Inspection on 01/11/05 for Courthouse Road

This inspection was carried out on 1st November 2005.

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

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

Other inspections for this house

Courthouse Road 22/08/08

Courthouse Road 24/08/06

Courthouse Road 23/06/05

Courthouse Road 08/03/05

Courthouse Road 21/04/04

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

CARE HOME ADULTS 18-65 237 Courthouse Road Maidenhead Berkshire SL6 6HF Lead Inspector Susan Burton Unannounced Inspection 1st November 2005 10:10 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 237 Courthouse Road Address Maidenhead Berkshire SL6 6HF 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) 0208 5699131 Owl Housing Limited Mrs Jacqueline Lewis Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: 237 Courthouse Road provides accommodation and care to four residents who have a learning disability. The Proprietors of the home are Owl Housing Ltd. The home is a domestic style four bedroom detached house in a residential area of Maidenhead. It is situated near to local shops and the town centre with easy access to the M4 and M40. Accommodation is provided in single bedrooms on the first floor. There is a lounge/dining room and a quiet lounge. There is a large mature rear garden and car parking to the front of the house.The home is staffed by a team, which comprises of a manager, Deputy Manager and support workers. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection on Tuesday 1st November 2005, which commenced at 10.10 and finished at 13.15. The Deputy Manager of the home was present during the inspection. This was a generally positive inspection, which looked at a number of key standards and also focused on one individual residents quality of life, the resident was able to give feedback herself to the inspector about the service in the home. What the service does well: What has improved since the last inspection? What they could do better: There have been no changes to the development of the homes large garden area. The home is to confirm formally to CSCI that it has completed/satisfied all the requirements of the Fire Authorities Fire Deficiency notice from March 2005. The residents Service User guide needs to be in an appropriate format, easy to use and a copy provided to each resident or representative. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 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. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5 The home has a Statement of Purpose and Service User Guide, which is a combined document. Residents have an individual written contract or statement of terms and conditions. EVIDENCE: The homes Statement of Purpose and Service User Guide were looked at during the inspection. Both documents are combined into one folder and it is not easy to see the difference between them. The Service User Guide should be written/presented in a resident friendly format; this could be pictures, video, audio or other suitable format. A copy should be provided for each resident or their representative. The Statement of Purpose and Service User Guide are to be reviewed to ensure they meet the standard and regulation and a copy is to be sent to CSCI. A residents contract/statement of terms and conditions was seen in place and appeared appropriate. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, Residents have personal plans, which reflect their needs and abilities and actions required by staff to support them. One resident did not have a personal plan available for inspection. Residents decisions and choices are acknowledged. EVIDENCE: The inspector examined one residents personal plan which contained a photograph, information on things that were essential to that individual, things that were important to her, things that she enjoyed and did not enjoy and how staff were to support her and communicate with her. Another residents personal plan was not yet available in a paper format. The home uses a computer for many aspects of its care documentation. Reviews of that individuals personal plan from 2004 and 2005 were seen and contained information, which recognised changing needs and support required by staff. It is recommended that all residents have a personal plan in place, which is available for inspection. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 10 The inspector was able to see from the records and from discussion with the individual resident that her wishes and choices are known and are supported by staff. The resident was seen to be assisted by staff when planning her finances for a shopping trip. The resident was asked where she wanted to have lunch and was able to exercise her own choice. Staff were seen to appropriately support the individual with her finances. The individual is given a sum of money each day by the staff to ensure she does not overspend and is assisted and encouraged to save up money for days out and for holidays. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,17 Residents are able to take part in appropriate activities, which they enjoy. Residents have a program of activities, which include taking part in local and specialist organisations events. Residents are able to enjoy appropriate family and personal relationships. Residents dietary needs are overviewed and monitored by the community dietician and the staff in the home. EVIDENCE: A resident in the home spoke to the inspector about the activities that she enjoyed. She had recently been on holiday to Butlins at Bognor Regis, photographs on the homes computer demonstrated various days out and her participation in social activities during the holiday. Staff had assisted the resident to obtain a passport and she was hoping to go to Disneyland in Paris very soon. The resident enjoys attending the local day centre where she learning about flower arranging, cooking and how to look good with make-up 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 12 and grooming. The resident was going shopping later and having lunch out. She was able to tell the inspector exactly what she wanted to buy and what her choice was for where she had lunch. The staff were seen to be supportive and enabling. The resident takes part in a craft workshop, which is available for anyone from the local community. She was able to show the inspector pictures of a blanket that she knitted herself for a charity. She also attends a local church group on a regular basis and had recently been to a Halloween disco run by the local Mencap group. Residents are encouraged to stay in contact with their families by telephone calls and with the assistance of staff to send postcards from their holidays. Staff will make sure that visits from family are reasonably private wherever possible. The resident was able to show the inspector photographs on the computer of visits from her niece. Residents have personal friends who are able to visit the home and make phone calls to each other. The inspector was able to see how the home supported two residents with their dietary needs. Both had been referred to the community dietician and guidelines for the management of the problem/issue were in place. Both residents are encouraged to manage appropriate dietary intake and weights were regularly recorded to evidence the improvement and/or maintenance of the individuals well-being. One resident was seen by the inspector to have made a significant improvement since the last inspection, staff advised the inspector on the strategies they employed to encourage the individual to gain weight, which was obviously successful. A staff member had cooked a simple and appetising meal at lunchtime for two of the residents who were going out later, both appeared to enjoy the meal. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 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, 20 Staff in the home were seen to provide sensitive care and support to the residents. Medication administration procedures appeared to be accurate and appropriate. EVIDENCE: The inspector was able to discreetly observe the staff practices while caring for the residents in the home. The member of the care staff on duty was seen to be sensitive to each of the residents needs and knowledgeable about how she could best support them. Residents preferences were acknowledged and understood. One of the residents was able to tell the inspector that she chose exactly what she wore each day and that she had chosen her own key worker. The inspector spoke to the male Deputy Manager about cross gender care and how it worked in the home and if he provided any personal care. The Deputy advised the inspector that he did on occasions provide personal care to the female residents. The home has a policy in place for staff that give care to the opposite gender. The homes medication cupboard was inspected and found to be appropriately organised, there is minimal administration of medication. The home uses a 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 14 monitored dosage system as none of the residents are able to self medicate. Medication administration records were correctly filled in and appeared satisfactory. There were no over-the-counter remedies; every item is prescribed for each individual resident. There are no covert medication practices taking place. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 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 The home had received no complaints since the last inspection. The home has a policy for the protection of vulnerable adults, which needs to be reviewed to ensure it is appropriate. EVIDENCE: The Deputy Manager advised the inspector that there had been no complaints since the previous inspection. The home has a pictorial complaints procedure for the residents. One of the residents was able to tell the inspector that if she wasnt happy with anything she knew that she was able to tell the staff about it. A comment in one of the residents daily logs was explored with the Deputy Manager, the inspector was reassured that the home was aware that one of the residents did not like a member of staff and they knew the reason for it. The explanation given did not appear to compromise the safety of the resident. The Deputy Manager was advised to ensure that documents fully reflect these issues for the protection of residents and the staff in the home. The home had a policy in place for the protection of vulnerable adults, which appeared to make reference to childrens procedures, it is recommended that this be reviewed to ensure it is appropriate to the needs and age group of the residents. The home also had copies of the local POVA guidelines. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 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): 24,30 A recommendation from the previous inspection that the home review access to the garden was not yet completed. A recommendation that staff be trained in infection control had been acted on. EVIDENCE: At the previous inspection the home was recommended to review the access and design of the garden to ensure that it was suitable for the needs of the residents. The Deputy Manager advised the inspector that an OT referral had been made to have a handrail put outside the kitchen door to improve the access to the garden. There had been no changes to the homes large garden, which the inspector was of the opinion, could be better utilised for the benefit and enjoyment of the residents. The Deputy Manager advised the inspector of that the home had budgetary limitations at this time. The Deputy Manager was able to confirm to the inspector that 10 members of staff had now been trained in infection control. The homes laundry room had now been provided with an impermeable covering which improved its hygiene and cleaning ability. The home was seen to have placed posters reminding staff how to wash their hands along with liquid soap dispensers and paper hand towels which was seen as good practice. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 17 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 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): None of these standards were inspected at this time. EVIDENCE: 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 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): 39,42 A previous recommendation that feedback be sought from residents families or other stakeholders had been acted on. A requirement from the previous inspection that the homes fire risk assessment reflect the residents vulnerability and mobility needs had been completed. The inspector was not aware if these risk assessments met the local fire authorities guidance. Confirmation that the home had met the fire deficiencies notice is required. EVIDENCE: The Manager had organised a quality assurance survey for relatives and visitors to the home, this included visiting health professionals. A random sample of the surveys were reviewed by the inspector and were found to give positive and supportive comments, one relative had stated that they were happy with the care and that the staff do a good job and that it was obvious that they cared very much. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 20 At the previous inspection it was noted that a Fire Officer from the Royal Berkshire Fire and Rescue Service had visited the home in March 2005 and had issued a notice of fire deficiencies, which included the homes fire risk assessment. Staff had put in place very individualised risk assessments for each resident, which was seen to be good practice. The inspector was not aware if these fire risk assessments met the local Fire Authority criteria/guidance. The home is required to confirm that it has completed all actions required by the Berkshire Fire and Rescue Services Fire Deficiency notice; this includes the fire risk assessments. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X X X 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 237 Courthouse Road Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000046686.V263448.R01.S.doc Version 5.0 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 Standard 1 Regulation 5&6 Requirement The homes Statement of Purpose and Service User Guide are to be reviewed to ensure that both documents meet regulation and schedule and a copy is to be sent CSCI. The Service User Guide is to be produced in a format suitable for the residents. The Registered Manager confirms in writing to CSCI that all actions/works as required by the Berkshire Fire & Rescue Service Fire Deficiency notice have been completed, and that the fire risk assessment meets their criteria. Timescale for action 01/02/06 2 42 23 (4) 01/02/06 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 6 Good Practice Recommendations Residents personal plans are completed and are up-todate and are available for inspection. DS0000046686.V263448.R01.S.doc Version 5.0 Page 23 237 Courthouse Road 2 3 24 23 The home reviews its access and design of the garden to ensure it is suitable for the needs of the residents. The homes POVA policy is reviewed to ensure it is appropriate for the resident needs and age group. 237 Courthouse Road DS0000046686.V263448.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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