Inspection on 04/02/06 for 224 Glenfrome Road

This inspection was carried out on 4th February 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

224 Glenfrome Road 31/08/07

224 Glenfrome Road 13/09/06

224 Glenfrome Road 16/08/05

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 Sam Fox Unannounced Inspection 4 February 2006 09:30 th 224 Glenfrome Road DS0000026638.V273656.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 224 Glenfrome Road DS0000026638.V273656.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. 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 224 Glenfrome Road Address Eastville Bristol BS5 6TR 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) 0117 9392192 01454 372151 Freeways Trust Ltd Miss Claire Anne Hayward Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 3 persons aged 18 - 64 years of age Date of last inspection 16th August 2005 Brief Description of the Service: 224 Glenfrome Road is registered to provide accommodation and personal care for up to three people with a learning disability aged between 18-64 years. Freeways Trust Limited, a charitable trust, operates it. The accommodation comprises a semi-detached house based over two floors in a residential area of Bristol. It is close to local shops and facilities. The home aims to provide support for people who are more able to live independently and it is not staffed for a whole twenty-four hour period. Glenfrome has strong links with a sister home, Underhay, which is in walkable distance. Both are staffed by the same team and residents at the home are able to summon help from Underhay in an emergency. 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second unannounced inspection. The main focus of which was to ensure that requirements made at the last inspection had been met and to check on residents’ welfare. The home is not staffed on a twenty-four hour basis so another major focus was to check residents’ abilities to summon assistance in an emergency. Evidence was primarily gained from discussion with two of the residents who live at Glenfrome Road who explained arrangements at the home. In addition to this key records were examined. Three requirements were not discussed (as the manager was not on site) – these will be carried forward with extended timescales and should not be viewed as an indication of poor practice. A number of standards were not inspected during this visit and this report should be read in conjunction with others so a fuller picture of then home can be gained. What the service does well: What has improved since the last inspection? The home was found to be cleaned to a good standard and a bedroom carpet has been replaced – thus meeting with a requirement made at the last inspection. Safety has been improved by the removal of a garage in the garden. Residents are fully involved in the care planning process and therefore can expect to be consulted with about all aspects of their care. 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 6 A record of food is now maintained and staff hours are rostrered – this meets with requirements made at the last inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 224 Glenfrome Road DS0000026638.V273656.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 224 Glenfrome Road DS0000026638.V273656.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): EVIDENCE: None of these standards were assessed during this visit. 224 Glenfrome Road DS0000026638.V273656.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): 7,8,9,10 Residents are supported to take risk as part of independent lifestyles and are consulted on all aspects of their lives within the home. EVIDENCE: Glenfrome Road operates a key worker system and residents explained that this was when they had one named staff who would give them additional support and advocate for them if they needed it. They said that they like this and it gave them more confidence. It was apparent that this system is working well within the home. Clearly the ethos at Glenfrome Road is to promote residents’ independence to the full and as such it is not staffed for a full twenty-four hour period. The emphasis is on supporting residents to make their own decisions and to dictate their own daily routines. It was clear, through discussion with them, that they are given support and guidance to achieve this effectively. In every aspect of their lives they expected and encouraged to make choices. One resident also said she had an advocate who she could speak to if she wasn’t happy. Residents are supported to take risks, including remaining at home alone, accessing community facilities independently and having control over their financial affairs. Lengthy discussion took place about this with two residents, 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 10 with a particular emphasis on whether they feel safe in the house and their feelings about getting support in an emergency. They explained that they had a “piper-line” system, which allowed them to call for assistance at any time of the day. They were fully aware of the circumstances which might mean they have to do this. They also confidently explained how they would contact the emergency services if necessary. Residents were fully aware of their rights about seeing anything that is written about them and knew they could expect staff not to talk about their personal details to others. Records are held safely and all staff receive training about confidentiality issues during their induction. 224 Glenfrome Road DS0000026638.V273656.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): 12,13,14,15,16 Residents are supported to lead active and interesting lifestyles and to have a positive community presence. They are sensitively empowered by staff to take full responsibility for the upkeep of their home. EVIDENCE: Residents are supported to lead active, interesting and independent lifestyles. They go to work, access college courses and attend resource activity centres. During their leisure time they pursue various activities according to their tastes – sometimes they are accompanied by staff and other times not, depending on the activity. They said they were pleased with what they did and that there no issues they would like to bring up about what they do during the week. At the time of this visit one resident was going away for the weekend to visit her family. It was apparent that all members of the household are support to maintain friendships and links in the community. They have made some friendships at Underhay and occasionally visit there. 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 12 The home has a vehicle which is used periodically by residents. It was noted on their files that there were agreements that they would contribute £8 per week towards this. The residents said they thought this was fair. Residents explained about their daily routines. They take full responsibility for the upkeep of the house but do get support and advice from staff if they need it. They collectively do the household chores, including cooking and laundry. They said they enjoyed having this responsibility and was part of the attraction for them moving to Glenfrome as it enabled them to be more independent. It was clear that staff sensitively balance the need to provide guidance without taking over or being too dictatorial. This is good practice. 224 Glenfrome Road DS0000026638.V273656.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 There are good systems in place to enable residents to maintain their physical and emotional health. Medication systems are safe. EVIDENCE: Residents explained that they led very independent lifestyles and did not need support with their personal care needs. They said they sometimes needed prompting to do their laundry. It was apparent that they could get up, go to bed and make their meals when they wished but were given guidance when they asked for it. In addition to this they have built up daily routines, which they like to stick to. They were observed wearing their own styles of dress and their appearance reflected their personalities. Residents explained that they could see their GPs when they wanted to and gave examples of when they had recently done so. In addition, both confirmed that they have regular optician and dentists appointments. One resident explained that they were recently having emotional problems for which they were getting additional support which they were pleased about. Health care needs are fully recorded on personal files. Each resident has a key worker who monitors this on a monthly basis. 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 14 There is limited medication held on the premises and residents said they took tablets independently with staff just making sure they had not missed a dose. They were satisfied with arrangements in this respect. 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 15 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 Residents can be confident they will be listened to and protected from abuse. EVIDENCE: The two residents consulted with were very clear about their expectations and they were aware of who they could complain to if they had any concerns – some of which they voiced during the inspection. These concerned every day issues, which were being resolved. (This was confirmed through further discussion with the manager). Residents also explained that they have regular house meetings which they always attend. During this time they talk about routines in the house and what they might like to change. It was apparent that they valued these meetings as a more formal way in which they could influence the running of the home. All staff employed by Freeways have had abuse awareness training and there are clear protocols in place to follow if there is suspected abuse. There have been some issues arising in the household which could be viewed as bullying or controlling behaviour. This has been dealt with sensitively and appropriately by the manager and staff team who have spoken honestly about this to residents and made clear that their expectations are. The relevant specialist advice has also been sought. 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 16 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 Residents’ benefit from living in a comfortable and homely environment. EVIDENCE: Glenfrome Road is a semi –detached house which blends in well with the local community and is close to a major superstore and bus routes. The home has a sitting room, small kitchen and bedroom on the ground floor. There are two bedrooms on the first floor and a bathroom on the first floor. The home was found to be comfortably furnished and generally homely in appearance. There was a smell of damp in the home and some of the paintwork in the hallway was peeling because of this. Residents’ bedrooms are personalised and reflect their individual tastes. They said they were satisfied with the facilities available within the home. The home was found to be cleaned to a satisfactory standard. There were risk assessments in relation to residents using cleaning products. All have been deemed safe to use them. 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 17 It was recommended at the last visit that the home explore why the washing machine is noisy. This has not been achieved. During this visit it was noisy and intrusive. Action needs to be taken to rectify this. 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 18 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): 31,32,33,34 Residents can be re-assured that the staff team have the expertise and skills to meet their needs. Recruitment procedures serve to protect vulnerable adults. EVIDENCE: Staff are flexibly employed at the home at peak times throughout the day. Residents said that this is mainly in the afternoon and early evening when they cook their meals. On the day of the inspection, for example, a member of staff was rostered to be in the house between the hours of 12.00am until 7.00pm They said they were satisfied with staffing levels. Hours are now identified on the staff rosta held at Underhay House. This meets with a requirement made at the last inspection. Freeways have formal recruitment procedures which include the obtaining of references and criminal records checks. All staff consulted with displayed a clear understanding of their roles and responsibilities and spoke sensitively and respectfully about residents’ needs. They confirmed that they receive supervision at regular intervals and said they were satisfied with the opportunities they were given to train. 224 Glenfrome Road DS0000026638.V273656.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): 41,42 Residents’ benefit from living in a safe environment. EVIDENCE: Residents explained that they have regular fire drills at the home and they were aware of the need to exit the house promptly. The home has smoke detectors and an alarm system. Freeways have a number of health and safety policies and the manager has attended training in relation to her responsibilities in this respect. It was also noted in staff minutes that issues of safety and risk assessments are frequently discussed, particularly if the manager has conducted a recent review. This is good practice. All portable electrical appliances had been tested on 16\12\05. It was not clear, however, when the gas central heating system had been serviced. The manager should confirm in writing whether this has been achieved as part of her response to this report. 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 20 There were a number of up to date health and safety risk assessments. All staff spoken with confirmed that they had their statutory training of fire, first aid, manual handling and food hygiene. 224 Glenfrome Road DS0000026638.V273656.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 x 2 x 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 3 32 3 33 3 34 3 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x x x x x 3 3 x 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 22 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 YA3 Regulation 15(1) Requirement Ensure there is an assessment of need and a care plan in place for the one individual agreeing to the hours of support Carried forward Timescale for action 30/03/06 2. YA9 13 (4) Expand on risk assessments, including being home alone if agreed with the placing authority Carried Forward Carried forward 30/03/06 3. 4. 5. 6. YA39 YA30 YA24 YA42 35 23(2)(c) 23(2)(b) 13(4)(c) Develop a quality assurance tool 30/03/06 30/03/06 30/06/06 30/03/06 Repair or replace washing machine Take action to treat the damp within the home Ensure the gas central heating system has been serviced in the last year RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provides to consider carrying out. No. Refer to Standard Good Practice Recommendations 224 Glenfrome Road DS0000026638.V273656.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos 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 DS0000026638.V273656.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!