Inspection on 13/02/06 for 24 Baveney Road

This inspection was carried out on 13th February 2006.

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

The inspector 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

24 Baveney Road 09/01/07

24 Baveney Road 19/07/05

24 Baveney Road 28/02/05

24 Baveney Road 12/07/04

24 Baveney Road 02/03/04

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Baveney Road, 24 24 Baveney Road Worcester Worcestershire WR2 6DS Lead Inspector R McGorman Unannounced Inspection 13 February 2006 15:00 th Baveney Road, 24 DS0000018627.V272145.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 Baveney Road, 24 DS0000018627.V272145.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. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Baveney Road, 24 Address 24 Baveney Road Worcester Worcestershire WR2 6DS 01905 420706 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) New Era Housing Association Limited To be appointed Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: 24, Baveney Road is registered to provide residential care for up to 4 adults who experience a learning disability. The premises is a large, detached house situated in a pleasant residential area, approximately 2 miles from the City of Worcester, with easy access to public transport and a range of amenities and facilities. The home is owned and run by the New Era Housing Association Ltd., and is part of The New Dimensions Group, which, as the parent Company, provides strategic direction and a range of functional support services. The name of the Organisation is in the process of being changed from ‘New Era’ to ‘Dimensions’ (UK) Ltd. The stated purpose of the organisation is, to work with people with learning difficulties, supporting them to make choices and to exercise control over their lives, and the main aim of the home is, to deliver a person-centred response to the needs and aspirations of the people we support. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine unannounced inspection was to follow up previous requirements and recommendations, and to monitor the care provision at 25,Baveney Road, Worcester, in relation to the stated aims and objectives of the home. The inspection took approximately 3 hours, when some time was spent with service users, and also talking with staff. Very positive comments were made about what it is like to work at the home. A tour of the building was also undertaken. Discussions were held with the manager and staff about the way in which the service is delivered, as service users are unable to communicate their opinions verbally. The records kept in respect of the maintenance of equipment, and safe working practices were also seen. What the service does well: What has improved since the last inspection? Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 6 The requirements from previous inspections have all been met. Ongoing progress and development is being made, and the introduction of a quality monitoring system known as PATH has focused the approach of staff, to the process of planning, action and review of the service provision. A new kitchen has been provided at the home, which is almost complete. A care manager has been appointed recently. 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. Baveney Road, 24 DS0000018627.V272145.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 Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 Appropriate documentation is in place to enable prospective service users to make an informed decision about their future care needs. EVIDENCE: A Statement of Purpose has been produced, which together with the Service Users Guide, provides detailed information for residents and their families, on which to base decisions about their future care needs. A statement of the Terms and Conditions of residence is also provided for each service user and, in addition, an individual contract is issued by the placing authority. Documentation is reviewed regularly, to ensure that it accurately reflects the specific aspects of the care that can be provided. The documentation is produced in an appropriate format if needed, and the Service Users Guide contains numerous photographs. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7 The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. The key-worker system ensures that service users living at the home are supported in making choices in all areas of their lives. EVIDENCE: An individual plan of care is produced for each service user, based on the initial assessment undertaken during the admission process. The care plans are very comprehensive, and the needs and individual preferences of each service user are identified as far as possible, and their participation in the daily life of the home, is constantly encouraged. Person Centred Planning is also being developed, and new documentation introduced. A new key-worker system is also being introduced at the home, with a specific carer assigned to each service user, who has responsibility for ensuring that appropriate care is provided Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 10 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): 14,16 & 17 Service users are involved in the daily arrangements both within and outside the home, and the opportunities made available to service users enable them to live as fulfilling a life as possible. There is a flexible approach to the provision of a healthy diet, and service users are encouraged to decide what to eat and when. EVIDENCE: Service users living at the home are encouraged to follow an ‘ordinary’ life style as far as possible, by using the same facilities as other members of the community, and being involved in a range of leisure activities, although for some of the service users a little encouragement is needed at times. Additional opportunities for service users are being explored with staff at the home, and arrangements for holidays are currently being planned. The arrangements regarding the provision of food reflect the preferences of each service user. Changes to menu planning, and the purchasing and cooking of food, are being proposed, to further promote the independence of service users. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 11 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 & 21 Procedures have been implemented to ensure that the personal and health care needs of service users are appropriately met. The systems in place for the administration of medication ensure that the health of service users is promoted. Training for staff in regard to the ageing, illness and possible death of a service user, will increase their awareness and ensure that dignity and respect are maintained. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 12 EVIDENCE: The personal and healthcare needs of service users are well documented, and there is evidence to show how staff understand and respond to them in an appropriate way. Health Action Plans are being implemented for all service users living at the home. Medication arrangements at the home are satisfactory. A profile is to be developed to include the side effects of each medicine, and will include a photograph of the service user attached to their individual medication records. A procedure is in place for dealing with the death of a service user. The issues relating to the ageing, illness and possible death of a service user, and the need for training to be provided, to increase the awareness of staff, were discussed with the manager. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 A satisfactory complaints procedure is in place at the home, and it enables everyone to express any concerns, views, opinions, and compliments. EVIDENCE: These standards were not inspected in detail, but were previously met. A clear procedure for the investigation of complaints has been produced and any issues are dealt with immediately. The document has been produced in a format that is understandable to service users. There have been no complaints to the home, since the last inspection Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,28 & 29 The premises are suitable for their purpose. They are comfortable and clean, and ensure as far as possible that the safety and wellbeing of service users is promoted, although fire safety precautions need to be reviewed The location of the house is convenient to local services and facilities, and the layout provides adequate communal space for the needs of service users. The standard of the accommodation is excellent. The décor and furnishings are in good condition, and provide service users with an attractive and homely place to live. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 15 EVIDENCE: The premises at 24, Baveney Road is a large detached house with accommodation on two floors, which is maintained to a satisfactory standard, and is suitable for its purpose. There are four single occupancy bedrooms for service users, and one room is provided with an en suite facility. The rooms are furnished to reflect the personality of their occupants, and some have sensory equipment. The need for replacement of items that have been soiled by a service user, i.e. a mattress and carpeting, were discussed with the Acting Care Manager. In addition, the house would benefit from double-glazing to the windows. The communal areas of the home are spacious and airy, nicely decorated and comfortably furnished. There is a large lounge and a separate dining room, for the use of service users. A pleasing new kitchen has been fitted, which has further improved facilities for service users. Appropriate aids and adaptations are provided, and contracts are in place for the servicing of equipment at the home, which is all in working order. The home has not received a recent visit from the Fire Safety Officer. The Fire Log Book was seen, and the appropriate checks have been undertaken with the required frequency, with the exception of the 3 monthly Fire Instruction for staff. In addition, the Fire Risk Assessment should be reviewed and updated. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34 & 35 The management support and supervision given to staff, enables a clear understanding of their roles and responsibilities, and ensures the promotion of the aims and objectives of the home. The recruitment policy and practices ensure that service users are supported and protected appropriately. The training programme available to staff ensures that they are effective in their work, and therefore able to provide appropriate care and support to service users. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 17 EVIDENCE: New Era provides relevant information for staff on joining the organisation, and also keeps them updated on new developments and any changes that take place. Each member of staff is given a Welcome Pack that contains details about the organisation, and its aims and objectives, an Employee Handbook that provides information about terms and conditions of employment and policies and procedures, and an Induction Checklist covering the first three months of employment. The acting manager confirmed that appropriate staffing levels are maintained to provide for the identified needs of service users. There have been few changes within the staff group recently, although a new member of staff is to join the team this week, and the acting manager has been in post for about one month. A thorough recruitment and selection procedure has been produced by the organisation, and includes a commitment to equal opportunities. Criminal Record Bureau checks are completed prior to an appointment being confirmed, and verbal and written references are also obtained. A training programme is in place at the home, and a training record is maintained for each member of staff. The Learning Disability Award Framework (LDAF) accredited training is being replaced by ‘New Approach Training’, which is an alternative to the NVQ. The training needs of staff are regularly reviewed, and care related courses are attended. The need for staff to have regular fire awareness training was identified. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 & 41 The care arrangements at 24, Baveney Road have been satisfactory, and staff and service users benefit from the positive leadership, and the person centred approach to the care they receive. Quality monitoring undertaken, and the views of service users, their relatives, staff and other interested parties are sought and responded to appropriately. The policies and procedures, and records maintained at the home, comply with legislative requirements and therefore help to safeguard the rights of service users. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 19 EVIDENCE: The care management responsibility for the home is now being undertaken by Ms Julie Bedford, who has recently joined the Organisation, and an application for registration is anticipated in the near future. The induction arrangements have been very extensive for the acting manager, who confirmed that she has been well supported since taking up her appointment. The quality assurance and monitoring systems for the Organisation includes an annual development plan for the region, and for each home, that involves service users together with the staff team, and which is part of the ongoing development of the Person Centred Planning process. Known as PATH (Planning Alternative Tomorrows with Hope), it has identified where people are at, where they would want to be in 12 months time, who they will need to help them to get there, the building bricks and the strengths needed, the first steps and who will do what. Reviews take place every 3 months, to determine what has been achieved, and what still has to be done. The outcomes are measured, the results collated, and an annual report produced. The policies and procedures are reviewed and updated regularly. The contents of all documents are discussed with service users and staff, and representative attend the Regional Advisory Forum Celebration events Records are maintained to a satisfactory standard at the home. They are up to date, and in good order. Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 3 29 3 30 X STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 2 15 X 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 2 2 X 3 3 3 X X Baveney Road, 24 DS0000018627.V272145.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 4 5 6 7 8 9 10 Refer to Standard YA14 YA17 YA19 YA20 YA21 YA24 YA24 YA26 YA35 YA37 Good Practice Recommendations The opportunities for service users to increase their activities should be further developed The independence of service users should be further promoted in regard to the provision of food Health Action Plans should be implemented for all service users Further development of the medication procedures should be undertaken, and should include a profile of side-effects, and a photograph of the service user Training should be provided for all staff at the home on death and bereavement The Fire Risk Assessment should be reviewed and updated Consideration should be given to replacing the windows with double glazed units Soiled carpet and items of furniture should be replaced Fire awareness training should be provided for staff every three months An application for registration from the proposed manager should be submitted to the Commission without delay DS0000018627.V272145.R01.S.doc Version 5.1 Page 22 Baveney Road, 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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