Inspection on 31/08/06 for 25 Welby Close

This inspection was carried out on 31st August 2006.

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 Welby Close 03/07/08

25 Welby Close 28/10/05

25 Welby Close 26/04/05

25 Welby Close 04/11/04

25 Welby Close 10/05/04

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Fairways

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

CARE HOME ADULTS 18-65 25 Welby Close 25 Welby Close Maidenhead Berkshire SL6 3PY Lead Inspector Kerry Kingston Unannounced Inspection 31st August 2006 1:45 25 Welby Close DS0000011285.V305090.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 25 Welby Close DS0000011285.V305090.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. 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 25 Welby Close Address 25 Welby Close Maidenhead Berkshire SL6 3PY 01628 824154 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) The Disabilities Trust Mr George Tuffour Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 Brief Description of the Service: 25 Welby Close is a residential home offering twenty-four hour care. The home is registered for three residents with learning difficulties. Service users have lived in the home for several years. The service is provided by The Disabilities Trust. The house is situated in a residential area. There are three bedrooms; all of the bedrooms are single and although only one of them has an en-suite facility, the two other residents have their own private bathrooms and toilets. There is also one communal toilet on the ground floor of the home. The home has its’ own transport. The fees are £1,514.29p per week. 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit which took place between the hours of 1.45 pm and 5.00 pm on the 31st August 2006, to collect additional information to inform the report for the key inspection. The Information was collected from a pre-inspection questionnaire, completed by the manager, surveys completed by two of the three service users, discussions with one staff member, the manager, limited observations of service users and staff, A tour of the home, service user and other records were also used to collect information, on the day of the visit. The home is registered for three service users. Service users have good verbal communication but chose not to speak with the inspector, they conveyed their wishes very clearly. What the service does well: 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. 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 6 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 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 7 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): 2 T The quality in this outcome area is good. Service Users made an informed choice about where they wanted to live and have an individual contract/statement of terms and conditions. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: There have been no new admissions since the last inspection, all service users had assessments prior to admission. Two service users noted on the service users surveys that they had been asked if they wanted to move to the home and had enough information about the home prior to admission. Service users are asked at review if they are happy in the home and if they wish to remain there, their responses are recorded. 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 8 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): 6,7 and 9 The quality in this outcome area is good. Service users individual needs are well met and their choices are encouraged and respected. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: All Service users individual care plans were seen, they included methods of communication, likes/dislikes, behavioural guidelines, risk assessments and activity planners. Care plans are reviewed (formally) annually and any necessary changes are made to the care plan to ensure the home is still meeting the needs of the service users. Additional meetings are held if there are any specific changing needs or behaviours to address. Daily notes, resident meetings, key worker meetings and service users’ attendance and contributions to their reviews, demonstrate that service users are encouraged to be an integral part of the decision-making processes. One service user, actively, chooses not to attend her review and this is also noted. All service users have appropriate risk assessments, which are updated frequently, they support service users to maintain and develop their 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 9 independence. These include independent access to the community and the operation of kitchen and household equipment. 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 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): 12,13,15,16 and 17 The quality in this outcome area is good. The home supports service users to enjoy a positive lifestyle, in which they have choice and some control. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: Each service user has an individual activity plan, one service user goes to external day services four times a week, one five times a week and one service user has a tailor made programme provided by residential staff (because of special requirements). Day activities include college courses, day centre and physical activities. Daily notes evidenced that activity programmes are adhered to unless a service user, actively, chooses not to participate. Service users access the community regularly. Two are able to go out without staff presence, detailed risk assessments support this activity. Although there is sometimes only one staff on duty, additional staff are provided if needed for specific activities. Records of day trips and evening outings are also kept in the home. 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 11 All service users have some contact with families, two visit their family homes regularly and are visited by family and friends. One has occasional visits but phones and keeps in touch with a family member. Staff facilitate contacts and encourage service users to maintain relationships outside of the home. Service users made it very clear that they did not wish to talk to the inspector but there was good evidence of their involvement in choosing their daily activities, food and daily routines (see standard 7). Menus were seen to offer wholesome and nutritious meals and no complaints about the food were made at the residents meetings. 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 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): 18,19 and 20 The quality in this outcome area is good. The service users are provided with a good standard of care that reflects their wishes and meets their health and personal care needs. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: Service users have individual records relating to all health appointments, health professionals write notes in the records or the staff complete them. Any health needs identified, are responded to quickly. Care plans note service users likes and dislikes. The staff have been in place for several years and are knowledgeable about the preferences likes and dislikes of the service users. There was evidence of appropriate action and discussions taking place with service users about their health and emotional needs. Medication records seen were accurate and staff are trained to administer medication using the Boots MDS system. Only trained staff administer medication. There were no specific guidelines for some medication that is used occasionally to help to control behaviours (see standard 23). 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is good. The service users are, generally, kept safe from abuse and are able to express their concerns and opinions, which are listened to. Guidelines relating to physical restraint need to be improved for safety. This judgement has been made using the available evidence, including a visit to the service. EVIDENCE: There have been no complaints since the last inspection. There have been three incidents where service users have been reported as missing. Individual Policies and procedures are in place so that staff know how to deal with these incidents .The home is addressing the issues of late arrivals home and the risk involved for one individual. Appropriate action is taken in the event of service users not returning home at the agreed time, guidelines could be more detailed for one service user. One service user deals with his own finances, the other two have family members acting as their appointees. Staff work hard to ensure service users deal with their monies as independently as possible. Cash records were accurate. Staff have been trained in the Protection of Vulnerable Adults and one staff member was able to explain fully what action he would take if there were any concerns around abuse or he received any complaints. Service user surveys noted that service users knew how to complain and to whom. Restraint is used very occasionally with one service user (there was one recorded incident) but there are no specific guidelines in place, for it’s use (see standard 20 and 35). 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 14 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 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): 24 and 30 The quality in this outcome area is adequate, there is an overall good standard of cleanliness and hygiene but there are two areas that need to be attended to. The home is comfortable, clean and safe. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: The home was clean and fresh and there is ongoing decorating. The service users have their own bathrooms and bedrooms. One bedroom had a ceiling that is in poor repair and the material needs to be checked. The washing machine is sited in the kitchen and there is no risk assessment currently, available. 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 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): 32,34 and 35 The quality in this outcome area is good. The staff are qualified and very competent but the behavioural guidelines should match the staffing ratios. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: Staff were observed, minimally as service users chose to stay in their rooms but they were seen to be treating service users with great respect. Notes of meetings and discussions with service users showed sensitivity, understanding and a very positive attitude towards them. Staff are supervised monthly (generally), staff said that they felt well supported and described the content of their supervision meetings. Staff are offered good training opportunities one has NV.Q.3 and one is pursuing N.V.Q. 4 (the home has three permanent staff members). The home is seeking to employ a female staff member, as there is currently an all male staff team and one female service user (help with personal care is not required.). No staff appointed since the last inspection, when recruitment records were seen to meet the standard. Head office check out agencies and the home only use staff from the company’s approved agency. One service user has occasional aggressive behaviours but his behavioural programme was not supported by the current staffing ratios i.e. the guidelines said call for help, there is often only one staff member on duty. This needs 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 17 review as it could be a danger to the service user and staff members (see standard 20 and 23). 25 Welby Close DS0000011285.V305090.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 The quality in this outcome area is good. The home is well managed, in the interests of the service users and they are safe in the home. This judgement has been made using available evidence, including a visit to the home. EVIDENCE: The manager is experienced and qualified and staff said that they find him supportive. Service users views are listened to and acted upon, as appropriate. The views of relatives, other professionals and service users are sought. Regulation 26 visits are completed monthly. The home does not have an annual development plan although it does make annual bids for capital for home improvements. All health and safety maintenance checks and tests are completed regularly and all staff have completed mandatory Health and Safety training, a few updates are needed. 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 19 25 Welby Close DS0000011285.V305090.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 X 2 3 3 X 4 X 5 X 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X 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 2 X 3 X 3 X X 3 X 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 21 NONE 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 3 Standard YA23 YA30 YA35 Regulation 13.7 . 8 16.2(j) 18.1(a) Requirement To develop detailed physical restraint guidelines that staff must adhere to. To risk assess the location of the washing facilities in the kitchen. To review staffing ratios in regard to behaviour programme guidelines. Timescale for action 01/11/06 01/12/06 01/11/06 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 2 3 Refer to Standard YA20 YA24 YA39 Good Practice Recommendations To develop detailed guidelines for the use of P.R.N medication. To check the ceiling in the downstairs bedroom and repair (as necessary). To produce an annual development plan to enable the home to monitor progress and performance. 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 25 Welby Close DS0000011285.V305090.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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