CARE HOME ADULTS 18-65
WELBY CLOSE 25 Welby Close Maidenhead Berkshire SL6 3PY Lead Inspector
Katy Brown Unannounced 26 April 2005 @ 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Welby Close Address 25 Welby Close Maidenhead Berkshire SL6 3PY 01628 824154 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) The Disabilities Trust Mr George Tuffour Care Home 3 Category(ies) of Learning Disabilitiy (LD) registration, with number of places WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 04/11/04 Brief Description of the Service: Welby Close cares for three adults. It is set in a residential area and the home has a vehicle to assist residents with transport requirements. Public transport is available to enable residents to visit local amenities and the town centre if they prefer. The home is on two levels with residents bedrooms on both floors; there are no aids and adaptations around the building as the residents that live there are not dependent them. All of the bedrooms are single and have ensuite facilities. There is one communal toilet on the ground floor of the home. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over four hours. There have been no additional visits made to Welby Close since the last announced inspection. A tour of the premises took place and staff records, residents’ care records and some of the homes’ records were inspected. One member of staff on duty, two of the three residents and the manager were spoken to. What the service does well: What has improved since the last inspection?
The manager and the staff are encouraging residents to explore different activities and try things that are new to them. Staff have received refresher training that enables them to continue to meet the needs of residents. The fire officer has visited the home and has asked for some improvements to be made that will ensure the safety of the residents’. This is something that is required by the Care Homes Regulations 2001.
WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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 WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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) 3 The staff employed at the home and the services and facilities that are available to residents are able to meet their identified needs. EVIDENCE: Individual records are kept for each resident and an inspection of the records for two residents’ living at the home, confirmed that their identified needs were being met and that specialist support was available when required. Residents’ that were spoken to said that staff were meeting their needs and that they were happy at the home. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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) 7 The residents can make decisions about their lives and are encouraged and supported by staff and the manager, to do so. EVIDENCE: Individual plans of care are available for all residents and any changes or limitations to their daily living have been discussed between residents and the home and a signed agreement has been completed. Residents that were spoken to said that they attend care review meetings and that they are involved in decisions that are made about their care. Residents would be provided with advocacy support if required or requested. All residents’ are registered to vote and one resident said, “ I am going to vote, to have a say in what happens to my town”. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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) 13 and 16 Residents are provided with opportunities to make decisions about the way the home is run and are able to recognise and maintain their own responsibilities within the home. They are also supported to take an active part in leisure activities and the community events of their choice. EVIDENCE: All residents have individual activities programmes, which enable them to be aware of what things they will be doing each day. The activities that are provided are a combination of community events, college classes and leisure pursuits. Staff are currently encouraging residents’ to explore new activities and to try things that they had not done previously. Residents’ said that they are looking forward to this. One resident that was spoken to, confirmed that he is able to choose whether he attends activities or not and gave an example of a member of staff collecting him early from the day centre when he wished to return home prior to the end of the session.
WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 Page 11 Staff provide regular meetings for residents to discuss their views and opinions about the home and how it is run. There is also a key worker system in place and residents said that their key-workers help them to sort out any problems that they might have. Residents are aware of the rules and policies within the home and are encouraged to discuss any areas of disagreement with each other in a one to one setting. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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 and 20 Generally the residents’ are provided with a good standard of care that reflects their wishes and meets their assessed needs and they are protected by the homes policies and procedures. However, staff must ensure that their own preferences do not take precedence over the resident’s wishes. EVIDENCE: Staff that were spoken to were very clear about individual residents’ needs, likes and dislikes and were seen treating them with respect and dignity and in a way that made them happy. One resident said that staff meet his needs and generally provide support around his wishes, although there had been occasions when staff had put their own needs before his own. The examples he gave included, an occasion when he was required to walk around certain shops to look for an item that a member of staff wished to purchase for their own use and also when a member of staff refused to accompany him to the bank or certain shops during the weekend as the town centre is busy at this time. Individual records are kept for identified medication needs and staff receive training in medication administration. Satisfactory polices and procedures are in place to support staff. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 Page 13 WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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 standard(s) 22 Not all residents feel confident that they could make a complaint as they are worried about the consequences if they do so. EVIDENCE: All residents have a copy of the complaints procedure and the manager and staff keep a record of complaints that are made at the home. The CSCI has not received any complaints in respect of this service A resident that was spoken to, said that he had never made a complaint, as he was concerned that something worrying might happen. He was concerned that the senior management team might become involved in the complaint and lots of things would change at the home. He said that he really liked it at the home and did not want to upset anyone or anything. During the visit, the resident discussed these concerns with the manager who has now agreed to explore possible ways to make complaining a less worrying process for residents. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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 standard(s) 30 There is collective responsibility between residents’ and staff, which ensures that the home is clean and hygienic and free from infection. EVIDENCE: There are policies available for the control of infection and residents confirmed that staff advise them of the importance of hygiene. A tour of the premises identified that the home is clean and hygienic and residents’ take responsibility for cleaning their own bedrooms and bathrooms. There is a washing machine and tumble dryer available and residents’ are responsible for the laundering of their clothes and bed linen. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Staff receive an induction to the home and a variety of training that enables them to provide a good service to the residents that live there. EVIDENCE: Staff that were spoken to, confirmed that they receive training that helps them meet the needs of residents and said that they have recently been registered on a number of refresher courses. Inspection of records identified that new staff receive an induction when starting work at the home; this will enable them to become familiar with the residents and their identified needs and also the homes policies and procedures. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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, 42 and 43 The manager and staff at the home seek residents views and opinions and ensure that they are reflected in the way that the home is run. The safety and welfare of residents’ is met through the health and safety policies and procedures and care practices at the home. EVIDENCE: A resident that was spoken to said that in the past they have been invited to attend The Disabilities Trust forums and meetings to discuss their views of the service provided. Residents confirmed that the manager and the staff do attempt to make changes if they are unhappy with anything and felt that their views are taken seriously. The home has satisfactory health and safety policies and procedures in place and an inspection of records identified that regular maintenance checks are completed for equipment used at the home. Requirements that were made by the fire officer during a visit in February have mostly been complied with, although some work is still required.
WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 Page 18 Representatives from the senior management team have been visiting the home on a monthly basis to monitor the service that is provided for residents’. However, the Commission has not been receiving copies of the reports that are completed following these visits. These reports enable the Commission to monitor the service provision during the time period between inspections. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 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 x x 3 x x Standard No 22 23
ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x 3 x x 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 3 x x 3 x Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
WELBY CLOSE Score 2 x 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 2 H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 Page 20 NA 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. 2. Standard 42 43 Regulation 13 26 Requirement That the registered provider ensures that the requirements made by the fire officer are met. That the registered provider supplies a copy of the completed monthly report on the conduct of the home to the Commission. Timescale for action 26 July 2005 26 May 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 18 22 Good Practice Recommendations Staff should respect the choices of residents and not put their own wishes first. Staff and the manager should seek ways to encourage residents to make a omplaint if they are unhappy. WELBY CLOSE H52-H01 11285 25 Welby Close V213843 260405 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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