Inspection on 19/06/07 for 25 Barossa Road

This inspection was carried out on 19th June 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

25 Barossa Road 27/01/06

25 Barossa Road 29/11/05

25 Barossa Road 06/09/04

25 Barossa Road 27/04/04

25 Barossa Road 17/02/04

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

CARE HOME ADULTS 18-65 Barossa Road (25) 25 Barossa Road Camberley Surrey GU15 4JE Lead Inspector Mary Williamson Unannounced Inspection 19th June 2007 10:15 Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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 Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barossa Road (25) Address 25 Barossa Road Camberley Surrey GU15 4JE 01276 66047 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) www.mencap.org.uk Royal Mencap Society Ann Kemp Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: UNDER 65 YEARS 27th January 2006 Date of last inspection Brief Description of the Service: 25 Barossa Road is a large detached property located in a residential area of Camberley, close to the shops, recreational facilities and other amenities of the town centre. The home is owned and managed by the Royal MENCAP Society and provides accommodation and care to up to eight people who have a learning disability. Communal areas consist of a good size lounge and a large kitchen/dining area. All bedrooms are single occupancy and have a hand washbasin fitted. No bedrooms have en-suite facilities. The accommodation is arranged over two floors with the first floor being reached by staircase. There is no passenger lift or chairlift fitted. There is a well-maintained garden to the rear of the property that is accessible to the service users and off road parking for two cars to the front of the building. The home does not have its own vehicle, however access to public transport is located close by. The fees charged in this service range from £330 to £563, which does not include the accommodation provided. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. The inspection took place over five and a half hours. Mary Williamson, Regulation Inspector, carried out the inspection. The Registered Manager Anne Kemp represented the establishment. A tour of the premises was undertaken and a number of records relating to the care of the residents and the management of the home were examined. It was possible to meet and talk with two residents who were spending the day at home and to meet and talk with four more residents during the afternoon when they returned from day care activities. They were all very happy with the care and support they receive, and were keen to share their experiences about living in the home with the inspector. There was opportunity to meet and talk with the staff on duty who had a good understanding of the needs of the residents. They were confident in their approach and carried out their duties in a professional and caring manner. The manager completed the AQAA, which was sent electronically prior to the inspection. Six resident survey feedback forms, and one GP comment card were returned to the inspector with positive comments regarding the home. The Commission for Social Care Inspection would like to thank the residents, manager, and the staff team for their help and hospitality during the inspection. What the service does well: The service provides a good standard of accommodation and support for the residents who live there. There is a homely and relaxed atmosphere with good interaction between staff and residents. The needs assessments and support plans in place are detailed and clearly written with the input of residents. There are good arrangements in place to meet the health care needs of residents and specialist support is available when required. Leisure activities are outlined in individual programmes and residents are supported to access community facilities and maintain family links. Staff training and development are ongoing with some staff undertaking NVQ awards. The home is well managed by an experienced and competent manager. There are good quality assurance systems in place. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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 Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have access to appropriate information prior to being admitted to the home. Needs assessments and contracts are in place. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. All the residents have a copy of these, which are also available in picture format. The residents at Barossa Road have been living there for several years. The last resident was admitted three years ago. The manager explained the admission process and the assessment format used. Three needs assessments were randomly sampled. These are informative, well maintained and reviewed at least yearly. One resident stated that she has asked for a review, as she wants to change her day service activities. Contracts of occupancy are in place, which have been signed by the residents. The manager stated that the landlord had recently changed. The contracts need to be updated to reflect this, and must also include the fees charged. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans outline residents’ personal goals and needs. Risk assessments are in place and residents are supported to make decisions about all aspects of daily living. EVIDENCE: Individual care plans based on the person centred approach are in place. These are known as “support plans” in this service. Three support plans were randomly sampled. These are written with the input of the residents, and information gathered from the needs assessment, and includes personal, emotional, educational, and recreational needs and goals. Residents sign these, and staff also sign to say that they understand the content of these plans. Monthly reviews of support plans take place, and are recorded. The manager stated that not all the residents have the support of a care manager and that funding authority reviews are undertaken by the “duty” care manager. The staff encourage and support residents to make decisions about the daily running of the home and all aspects of their daily living. Decisions regarding the running of the home are made at residents weekly meetings. Topics include menus and house shopping. The rota for washing up, laying the Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 10 tables, emptying the bin, and feeding the cat are also discussed. One to one support is also in place using the key worker system when personal needs and independent living skills are promoted. Residents are confident and were observed preparing lunch and afternoon drinks. Risk assessments are in place for all identified risks within the home and in the community. These are individual, well written and do not restrict their independent lifestyle. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate activities are in place and residents participate in community living. Family links are maintained if possible and residents’ nutritional needs are met. EVIDENCE: Individual programmes of activities are in place, which have been agreed with the residents and reviewed on a regular basis. These include attending various day centres, cookery classes, adult education classes, and swimming. One resident stated that she enjoyed attending these activities and another stared that she has requested a review to change her attendance for another centre. Community facilities are accessed and some residents attend an evening class, another attends a sports night, while others like to go to the cinema, visit the library, go to the local pub, and shopping trips. Holidays are organised and several residents spoke of their holiday to Hayling Island and all the entertainment they enjoyed there. One staff member books shows and special events and several residents recently went to see “Take That Experience”. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 12 A pottery class is organised as a home activity. All the residents have a “home day” when they are supported to do their personal shopping, laundry, and tidy their room. Spiritual needs are supported and two residents attend church weekly. Residents also attend a church club during the week. Family links are maintained whenever possible. Visitors are welcome in the home at any reasonable time and relatives may attend reviews by invitation. One resident goes to visit her relatives periodically. Residents are encouraged to follow a healthy eating plan. The residents plan menus during their weekly house meetings. The menus are varied, wholesome and meet the dietary needs of the residents. The main meal is served in the evening to suit the resident’s daily activity programme. Residents are supported to shop and prepare meals. The manager stated that if the shopping is done on line that the residents are also involved. Special diets are catered for and one resident spoke of her specific needs and was aware of what she was able to eat. The kitchen was clean, tidy and busy with residents making drinks and snacks at various times throughout the day. The fridge door handle is broken and needs to be replaced. A staff member was trying to order a replacement handle on line during the inspection but was unsuccessful. The kitchen worktop near the gas cooker is in disrepair and needs to be replaced, as it is a health and safety risk. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate arrangements are in place to meet the physical and emotional needs of the residents in a way they prefer as outlined in individual support plans. The medication policy in place protects the residents living in the home. EVIDENCE: Personal care is carried out as outlined in individual support plans. All the residents are registered with various GPs locally. Two residents stated that the staff support them when they attend appointments. There is also access to the diabetic nurse and the continence adviser. Chiropody treatment is available, and the manager stated that this was in the process of being changed to an alternative practice. All the residents visit a dentist and an optician according to individual needs. Specialist input can be accessed by referral by the GP. One GP comment card was received with positive feedback about the home. There is a medication administration policy in place and all staff who administer medication are familiar with this policy. Following a requirement from the last inspection the home has purchased a new medication storage cabinet, which is located in the office. Boots the chemist supply all the Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 14 medication to the home mainly in blister pack format. They also undertake periodic audits. The home keeps a record of all medication entering and leaving the home. The medication record charts were seen and are well maintained. Training is provided for staff during induction training in the form of medication workbooks. Once completed these are sent for assessment and a certificate of competence issued. Arrangements are in place for the safe storage and administration of insulin for two residents. The home has a booklet in place titled “All my medication”, which is in picture format and explains to residents all they should know about the medication they are taking, the side effects, how to store medicine and how to reorder. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure and the abuse awareness procedure in place protect the residents living in the home. EVIDENCE: The home has a complaints procedure in place and this is also included in the Service User Guide. Residents are aware of this procedure and one stated that she would tell staff if she had anything to complain about. There have been no complaints since the last inspection. There is also an abuse awareness procedure in place and all staff undertake training in this procedure, which is included in the induction programme. During conversation with staff they were able to demonstrate their understanding of abuse and how to respond to any such allegation. The home has a copy of Surrey’s Multi Agency Policies and Procedures on Safeguarding Vulnerable Adults in place. The manager has not attended local authority training in these procedures and a requirement has been made regarding this. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and comfortable home, which is generally well maintained and homely. EVIDENCE: Residents live in a homely environment, which is well furnished and decorated to a good standard. The communal areas of the home include a large lounge, which has recently been decorated, and a spacious dining room/open plan kitchen. There is also a well maintained back garden for residents’ use. Individual bedrooms are personalised to reflect individual personalities and hobbies. These are also furnished to a good standard. The manager stated that the home is due to be refurbished in the near future. A new carpet for the ground floor hallway, as the current one has bleach stains, and the repainting of some outside window frames should be considered in this refurbishment. The home is clean and tidy. The laundry is well equipped and meets the requirements of the home. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a staff team, competent and qualified to undertake their duties. Residents are protected by the organisation’s recruitment procedures. EVIDENCE: Staff spoken to demonstrated a good understanding, and knowledge of the residents’ assessed needs. They are confident in their roles, and undertake their duties in a competent and professional manner. The manager stated that additional staff support is provided when required to enable residents to maintain their activity programme. All staff undertake induction and foundation training, which was evidenced in individual staff training files. NVQ is ongoing with some staff members having achieved NVQ Level 2 and more identified to undertake this in the near future. Formal supervision is in place and this is undertaken every six weeks. Staff also receive annual appraisals. The recruitment policy in place protects the residents living in the home. Three staff recruitment files were sampled. These contained all the required documentation including two written references, an employment history and a CRB (Criminal Records Bureau) disclosure. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from a well managed home, which is run in their best interests and promotes their health, safety and welfare. EVIDENCE: The home is well managed by a competent manager who is experienced in meeting the needs of residents with a learning disability. She has worked with MENCAP for several years, and became the registered manager since the last inspection. She is currently undertaking her NVQ level 4 in management. The manager operates a hands on and open door approach style of management, and has good leadership skills. The home has good quality assurance systems in place. These include regular Regulation 26 visits by the service manager, weekly residents meetings, staff Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 19 meetings, monthly compliance report undertaken by the manager, which is sent to head office, and yearly residents and staff surveys. The home has a wide range of health and safety policies and procedures in place some of which were sampled throughout the inspection. Staff are aware of these procedures as they undertake health and safety training during their induction, and this is updated regularly. COSHH procedures are also observed. Fire safety is observed and fire alarms and equipment are maintained by contract. The manager undertakes weekly checks and fire drills undertaken three monthly. All staff receive six monthly fire safety training. Accidents and incidents are recorded satisfactorily and acted upon accordingly. Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 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 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 21 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 YA5 Regulation 5(1)(b)(c) Requirement Each resident must be provided with a contract of occupancy outlining in detail the accommodation and support provided. This should also include the breakdown of fees, the amount and method of payment and by whom. The contracts also need to be updated to include the new landlord’s name and address and a contact telephone number. The fridge handle must be replaced as this is currently being held together with selotape. The worktop in the kitchen next to the cooker needs to be replaced, as this is chipped and presenting as a health and safety hazard. The registered manager must attend the training provided by the local authority in safeguarding vulnerable adults, in order to protect the residents, and be able to implement correct procedures if an abuse situation occurred. Timescale for action 19/07/07 2 YA24 23(2)(c) 19/07/07 3 YA23 13(6) 19/07/07 Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Barossa Road (25) DS0000013469.V322234.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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