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Inspection on 19/07/05 for 24 Baveney Road

Also see our care home review for 24 Baveney Road for more information

This inspection was carried out on 19th July 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The organisational skills of the management are excellent, as evidenced in the comprehensive documentation maintained at the home. Good lines of communication ensure that everyone has the relevant information to enable appropriate decisions to be made. The initial impression gained is that the home is well maintained and cared for, and that it is comfortable and secure. The needs of service users are anticipated, and responded to appropriately. The individuality of each service user is recognised and the commitment of staff to their role in supporting and enabling service users and to person centred work with service users, is commendable. Health Action Plans have been developed for each service user, which are detailed and informative, and ensure a full understanding of their healthcare needs

What has improved since the last inspection?

The requirements from previous inspections had 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 dining room suite, and new carpets have been provided at the home. In addition a new stereo and television have also been purchased.

What the care home could do better:

`We are in the cycle of continuous improvement`, describes the view of staff at the home. The need to build on existing strengths was identified. Recruitment and retention of good calibre staff was also considered to be an ongoing priority for the organisation.

CARE HOME ADULTS 18-65 24 BAVENEY ROAD Worcester WR2 6DS Lead Inspector Rachel McGorman Unannounced 19 July 2005 - 10:00 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. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 24 Baveney Road Address Worcester WR2 6DS 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) 01905 420706 New Era Housing Association Limited Mrs Diane Wood CRH 4 Learning Disability 4 Category(ies) of LD registration, with number of places 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration. Date of last inspection 28 February 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 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. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 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. The care records of service users were inspected, and detailed discussions held with the manager and staff about the content, as service users were 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: The organisational skills of the management are excellent, as evidenced in the comprehensive documentation maintained at the home. Good lines of communication ensure that everyone has the relevant information to enable appropriate decisions to be made. The initial impression gained is that the home is well maintained and cared for, and that it is comfortable and secure. The needs of service users are anticipated, and responded to appropriately. The individuality of each service user is recognised and the commitment of staff to their role in supporting and enabling service users and to person centred work with service users, is commendable. Health Action Plans have been developed for each service user, which are detailed and informative, and ensure a full understanding of their healthcare needs 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 6 What has improved since 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. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 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 standard(s) 1,2,3,4 & 5 Appropriate documentation is in place to enable prospective service users to make an informed decision about their future care needs. The admissions procedure is followed in detail, and all proposed admissions to the home are planned very thoroughly, over several weeks, to ensure an appropriate decision is made, both by the home and the service user. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 9 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. The documentation is produced in an appropriate format if needed, and the Service Users Guide contains numerous photographs. The admission procedure includes extensive assessment by staff from the home, and a Community Care Assessment is undertaken by a social worker. A gradual introduction is made to the home following the initial referral, and a place is only offered if it seems likely that a suitable service can be provided for the prospective service user. Admission is agreed on a trial basis initially. There have been no recent admissions to the home. The positive interactions observed during the course of the inspection between staff and service users, confirmed that staff were competent in the delivery of appropriate care, and were able to meet the differing needs of service users, some of whom have limited verbal communication skills. A statement of terms and conditions of residence is provided for service users. The details of these documents are discussed with each individual, and their family, or representative, and a contract is provided for each service user by the placing authority. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 10 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 The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. Service users living at the home are supported in making choices in all areas of their lives. Risk management strategies are in place, enable a responsible approach to the risks associated with the various activities of daily living. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 11 EVIDENCE: An individual plan of care is produced for each service user, based on the initial assessment undertaken during the admission process. The plans seen are very comprehensive, detailing the specific needs of service users and how these are to be met. A key-worker is assigned to each service user, and has responsibility for ensuring that appropriate care is provided. Monthly meetings are held with the service user, and on-going assessment is also undertaken, any changes are monitored over a period of time, and amendments made when necessary. The needs and individual preferences of every service user living at 24 Baveney Road are identified as far as possible, and their participation in the daily life of the home is encouraged by everyone working there. A Person Centred Approach is part of the philosophy of the care provision in homes run by New Era, and in addition it is the policy of the Organisation to consult service users on policy development and review. Risk assessments are completed, in relation to the premises, to the activities undertaken, and any restrictions imposed, and also in respect of every aspect of the life of each service user. A Confidentiality Code has been produced by the Organisation, which is clearly understood by staff, and reassures service users that information about them is handled appropriately. Training is also given to all staff. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 12 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 Service users are involved in the daily arrangements at the home, as appropriate, and are the focus of the delivery of the high standard of person centred care that is provided. The opportunities made available to service users enable them to live as fulfilling a life as possible. The involvement of each individual in planning their activities, both within and outside the home, means that they are able to choose what they wish to do, and that everything revolves around them. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 13 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. Arrangements for holidays are made, as appropriate, and service users wishes not to go away on holiday, if this is their choice, would also be considered. Links with family and friends are promoted, with a high degree of support provided by staff, to both the family, and to the service user. The limited communication skills of some service users preclude involvement in paid employment or educational opportunities, although others have expressed their wish not to be involved, which is respected. Social activities are available, and these may be undertaken in-house or in the community, and they may be group or individual arrangements, but they are varied and flexible, and reflect the preferences of each service user. A Daily Reflective Diary is maintained for service users living at the home, and is completed twice a day. The detailed record of the daily experiences of each person, enables staff to monitor various aspects of the activity in which they are involved, and to also maintain an ongoing record of their daily lives. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 14 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 Support is provided to each service user, and encouragement given to promoting independence as far as possible, in meeting the personal care needs of each individual. Advice and guidance is available from the primary healthcare teams, and associated specialists, to ensure that the health needs of service users are fully understood, and that appropriate responses are made. 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. Personal care is provided in the privacy of the service users room or bathroom, as appropriate. The healthcare of service users is closely monitored, and additional specialist support and advice is sought from the primary health care team, and other health professionals, when necessary. Health Action Plans have been implemented for all service users living at the home. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 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 standard(s) 22 & 23 A satisfactory complaints procedure is followed at the home, and all interested parties are encouraged to express their views and opinions, which are taken seriously by staff, and responded to appropriately. The awareness of the management, together with the training provided for staff, ensures the protection of service users from all forms of abuse. EVIDENCE: 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. Discussions have been held with service users and their families regarding the process, and all complaints are recorded. The complaints and compliments log was checked, and there had been no complaints made to the home recently. Several very positive comments were recorded and also a letter expressing appreciation was seen. Excellent relationships are also enjoyed with the neighbours, and the local community. Staff are able to demonstrate a clear understanding of the issues relating to abuse, and also to their individual role as an advocate for service users. An appropriate procedure is in place relating to the many aspects of abuse and the protection of vulnerable adults. Training for all staff on the Protection of Vulnerable Adults (POVA) has been provided. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 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 standard(s) 24,25,27,28 &30 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. The premises are very 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. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 17 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. Bedroom doors are fitted with locks that meet the agreed specification, i.e. they unlock with a single action. The rooms are furnished to reflect the personality of their occupants, and some have sensory equipment, specific to the needs of the individual service user. Adequate communal toilet and bathing facilities are also provided. The home is clean and free from offensive odours, and procedures are in place in regard to the control of infection. Staff have training in health and safety matters. There are no outstanding requirements following the last visit of the Environmental Health officer, which took place earlier in the year. The home has not received a recent visit from the Fire Safety Officer, and there are no outstanding requirements from the previous inspection. The Fire Log Book was seen, and the appropriate checks have been undertaken with the required frequency. The communal areas of the home are spacious and airy, nicely decorated and comfortably furnished. Sensory equipment is also provided for the benefit of service users. There is a large lounge and a separate dining room, for the use of service users. Proposals have been made for a new kitchen to be fitted, which would further improve facilities for service users. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,36 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 home has an experienced and competent team of staff, who are able to ensure that the needs of service users living at the home can be effectively met. The extensive training programme available to staff ensures that they are competent in their work, and therefore able to provide appropriate care and support to service users. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 19 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 A training programme is in place at the home that includes Induction and Foundation training, the Learning Disability Award Framework (LDAF) accredited training, and the NVQ training. The training needs of staff are regularly reviewed, and care related courses are attended. A training record is maintained in respect of each member of staff. The rotas indicate that staffing is being maintained at a satisfactory level, and this enables many planned activities to be undertaken with service users. There have been several staff changes in recent months, and this has necessitated the use of agency staff, although they are usually known to the home and to the service users, which provides some continuity of care. Supervision sessions are organised on a regular basis, approximately every 6 weeks, and an annual appraisal is undertaken with each member of staff. Staff meetings are held on a regular basis, usually every month. All staff are provided with the General Social Care Council’s Code of Conduct Practice. Comments from staff were all very positive about their experiences of working at the home, and also of being employed by New Era, and this will inevitably be of benefit to service users. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 20 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) 37,38,39,42 &43 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. The health, safety and welfare of service users is promoted and protected in respect of all safe working practices. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 21 EVIDENCE: The care manager is leaving the organisation this week, and the management responsibility for the home will be taken up by Mrs Susan Lawley, who is currently managing another of the New Era homes in Worcester. An application for registration is anticipated in the near future. There is clear evidence of effective person centred care being delivered, and the home is being managed in an open and transparent manner, which is fully inclusive of service users. The positive interactions observed between staff and service users were pleasing to observe. An annual development plan has been produced which involves the whole home. The team has identified where they 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 of achievements will take place every 3 months, and the outcomes will be measured. A comprehensive health and safety policy has been produced and staff are trained in safe working practices. Appropriate risk assessments are undertaken. Notifications are made to the Commission under Regulation 37, when necessary. A Business Plan is produced by the Organisation, which considers proposals for the next 5 years, and covers all aspects of the work of the New Dimensions Group. A copy of the Plan has been produced specifically for service users. Appropriate insurance cover is in place in respect of the business and the property. 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 22 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 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 24 BAVENEY ROAD Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 3 3 x x 3 3 E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 23 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 Regulation Requirement There are no requirements following this inspection 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. Refer to Standard 28 37 Good Practice Recommendations Consideration should be given to fitting a new kitchen at the home An application for registration for the proposed manager should be submitted to the Commission without delay 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 24 Commission for Social Care Inspection The Coach House John Comyn Drive Droitwich Road Worcester WR4 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. Extracts may not be used or reproduced without the express permission of CSCI 24 BAVENEY ROAD E52 S18627 (24) Baveney Road V236697 190705.doc Version 1.40 Page 25 - 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!