CARE HOME ADULTS 18-65
Barossa Road (25) 25 Barossa Road Camberley Surrey GU15 4JE Lead Inspector
Marianne Barham Unannounced Inspection 27th January 2006 13:10 Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 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) Royal Mencap (Housing & Support Services) Mrs Clare Church Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The age/age range of the persons to be accommodated will be: UNDER 65 YEARS 29th November 2005 Date of last inspection Brief Description of the Service: 25 Barossa Road is a large semi-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. Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out at 13.10pm by Marianne Barham, regulation inspector. The inspection was undertaken over a period of two and a half hours and was the second inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The acting manager of the home, Anne Kemp was not on duty but spoke to the inspector over the telephone and a total of three staff members and two service users were spoken with, the remaining five service users being out at planned activities during this inspection. Records relating to the care of service users and management of the home were also examined as part of this inspection. What the service does well: What has improved since the last inspection?
The acting manager is now receiving more support and supervision from her senior manager and this helps her to carry out her role more effectively. The acting manager has also untaken training on management duties such as supervision and appraisal and disciplinary training. This was recommended at the last inspection on 29th November 2005. The acting manager has consulted with colleagues and has now put together a service users guide that is in picture format making it easier to understand for Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 6 the service users. This is now ready to be put into packs to give to each service user, meeting a requirement made at 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.
Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Prospective service users have enough information to make a choice about where they live and each service user has their individual needs and aspirations assessed. EVIDENCE: A requirement was made at the last inspection on 29th November 2005 that the service users guide be produced in a format that is more accessible to them, for example in pictorial form, and that they each receive a copy. It was pleasing to see that the home is working towards this, the manager has consulted with colleagues and a template has been produced that the inspector was able to see, and this is expected to be completed and a copy given to the service users within the agreed timescale of 28th February 2006. Each service user has an individual ‘life plan’ in place that incorporates an assessment of their needs. The assessment is comprehensive, covering all aspects of everyday living as well as recreational, educational needs and aspirations. Individual assessments were examined for four service users. These were clearly written and demonstrated good evidence of the service user’s participation and of regular review having been carried out. Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The home supports and encourages service users to make decisions about their lives. EVIDENCE: The home encourages and supports service users to be involved in the daily running of the home as fully as possible. There is a key work system in place and each service user has one to one time weekly with their key-worker during which independent living skills are promoted. Service users meetings are held weekly in the home at which the service users are able to air their views and discuss any changes they would like to see, for example the menus or daily routines. These meetings are recorded. Two service users spoken with told the inspector that they are able to get up and go to bed when they wish, can choose what they wear, when to shower or have a bath and what to eat or drink. The inspector was able to observe the service users deciding what to have for lunch and making hot drinks for themselves and the inspector, which was very much appreciated. Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 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): 12, 13 and 17 The home supports service users to take part in activities suitable to their age, abilities and preferences and to be a part of the local community. Service users are offered a balanced, healthy diet that takes account of their individual needs and tastes. EVIDENCE: Each service user has an individual timetable of activities in place. These are agreed in consultation with the service user at their review meetings. There are a variety of activities on offer located in local day centres or at colleges offering adult education courses. Service users’ religious and cultural needs are recorded in their individual ‘life plans’ and they are supported to attend religious services if they wish to do so. Good use is made of the facilities in the local community such as the cinema, library, leisure centre and pubs as well as the local shops. The two service users at home during this inspection had recently returned from a shopping trip and said that they enjoyed going out to their activities
Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 11 and to the town centre. Both said that they could choose how to spend their time and one spoke about the arrangements for a forthcoming holiday. Menus are planned at the weekly service users meetings with support from the care staff. The kitchen/dining area is large enough to accommodate the service users and staff members to take their meals together and is very homely. Food is purchased at the local supermarket and was seen to be stored appropriately. All members of staff have undergone food hygiene training and records of fridge/freezer temperatures and of foods cooked are maintained. The kitchen and dining area were seen to be very clean and tidy. The service users spoken with said that they liked the meals in the home and that they helped to cook them. Both said they liked to help in the kitchen and going out to do the food shopping. The inspector was able to observe these service users putting the shopping away and discuss the evening meal planned with the care staff. Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 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 the following standard(s): 20 The home’s policies and practices for dealing with medicines generally protect the service users, however records for the receipt and return of medication need to be kept and the storage of the medication is not adequate. EVIDENCE: The medication is supplied by the local pharmacy, mainly in blister packs. The pharmacy carries out audits and advisory visits to the home. The medication administration record (MAR) charts are pre-printed and sent with each new order of medication to the home. The MAR charts were examined and no gaps or errors were in evidence. The home does not keep a record of medicines received into the home or returned to the pharmacy and a requirement has been made to address this. The home has a policy and procedure in place for dealing with medicines and each service user has an individual medication profile and photograph that helps to reduce the risk of errors. All members of staff have received training to administer medication and a list of those trained is kept in the medication file. The medication is currently stored in a locked filing cabinet in the office. The inspector was able to see the medication in this cabinet and is concerned that
Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 13 there is a risk of error occurring as the medication is all mixed together with no facility to store each individual’s medication apart from the other. The office is currently undergoing refurbishment and the inspector strongly recommends that a purpose built medication cabinet is purchased and fitted during this refurbishment that is large enough to accommodate the blister packs and store each service users’ boxed or bottled medication apart. Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 14 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): 23 The home protects service users from abuse. EVIDENCE: All members of staff in the home have attend the ‘respond and respect’ training provided by MENCAP and those members of staff spoken with were able to demonstrate a good level of knowledge and understanding of adult abuse issues and their responsibilities in this area. The home did not have a copy of the Surrey Multi-Agency Procedures on the protection of vulnerable adults from abuse, however the member of staff in charge was seen to order this during the inspection, therefore no recommendation has been made. Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 15 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): N/A These standards were not assessed at this inspection. Please see report dated 29th November 2005 for detail on these standards. EVIDENCE: Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 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): 32 The staff team are experienced and know the service users well, however they are in need of NVQ training to be appropriately qualified and competent to carry out their jobs effectively. EVIDENCE: Members of staff spoken with were experienced and demonstrated a good level of knowledge and understanding of the needs of the service users and their roles and responsibilities in the home. It was of concern to see that not one member of staff in the home had undertaken NVQ training, including the home manager this fails to meet the minimum standard of fifty percent of the workforce achieving NVQ level two by 2005. A requirement has been made to address this. The inspector had intended to assess standard 34 at this inspection, however it was not possible to see the staffing recruitment records owing to the home manager not being on duty therefore these will be examined at the next inspection. Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 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 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 and 42 The home is well run, however the manager still requires training and support to manage the home effectively. The health, welfare and safety of service users is promoted and protected by the home. EVIDENCE: A requirement was made at the last inspection on 29th November 2005 that the manager be provided with greater supervision and support from her line manager and training relating to the management of the home be undertaken. The manager informed the inspector over the telephone that she is now receiving supervision regularly and has attended courses such as supervision and appraisal, disciplinary training since the last inspection. The requirement also stated that the registered person must provide the Commission with written confirmation of how it intends to ensure sufficient training and support is given to the manager so that she can carry out her role effectively. This was not done therefore the requirement is carried over. Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 18 It was also disappointing to see that the manager is not yet registered on the NVQ level 4/Registered Managers Award, despite not having any care qualification. The manager informed the inspector that she is attending a meeting on 10th February 2006 to discuss this. The manager is still unclear as to whether she is to be the permanent manager in the home and also said that she had had four line managers since May 2005 owing to an organisational restructure. A requirement has been made the organisation clarify their intention regarding the management of the home and provision of senior management to the Commission. The home has policies and procedures in place for health and safety that all members of staff sign as read. Health and safety audits are carried out monthly and there is a programme of routine maintenance and repairs in place. Fire equipment, alarms etc are checked quarterly with alarm tests weekly and evacuations monthly. All members of staff have received training on health and safety issues at induction and are updated annually. Records are maintained of servicing and repair of equipment and fire, electrical and gas safety certificates are held in the home. Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 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 3 X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 1 X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Barossa Road (25) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 3 X DS0000013469.V260748.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES 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 20 Regulation 13 (2) Requirement The registered person must ensure that records are maintained in the home of all medication received into the home and/or returned to the pharmacy and that these are signed by the member of staff and/or the pharmacist. The registered person must ensure that at least 50 of the staff employed in the home including those working on bank or agency system must commence on NVQ level 2 (minimum) training. The registered person must clarify in writing to the Commission the management arrangements intended for the home and of the arrangements regarding the senior management of the home manager. Timescale for action 28/02/06 2 32 18 (1) (a) (b) 31/03/06 3 37 8 (1) (a) (b) 28/02/06 Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 21 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 20 Good Practice Recommendations It is strongly recommended that a purpose built medication cabinet is purchased and fitted during the office refurbishment in order to store the medication safely and appropriately. It is very strongly recommended that the acting manager is registered to commence NVQ level4/Registered Managers Award at the earliest opportunity owing to the fact that she has no qualification in care or management yet is in day to charge of the home. 2 37 Barossa Road (25) DS0000013469.V260748.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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