CARE HOME ADULTS 18-65
Barossa Road (25) 25 Barossa Road Camberley Surrey GU15 4JE Lead Inspector
Marianne Barham Unannounced Inspection 29th November 2005 12:40 Barossa Road (25) DS0000013469.V260717.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.V260717.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.V260717.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.V260717.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 6th September 2004 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.V260717.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 12.40pm by Marianne Barham, regulation inspector. The inspection was undertaken over a period of three hours and was the first inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The acting manager of the home, Anne Kemp was present 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 service users’ bedrooms have recently been re-decorated creating a nicer environment for them. The service users were involved as fully as possible in choosing the colour scheme and soft furnishings for their rooms. Formal staff supervision and appraisal has now been introduced, meeting a requirement made at the last inspection on 6th September 2004. This helps staff members to understand their role and carry out their duties more effectively.
Barossa Road (25) DS0000013469.V260717.R01.S.doc Version 5.0 Page 6 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.V260717.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.V260717.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 Service users do not have enough information to make an informed choice about where they live. EVIDENCE: A requirement was made at the last inspection on 6th September 2004 to produce a service users guide in order to give service users enough information about the home. Whilst it was pleasing to see that a guide had been produced, meeting the requirement, it was disappointing to see that it had not been given to the service users. It was also disappointing to see that the guide is not available in an accessible format such as pictorial. A further requirement has been made that the guide is made available in a format the service users understand and that a copy is given to each of them. Barossa Road (25) DS0000013469.V260717.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): 6 and 9 Each service user has an individual care plan that reflects their changing needs and goals, and they are supported to take acceptable risks as part of an independent lifestyle. EVIDENCE: All service users have an individual care plan generated from the initial assessment. Service users also each have a ‘life plan’ that focuses on their aspirations as well as their assessed needs. The plans give clear information on all aspects of the person’s needs and how to meet them. All care plans are signed as read by the service users or have a record of the plan being explained to them. All plans are reviewed and updated on a regular basis and diary notes are kept for each service user. Service users are encouraged to be as independent as possible by the home, with a variety of detailed risk assessments being completed for each service user and clear guidance for staff to follow put in place. There was evidence to show that the risk assessments are reviewed regularly. Barossa Road (25) DS0000013469.V260717.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): 15 and 16 Service users are supported to have appropriate personal, family and sexual relationships and their rights and responsibilities are recognised and respected by the home. EVIDENCE: Service users can receive visitors at any time, without a prior appointment. The manager stated that contact with families and friends are actively encouraged and the home supports the service users in this. Service users are able to see their visitors in their rooms if they wish to have privacy and they would be supported by the home if they wanted to have a consenting sexual relationship. The home involves service users as fully as possible in the daily running of the home, they are encouraged to make choices about how they spend their time, who they spend it with, when to get up and go to bed and what to wear. All service users have free access to all communal areas of the home including the gardens.
Barossa Road (25) DS0000013469.V260717.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 Service users’ physical and emotional health needs are met by the home and they receive personal support in the way they prefer and require EVIDENCE: Service users’ preferences and needs regarding how they are supported is recorded in their care plans. Members of staff on duty demonstrated a high level of knowledge and understanding of each person’s individual needs and preferences. All service users are registered at local GP practices and specialist health professionals are accessed through them. Staff members are made aware of the service users health and care needs through the care planning process in the home. Service users are also registered with a local dentist practice, an optician, and a chiropodist. Barossa Road (25) DS0000013469.V260717.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users’ views are listened to and acted upon by the home. EVIDENCE: The home has a complaints procedure in place that gives clear guidance on the steps to follow when making or receiving a complaint. This is posted on the notice board in the kitchen and is also in the service users guide a copy of which has been given to all service users. A record is kept of all complaints received and actions taken to address them. Barossa Road (25) DS0000013469.V260717.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 The home is clean, safe and comfortable and service users bedrooms reflect their individual needs, interests and preferences. EVIDENCE: The home is suitable for its stated purpose with adaptations fitted as necessary. All communal areas are comfortably furnished with pleasant décor. The spacious kitchen is well equipped and fully accessible to the service users. Service users bedrooms are of a good size and are comfortably furnished with plenty of storage. The rooms are decorated according to the service user’s taste and reflect their individual interests and hobbies. Two service users spoken with said they liked their bedrooms and one took great pleasure in showing the inspector their room and personal possessions. The home is clean and tidy throughout with adequate provision made for laundry and waste disposal. Barossa Road (25) DS0000013469.V260717.R01.S.doc Version 5.0 Page 14 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): 35 Service users’ needs are met by, appropriately trained staff. EVIDENCE: The home has a training programme in place with detailed records kept on computer of all staff training. Training needs are identified initially at induction and then through the homes supervision and appraisal process. Members of staff spoken with felt that they receive a good level of training and were able to identify various training courses undertaken in the last year. These included developmental training as well as mandatory training. Barossa Road (25) DS0000013469.V260717.R01.S.doc Version 5.0 Page 15 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 39 The home is well run, however the acting manager would benefit from training in order to carry out her duties effectively. Service users views are sought and acted upon by the home. EVIDENCE: The home currently has an acting manager, appointed in September 2005. During discussion with the acting manager it became apparent that she is unclear as to whether this role is to be permanent. This was of concern as the previous manager left the home over a year ago. The acting manager is competent and demonstrates a good knowledge of the needs of service users and the processes involved in the running of the home, however she has not undertaken any formal training such as NVQ in care or management despite having worked for MENCAP for seven years. A requirement has been made that the intended management arrangements for the home are communicated to the Commission and what training is to be provided to the acting manager in order for her to carry out her role.
Barossa Road (25) DS0000013469.V260717.R01.S.doc Version 5.0 Page 16 The home sends out an annual survey to service users, relatives and people involved in the service users lives. The results of this survey are then published along with actions to be taken to address any shortfalls in the service, and made available on request. Service users meetings are held regularly and are recorded, all service users attend. Barossa Road (25) DS0000013469.V260717.R01.S.doc Version 5.0 Page 17 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 1 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Barossa Road (25) Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X X X DS0000013469.V260717.R01.S.doc Version 5.0 Page 18 NO 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 37 Regulation 8(1)(a)(b) (2)(a)(b) Requirement The registered person must clarify management arrangements planned for the home and submit details to the Commission of how they will ensure that the acting manager receives sufficient training and support to be able to carry out her role effectively. Each service user must be supplied with a copy of the service user guide in a format that is accessible to them. Timescale for action 29/12/05 2 1 4(1)(2) 5(1)(2) 28/02/06 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 37 Good Practice Recommendations It is strongly recommended that the acting manager is given more frequent supervision sessions with the senior manager than she is receiving at present owing to her lack of NVQ or equivalent training. Barossa Road (25) DS0000013469.V260717.R01.S.doc Version 5.0 Page 19 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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