relevant. The statement of purpose clearly described the process of reviews, which was monthly by the key worker with a six to twelve monthly review involving relatives where relevant, based on the wishes of the individual. However the National Minimum Standards clearly states that a review of the care plan must take place at least every six months or more frequently where needs are changing. Both staff and residents were clear about the key worker role and spoke positively about the relationships that they had built. Staff spoken with had a good understanding of their roles and the care needs of the residents. The inspector observed positive and inclusive communication towards the individuals living in the home. Risk assessments were evident in two of the three care files seen. Generally risk assessments were limited in their topic and did not include accessing the community and activities in the home. These should be expanded to ensure that the level of independence given to individuals is appropriate and that individuals have the appropriate skills to ensure their safety. It became apparent that at times all three individuals could be in the home without staff. One of the individual’s care plan states that the home must be staffed at all times when in the home. This must be discussed and agreed with the placing authority and risk assessed. Risk assessments must include dealing with emergencies, accessing the community independently, completing household activities and for one individual bathing. This list is not exhaustive. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 14 Care plans included positive strategies for dealing with challenging behaviour including triggers and techniques for supporting individuals giving staff clear guidance. The home had sought support and guidance from the Community Learning Disability Team, Psychology and the consultant psychiatrist. This is good practice. Residents stated that they were actively encouraged to make decisions on how they wanted to spend their day from getting up to going to bed. Residents were encouraged to be actively involved in resident’s meetings making decisions about the home. Residents confirmed that they had been involved in deciding the rules of the home. The emphasis on the rules being it was the residents’ home and the guidelines were for staff and residents. These rules were appropriate to the setting and no different from those imposed on any group sharing a home together. Records were held securely. Residents stated that they could read their care files at leisure in addition residents had signed their plans of care, reviews and risk assessments. Staff on duty confirmed this information and were aware of the need to respect the individual’s in the home’s confidentiality. In conclusion, whilst in part the standards are met. The home must develop their own care planning system and ensure that the reviews occur as stated in the statement of purpose. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 15 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) 11,12,13,14,15,16,17 Residents are supported to be as independent as possible, taking control over their lives and choosing how to spend their time. Residents are supported to choose a healthy balanced diet. However, the menu must be fully documented to demonstrate that the residents have a varied and nutritious menu. Friends and families were evidently important to the residents and supported by the home’s care staff. EVIDENCE: The two residents were observed actively planning their day and making arrangements with staff. One of the residents told the inspector that they had lots of opportunities to go out with staff and some independently. Residents were keen to share information about trips out with the staff and the planned holiday. Residents stated that they had a choice of destinations for this year’s annual holiday and one group was going to France and the other Cornwall. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 16 Timetables indicated that the residents were offered a structured timetable that was tailored to the individual based on choice. Residents told the inspector that they were supported to go to work and college, whilst another attended a day centre. Residents told the inspector that regular trips are planned to places of interest during the weekend. There was a notice board about local events such as Seymour’s Disco and trips to the theatre. A resident stated that they had recently been to the cinema and a meal at a local pub. Residents stated that there were no restrictions on accessing the local community and they were free to come and go as they wished. However, there were no risk assessments supporting that individuals were safe and had the appropriate skills to be able to move safely around the community. One of the residents clearly requires support 24 hours however, it came to light that there were occasions for short periods where this person was in the home without staff support. This must be clearly documented in the plan of care with clear guidelines and monitored by the care staff and only with the agreement of the placing authority. Care records included information about friends and family and how to contact them and significant dates like birthdays. Residents stated that they are supported to use the telephone, write letters and make arrangements to visit their relatives. Residents at Glenfrome Road told the inspector that they are supported to invite friends for tea and visit individuals in the house around the corner. However when visiting Underhay House this is subject to an invite from residents who live there. It was evident from observation and discussions with the residents and staff that the daily routine of the home is resident led. Individuals stated that they could get up and go to bed when they wanted and help themselves to snacks and drinks. Residents stated that they assist with the cleaning of their bedrooms and preparation of the meals, washing up and general household chores. Residents were observed assisting with the meal preparation and clearing the table after the lunchtime meal. Residents saw this involvement as positive. It was evident that the emphasis was that it was the resident’s home. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 17 Residents stated that the food was good and choice was available to them. This was evident during the lunchtime but this level of choice was not documented on the menu and the lunchtime meal stated snack and not what it consisted off. The home must maintain a record of actual food, which is available to the residents on a daily basis. Residents stated that the focus of the meal planning was to encourage people to eat more healthily. A resident stated that they enjoyed cooking Mexican dishes and staff support was given. The residents invited the inspector to participate in the mid day meal. Residents chose to eat either in the lounge/dining area or the garden. The lunchtime meal, which consisted of quiche and salad, was relaxed with staff members joining in. Fruit was readily available in the lounge and the dining area. Residents stated that during the week the main meal was served in the evenings. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 18 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) 18,19,20,21 Resident’s personal and health care needs were being met. There were safe systems in place for the administration of medication. The home was in the first stages of discussing the wishes of individuals in respect of illness and dying. The residents are a relatively young group. EVIDENCE: Residents stated that the day was resident led and individuals chose when to get up and go to bed. This was clearly documented in care records. Information in care records demonstrated that the home was accessing support and guidance from other professionals ensuring a multi-disciplinary approach. This is good practice. The home has a key worker system. The residents confirmed this. This was described in the statement of purpose and the service user guide. Staff stated during the inspection at Underhay House that this is covered during induction and discussed and reviewed at supervisions. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 19 There were clear records demonstrating that the individuals health care needs were being met including routine visits to the doctors, opticians, dentist and where relevant the chiropodist. There was evidence in the form of letters from consultant psychiatrists that they were involved in reviewing the mental health states of individuals. The monthly key worker report included health monitoring and developing an action plan. One resident was observed being supported to contact the doctor to make an appointment. It was evident that the resident was in control and made the telephone call and agreed the time. Another resident was supported to attend an appointment, staff asked whether support was required rather than took it for granted and the individual was given a choice of what staff could support them. This is good practice. The home is informing the Commission for Social Care Inspection of events that affect the well being of the residents in respect of regulation 37. The medication system was seen and found to be satisfactory. Including recording, administration and the training of staff. The home is in the process of seeking the views and where appropriate the views of relatives on the wishes in the event of the individual’s death. This will be followed up at the next inspection. The home has a policy to guide staff through the procedure in the event of a death of a resident. The home has demonstrated that they are meeting the standards relating to personal care and healthcare. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 20 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) 22,23 Residents are confident that a complaint would be taken seriously and responded to in an appropriate manner. Residents are protected from abuse by the home’s policies and training package for staff. EVIDENCE: The complaints procedure was readily available to individuals living in the home and a copy was on the notice board. Evidence was provided that this was regularly discussed with residents at meetings and in care files residents had signed a record to say that they had been given a copy. This is good practice. The inspector asked both residents their understanding of the complaint procedure. All residents stated that they would discuss with staff, the manager or relatives. The inspector noted that residents’ views are sought at residents meetings and during the monthly care plan reviews, which are completed by the individual’s key worker. The home was able to demonstrate compliance to one of the requirements relating to the training of staff in protection. Training for staff was organised for the beginning of August 2005. The manager stated that she delivered this training as she has attended a ‘train the trainer’ course for protection of vulnerable adults. The manager stated she is still waiting for her certificate of attendance. This must be available for the next inspection to demonstrate the manager is competent to provide this training to the team. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 21 Three members of staff were asked what was they understanding of abuse and how would they would respond to an allegation whilst at the inspection at Underhay House. The responses were appropriate. Staff work both at Glenfrome Road and Underhay House. The home has a whistle blowing policy. All staff and residents were aware of the senior management structure of Freeways and people that they could contact if concerns were raised about the home. The manager stated that residents hold their personal allowances and excess money is kept at Underhay House for security and that only the manager, the deputy and a senior member of staff have access to this. Two residents spoken with stated that they were happy with the system and that they only need to speak with one of the three staff to have access to additional money if required. Residents stated that they have a lockable space to keep money secure. However, it came to light that one person’s lock was broken. The manager stated that this would be addressed. A random selection of finances was checked during the July inspection at Underhay House. Monies accounted with records. There were individual plans relating to support needs of the individuals in respect of their finances. Individuals have their bank accounts and there was a record of all transactions and evidence that personal allowances and benefits were being paid to the individuals. The home operates a safe system for the administration of the finances of the residents. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 22 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) 24,25,26,27,28,29,30 Residents live in a small homely environment, which is clean and meets their needs. However, the home has failed to move the garage within the given timescale, this must be addressed to ensure the safety of residents, staff and visitors. EVIDENCE: Glenfrome Road provides a small homely environment to the three individuals living there. The home is in keeping with the local area and is close to local amenities and transport links to the city centre and surrounding areas. Residents were evidently proud of their home and were actively involved in keeping it clean and tidy. All areas viewed on this occasion were clean and free from odour. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 23 Residents have their own room, which has been personalised and decorated to reflect their tastes. Residents stated that they make full use of the lounge and their bedrooms and enjoyed each other’s company. Residents stated that they could watch television in their bedrooms or together in the lounge. One of the bedrooms had an iron burn on the carpet. The inspector was informed that this was from a previous occupant. This must be replaced and another would benefit from a clean or being replaced. Residents told the inspector that they had keys to both the front door and their bedrooms. It was evident that their bedroom was their own private space and individuals, whether staff or a fellow resident, could only enter by invitation. There are a number of aids and adaptations to maximise independence including a piper line to enable residents to contact the emergency services when staff are not available. There were bath aids and aids to assist in the kitchen which had been identified by the staff and an assessment by a qualified occupational therapist. There was a light sensor in one bedroom, to enable a hearing disabled person to hear the fire alarm. Further aids were being explored for this particular individual. The laundry facilities are sited in the kitchen/lounge/diner it was noted that the washing machine was noisy. This was noted at the last inspection. Considering this is in the communal lounge the home must investigate and reduce the noise level to the resident’s benefit. Adequate bathing and toilet facilities were provided to individuals living in the home. There was sufficient hand washing facilities with soap and towels. There is one outstanding requirement for the home to remove the garage original date agreed by the home and the Commission for Social Care Inspection was May 2005. The manager stated that the maintenance department assessed the garage as not being a priority unless there is a frost. A building contractor visited on the day of the inspection to arrange a date with the home to remove the garage pending the agreement of the trustees from Freeways Trust. This has been extended to enable the home to comply. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 24 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 standard(s) 31,32,33,34,35,36 Competent staff support residents, however, the home must ensure there is evidence in the home of a thorough recruitment procedure being undertaken. EVIDENCE: The home must have a staff rota, which includes evidence of how each of the individual hours as agreed by Social Services is being provided to the residents. One resident has a 24-hour care package and two have been allocated 49 hours and do not necessarily require night cover. There was no care plan from the placing authority confirming this arrangement for one of the individuals. The manager stated that the placement for the individual who requires 24 hour care is under review so as not to reduce the independence of the other two individuals. The home shares the same staff and manager as Underhay House. This was inspected in July 2005. The following information was taken from that inspection, which took place on the 19th July 2005 and was not reviewed on this occasion due to the short time lapse. Residents stated that whilst the team work in both homes, there are regular staff that support them and could recall what staff work on what days. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 25 Staff recruitment was discussed. Whilst residents have been involved in drawing up the person specification and have been encouraged to participate in the informal visits of prospective employees they are not involved in the interviewing. The manager stated that the organisation is exploring resident involvement in recruitment and one resident was involved in the employment of staff at the day centre. This will be followed up at the next inspection in relation to increased participation of individuals in the recruitment of staff. Information supporting the recruitment of staff was seen. This was all in place as per the legislation except for proof of identification including a photograph. The manager stated that she had seen this as part of the criminal record bureau check but had not realised that a copy had to be held in the home. The manager stated that this would be addressed. Staff training records and a training plan was seen. This demonstrated that staff are supported to progress through areas of training including a formal induction programme, the learning Disability Award Framework and then on to a National Vocational Qualification. Evidence was provided that in addition staff attended training relevant to the care needs of the individuals in the home and the statutory health and safety training. There are three staff with an NVQ 3 or 2 in care. The manager stated that once staff complete the Learning Disability Award Framework, a further four staff will be enrolling to complete an NVQ in care. There are three assessors in the home; however, the home uses an external assessor. The home is working towards the government’s strategic plan of 50 of the workforce having an NVQ in care by December 2005. Staff stated that they felt supported in their roles and regular staff meetings and supervisions with the manager were taking place. This was further evidenced via minutes of meetings and supervision records. Staff meeting minutes demonstrated that there was an open culture and staff were encouraged to share their views on a wide range of topics relating to the running of a care home. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 26 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) 37.38,39,41,42,43 Residents live in a well managed home and a safe environment. However, the home failed to demonstrate how the quality was monitored which included seeking the views of the residents, relatives and significant others. EVIDENCE: Miss Hayward is the registered manager for the home. She has obtained an NVQ 4 in care and management and an NVQ 3 in training and development. She is also an NVQ Assessor. There was evidence that Miss Hayward was keeping up to date and attending periodic training. Ms Hayward is the registered manager for Underhay House and Glenfrome Road. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 27 Staff stated that there was an open door culture in the home both with the manager, the deputy and the team leader. Staff and the residents were aware of the hierarchy within the organisation. It was evident that the provider visited the home on a monthly basis and spoke with the manager, staff and the residents. The Commission for Social Care Inspection receives copies of the monthly provider visits. However, the information is recorded in one report for both homes as these are two separate registrations it would beneficial to separate these reports. The manager stated that presently there is no formal quality assurance tool which seeks the views of the residents, their relatives or significant others. This then should inform the home’s business plan. The manager stated the home is in the process of developing a business plan and a senior manager is assisting in the process. The inspector looks forward to seeing this at the next inspection. The inspector viewed a number of records relating to health and safety. The home has a comprehensive policy on health and safety giving guidance to staff and residents. This was displayed in the office along with the Health and Safety Poster. Fire records were current demonstrating that staff attend periodic training and drills as prescribed by the fire officer and checks were being completed on the fire equipment. This was in response to a requirement from the previous inspection. The home has a risk assessment on fire, and COSHH. These had been kept under review. There was no up to date gas or electrical equipment certificate. The manager stated that these are held at the main office at Freeways Trust. It is strongly recommended that copies be held in the home. The home has a current certificate of public liability insurance. The manager stated that there has been a further issue with the response to general house repairs but this has recently been alleviated as a new person has taken this responsibility on due to a period of absence of the Property Development Manager. The manager stated that works are prioritised and are now being completed within a more realistic timescale. This will be monitored at the next inspection. It was noted that the home does not have a repair book as this is recorded in Underhay House. During the inspection a resident told the manager of two areas that required minor maintenance. It would be strongly recommended that a repair book be maintained in the home. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 28 There are two requirements relating to the records for the home to maintain a record of visitors to the home and for a record to be maintained of the staff rota, which includes any alterations. the home must be able to demonstrate how each individual is allocated hours as detailed in the plan of care from Social Services. Budgets were discussed and the manager stated that they have recently been given the staffing budget to enable them to plan more effectively the day-today staffing of the home. The manager stated that the provider regularly discusses the budgets and a plan is devised to ensure that the home remains within budget. There was no evidence from this inspection that the home was not viable. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 29 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 3 2 2 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 2 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 224 Glenfrome Road Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 x 2 3 3 Version 1.30 Page 30 D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc 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 6 Regulation 15 (1) Requirement To ensure plans of care are reviewed a minimum of six monthly involving the resident. To ensure that the home expands on the plan of care drawn up by the placing authority. Ensure that there is an assessment of need and a care plan in place for the one individual agreeing to the hours of support. To expand on risk assessments as discussed at the inspection including being home alone if agreed with the placing authority. The home must maintain an accurate record of food that is available to residents in the home demonstrating that residents have a nutritious and varied diet and are given choice. For the home to maintain a staff rota in the home demonstrating that individual hours are in place. To replace the carpet in bedroom 3. to remove the garage in the garden as per the advice of the Timescale for action 19/12/05 2. 3,6 15 (1) 19/9/05 3. 9 13 (4) 19/12/05 4. 17 17 (2) 16 (2) Schedule 4.13 17 (2) Schedule 4.7 23 (2) 23 (2) 19/9/05 5. 33 16/9/05 6. 7. 26 28 16/12/05 30/9/05 Page 31 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 8. 39,41 35 9. 41 17 (2) Shedule 4.17 maintenance department. (Outstanding requirement 31st May 2005). For the home to develop a quality assurance tool, which seeks the views of the residents and where relevant relatives and to develop a business plan addressing the issues. Maintain a record of visitors to the home. 19/1/06 23/8/05 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. 2. 3. Refer to Standard 42 26 30 Good Practice Recommendations For the home to maintain a repair book which is accessible to the residents. To deep clean carpet in room 1 To explore why the wasing machine is noisy. 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 32 Commission for Social Care Inspection 300 Aztec West Almondsbury South Gloucestershire BS32 4RG 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 224 Glenfrome Road D56_D05 S26638_GLENFROMEROAD_V233275_160805_Stage 4.doc Version 1.30 Page 33 - 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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