Inspection on 04/07/05 for 24a Corporation Road

This inspection was carried out on 4th July 2005.

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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

24a Corporation Road 30/05/07

24a Corporation Road 06/07/06

24a Corporation Road 31/01/06

24a Corporation Road 03/03/05

24a Corporation Road 04/01/05

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Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 24A CORPORATION ROAD Chelmsford Essex CM1 2AR Lead Inspector Jane Greaves Final Unannounced 4th July 2005 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. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 24a Corporation Road Address Chelmsford, Essex CM1 2AR 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) 01245 495010 Redbridge Housing Association Frances Elizabeth Beard Care Home 8 Category(ies) of Learning disability 18-65 (8) Learning disability registration, with number over 65 years of age (2), Physical disability (4) of places 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Eight persons of either sex, under the age of 65 years, who require care by reason of a learning disability, of whom four also have a physical disability. 2. Two persons of either sex, aged 65 years and over, who require care by reason of a learning disabilty, whose names were made known to the National Care Standards Commission in June 2003. Date of last inspection 03/03/05 Brief Description of the Service: 24a, Corporation Road is a modern, purpose built, single storey property situated in a quiet residential area close to Chelmsford town centre. The property is divided into two separate living units each with four single bedrooms, bathrooms, toilets and communal facilities. The home provides accommodation and care for 8 adults with learning disabilities and physical disabilities who have medium to high dependency needs. The home aims to empower service users to maximise their independence and to integrate into the local community. Specialist equipment, including baths and hoists, are provided and all bedrooms are suitable for wheelchair users. The grounds are private and secure with adequate parking facilities available to the front of the property. The home is situated on a bus route although the town itself is within walking distance. The registered proprietor is Redbridge Community Housing Limited, a voluntary organisation. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place one day in July 2005 over 2 hours. 16 of the 43 National Minimum Standards were assessed with 10 being met. Five of the six standards that were not met remained outstanding from previous inspections. At the time of the inspection 3 residents were away on holiday, two were at the day centre and three were at home. The inspector was assisted with this inspection by support staff and the home’s registered manager, Mrs Frances Beard. What the service does well: What has improved since the last inspection? What they could do better: Records relating to staff recruitment, staff supervision and appraisals and quality assurance surveys undertaken should be made available for scrutiny by the Commission for Social Care Inspection. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 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. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .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 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .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 Prospective residents had the information they needed to make an informed choice about where to live. EVIDENCE: The service User Guide and the Statement of Purpose had been further developed in a resident friendly format in order to enable prospective residents to make informed choices. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 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 standard(s) 6 and 9 Residents were comfortable with the knowledge that their assessed and changing needs were reflected in their individual plans of care. Residents were supported to take risks as part of an independent lifestyle. EVIDENCE: The plans of care of individual residents were comprehensive and detailed including regular reviews to assess changes in individuals’ care packages. Changes were documented clearly enabling support staff to deliver care appropriately. Staff members supported the residents to take risks as part of their everyday independent lifestyles. Some residents had been horse riding and others went swimming regularly, assessments of the risks involved and ways to reduce the potential risk to the resident were documented. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 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 standard(s) 14, 16 and 17 Residents enjoyed various leisure activities but were not provided with a 7 day holiday as part of the contract. The residents’ rights were respected and responsibilities recognised in their daily lives. Residents were offered a healthy diet and enjoyed their meals and mealtimes. EVIDENCE: The organisation did not provide residents with the option of a 7 day break away from the home as part of the basic contract price. This is a matter of funding and is being negotiated between RCHL and Social Services. From conversation with one of the residents at home on the day of the inspection, with the support staff and sampling care plans it was evident that the rights of individual residents were protected and they were encouraged to take responsibilities appropriate to their abilities. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 11 The main meal of the day at 24a, Corporation Road was served in the evening to take account of the residents’ daily lives and activities. Food stocks in the freezer, fridges and cupboards were varied and plentiful and a folder of mouth watering picture prompts was available to assist the residents in planning the weekly menus. A record was made of all food served to each resident and what alternatives were chosen. The kitchens in both houses had been refurbished and were bright, fresh and clean. The carpeting had been replace in the dining areas also. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 12 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 Residents received personal support in the way they preferred and required. EVIDENCE: Residents at 24a, Corporation Road were robustly supported to be individuals. Personal care was delivered as unobtrusively as possible. Any ‘gender specific’ requests from residents regarding their care provision were respected and actioned by the staff team. Residents selected what clothing they wished to wear, they were supported to visit the local hairdressing salon and to make choices regarding haircuts and treatments. Residents were able to go to bed and arise when they so wished. Residents had a key worker assigned to them. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 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 standard(s) Residents were confident their views were listened to and acted on however; the outcomes of complaints made were not appropriately recorded. Support staff did not have specific training to protect the residents from abuse, neglect and self-harm. EVIDENCE: The previous inspection highlighted that detail of the outcomes of complaint investigations and resulting actions to be taken to address the complaint must be recorded. This was still an outstanding requirement at this inspection. The registered manager was advised to write the required detail on the current complaints form even if an appropriate ‘section’ had not yet been added by RCHL. At the previous inspection in March 2005 the inspector was informed that PoVA training was to be secured for all support staff as a matter of urgency. Since then all RCHL training courses have been suspended whilst the organisation reviews it‘s training provision. All staff spoken with and the registered manager showed good awareness of the protection of vulnerable adults from abuse and all staff members had been given the ‘Protecting Vulnerable Adults’ booklet. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 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 standard(s) 30 On the day of this inspection the home appeared clean and hygienic. EVIDENCE: The home generally appeared clean and hygienic. As mentioned previously in this report both kitchens had been refurbished. Some carpets in communal areas were stained and scheduled for replacement. Refresher training in the control of infection had not yet been undertaken due to the temporary suspension of the training program. Laundry facilities were sited away from food preparation and serving areas. The laundry floor finishes were impermeable and the washing machines had the specified programming ability to meet disinfection standards. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 15 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) 33,35 and 36 An effective staff team supported residents. Appropriately trained staff met residents’ individual and joint needs. Residents benefited from well-supported and supervised staff. EVIDENCE: The staffing numbers had increased due to successful recruiting resulting in the registered manager reducing the care hours she had been working. The relief team had also increased in numbers and the use of agency services had reduced. The organisation provided specific user group training for support staff but this had been temporarily suspended whilst the training for the organisation as a whole had undergone re-evaluation. The registered manager had developed an individual training matrix for all support staff identifying training received and required. This record is maintained on the individual staff files and was not seen at this inspection. Staff appraisals and supervision sessions were arranged and a clear schedule was on the wall of the office. RCHL still maintain that it is a breach of confidentiality for Commission for Social Care inspectors to have access to 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 16 supervision and appraisal records. The deputy manager offered her personal file for scrutiny. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 17 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) 39 and 40 Self-monitoring and quality reviews took place however there was no confirmation that residents’ views were the basis for these. Residents’ rights and best interests were safe guarded by the home’s policies and procedures. EVIDENCE: The registered manager confirmed that a quality assurance survey was undertaken by the organisation at least annually. A memo from the Chief Executive of RCHL was sent to all managers stating that results of the QA surveys of residents and staff must not be shown to the Commission for Social Care Inspection due to Data Protection issues and that it is an internal audit and apparently not relevant. The organisation’s policies and procedures were easily accessible to staff and residents alike. They were kept regularly under review and were being developed into a resident friendly format. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 18 Some records required by the Commission for Social Care inspection were not available for inspection. Records relating to staff recruitment, staff supervision and appraisals, and the results of the Quality Assurance audit were not available for this inspection. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 19 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 x x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x 2 x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 24A CORPORATION ROAD Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x 2 3 2 x x I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 20 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 YA22 Regulation 22 (8) Requirement Timescale for action 31st October 2005 2. YA23 3. YA36 and YA41 4. YA39 The registered person shall supply to the Commission on request a statement containing a summary of the complaints made during the preceding twelve months and the action taken in response. THIS IS A REPEAT REQUIREMENT 13 (6) The registered person shall make arrangements, by training staff or other measures, to prevent residents being harmed/suffering abuse/being placed at risk of harm or abuse. Section 31 The registered person must (4)(a) ensure all records pertaining to Care the running of the care service Standards are made available for scrutiny Act 2000 by the Commission for Social Care Inspection,This specifically relates to records held in relation to staff and Quality Assurance surveys. THIS IS A REPEAT REQUIREMENT. 24 The registered person shall supply to the Commission a report in respect of any quality review conducted by him and make a copy of the report available to service users. THIS IS A REPEAT REQUIREMENT I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc 31st October 2005 31st October 2005 31st October 2005 24A CORPORATION ROAD Version 1.40 Page 21 5. 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 YA14 Good Practice Recommendations The registered person should ensure that residents have the option of a 7 day break away from the home as part of the basic contract price. THIS IS A REPEAT RECCOMMENDATION. 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 22 Commission for Social Care Inspection Fairfax House Causton Road Colchester Essex C01 1RJ 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 24A CORPORATION ROAD I56-I05 S17731 Corporation Road V233953 UI 200605 Stage 4 .doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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