Inspection on 21/11/05 for 26 Cheddar Grove

This inspection was carried out on 21st November 2005.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

26 Cheddar Grove 29/10/07

26 Cheddar Grove 14/02/07

26 Cheddar Grove 07/02/06

26 Cheddar Grove 18/02/05

26 Cheddar Grove 29/09/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Cheddar Grove 26 Cheddar Grove Bedminster Bristol BS13 7EN Lead Inspector Karen Walker Unannounced Inspection 21st November 2005 09:30 Cheddar Grove DS0000020273.V263993.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 Cheddar Grove DS0000020273.V263993.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. Cheddar Grove DS0000020273.V263993.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cheddar Grove Address 26 Cheddar Grove Bedminster Bristol BS13 7EN 0117 9077214 0117 9699000 colin.westwoodrandontrust.org 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 Brandon Trust Mr Colin Richard Westwood Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (7) of places Cheddar Grove DS0000020273.V263993.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Manager must be a RN on parts 5 or 14 of the NMC register Staffing Notice dated 28/03/1994 applies May accommodate up to 7 persons aged 40 years or over, with Learning disabilities. 18th February 2005 Date of last inspection Brief Description of the Service: Cheddar Grove is a large (ex Vicarage) house set in a quiet area of Bedminster Down on the outskirts of Bristol. It has good links with local amenities, shops, pubs and a post office, which are all within walking distance. The house has seven bedrooms, four of which are on the ground floor. There is a large back garden overlooking a school field. The home has qualified nurses on duty at all times and caters for adults with learning difficulties and mild challenging behaviour. The aim of the home is to provide total support for residents in all aspects of their lives. Residents are encouraged to develop self-confidence and life skills. Residents are taken on various holidays, outings and have links with local colleges and day centres. The home caters for ambulant and non-ambulant residents and have mobility aids so all parts of the home are accessible. Cheddar Grove DS0000020273.V263993.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and the inspector met with the manager of the home and with a number of residents. Residents appeared happy in their home and positive comments were received. One resident responded favourably when asked ‘do you like living here’. Staff were observed interacting with residents in a friendly but respectful way. The inspector examined documentation relating to 3 residents. Various documentation relating to service provision, management and safety of the home was also examined. What the service does well: What has improved since the last inspection? What they could do better: Residents will benefit from up to date care plans that are regularly reviewed to reflect the support they currently receive. Cheddar Grove DS0000020273.V263993.R01.S.doc Version 5.0 Page 6 The manager must ensure a care plan is put in place to support residents with the management of their epilepsy. An associated risk assessment should be provided where necessary. It is necessary to put in place an epilepsy profile for the administration of ‘as and when’ (PRN) rectal diazepam this will ensure staff provide adequate support consistently. Residents will benefit from a ‘checking system’ put in place to monitor all healthcare visits and appointments. This will ensure annual check-ups take place with the appropriate healthcare professional. To promote the safety of residents, staff must ensure they receive the appropriate fire training within the timescales dictated by the Avon Fire Service. 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. Cheddar Grove DS0000020273.V263993.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 Cheddar Grove DS0000020273.V263993.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): 1,5 Prospective residents are given information to aid them in their choice of home. They are given a contract detailing the terms and conditions of occupancy. This would benefit from being in a user-friendly format. EVIDENCE: The inspector saw that all residents have been provided with a copy of the service user guide and statement of purpose. Residents’ contracts were included in these documents and were kept in residents’ bedrooms. It was noted that these documents were not in a user-friendly format. The service user guide and statement of purpose were examined and it was noted that they contained all the necessary information as required by legislation. Cheddar Grove DS0000020273.V263993.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): 6-10 Risk assessments in place evidence that residents take supported risks as part of an independent lifestyle. The majority of the residents’ needs are reflected in the care plans and associated risk assessments. Residents are confident that records are stored appropriately and confidences are kept. Residents benefit from an inclusive household where they are empowered to make decisions. EVIDENCE: The inspector examined care plans and noted that some were in need of review as they dated back to May 2004. Cheddar Grove DS0000020273.V263993.R01.S.doc Version 5.0 Page 10 It was noted through case tracking that there was limited information available regarding the management and support of one person’s epilepsy, there was no care plan or risk assessment. This was discussed with the manager and a requirement made. Other care plans reflect the needs of the individual and link to the risk assessments in place. Generally the risk assessments were detailed and current, including manual handling, transferring from chair to bed etc, choking, access to the bedroom, use of hydrotherapy, falls and use of oxygen when outside of the home. The manager demonstrated how moving a resident to a downstairs bedroom dramatically reduced the risk of falls. The inspector saw that documentation relating to residents and the running of the home was stored appropriately. The home has the advantage of a computer where information is also stored and received. There is a confidentiality policy and the manager is aware of the data protection act. The manager said that all staff have their own password and do not have direct access to all the information stored. The home has regular house meeting, which include residents being supported to express their views. Records show that residents have chosen their own wallpaper and bedroom furnishings and chosen and contributed towards planning their holidays. Cheddar Grove DS0000020273.V263993.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Residents take part in many appropriate activitities both in the local and wider community. Residents have appropriate friendships and are supported to maintain them. EVIDENCE: The inspector noted that all residents had a social timetable and one resident particularly enjoys current affairs. She is supported to attend a relevant college course. Records show that residents are members of their local community and use the facilities on offer. The manager said that all of the residents had been on holiday this year. Minutes of the residents meetings evidence that residents were supported to make individual choices about the type of holiday they wanted to go on. The inspector viewed pictures of the residents enjoying various activitities. The manager said that relatives and friends were welcome to visit at any time. Residents are also supported to visit friends in their own homes. Families are invited to visit the home to celebrate formal occasions such as birthdays. Cheddar Grove DS0000020273.V263993.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): 18-21 Residents receive personal support in the way they prefer. In order to safeguard residents a detailed PRN protocol is required to ensure all staff have access to up to date information regarding the administration of rectal diazepam. Not all residents’ healthcare needs are being adequately met. EVIDENCE: Through case tracking the inspector could find no evidence of two residents visiting the dentist. The manager said this was due to one resident having no teeth and the other having dentures. A requirement was made to ensure all residents have access to the appropriate healthcare facilities including the dentist and optician. It was further recommended that a ‘quick view’ sheet be put in place to record all healthcare visits including doctors, dentist, opticians and chiropodist. Key-workers will then see at a glance when annual visits are due. Cheddar Grove DS0000020273.V263993.R01.S.doc Version 5.0 Page 13 The medication records show that one resident is written up for rectal diazepam PRN. There is inadequate information available to assist staff in the decision to administer. Staff should also be aware of when a second dose can be given and when to call the emergency services. A detailed PRN protocol is required to ensure all staff have access to up to date information. There is no risk assessment or additional information in the individuals care plan. The care plan did not include any information relating to the wishes of individuals regarding their illness or death. Although this is a difficult subject to broach those that know the individual well can make a valuable contribution to the plan supporting the residents to have their last wishes met. The home has guidelines on the “last offices” to be carried out by staff in the event of a resident dying in the home. Staff members were observed speaking to residents respectfully in a friendly helpful fashion. Personal care was provided in private and staff were seen knocking on residents doors. Cheddar Grove DS0000020273.V263993.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): 22,23 Residents are protected from potential abuse and their views and concerns are listened to and acted upon. EVIDENCE: The inspector saw that there were adequate policies in place regarding the protection of vulnerable adults. Staff were aware of the whistle blowing policy and policies were discussed at team meetings. The inspector saw that the ‘No Secrets’ in Bristol DOH document was available to all staff alongside the General Social Care Council (GSCC) codes of conduct. The inspector saw the minutes from the residents meetings and noted that residents were asked to share any concerns they may have. The complaints procedure was available in each resident’s bedroom. The complaints book detailed no complaints. The inspector observed the manager balancing the residents’ finances and a random check of 3 financial records were found to be correct. Cheddar Grove DS0000020273.V263993.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): 24-30 The homes premises are suitable for its stated purpose, accessible, safe and well maintained. The environment meets the needs of the current resident group. EVIDENCE: The inspector toured the environment and found all residents bedrooms to be clean and tidy. The bedrooms were individualised and contained various furniture depending on the residents need. All of the radiators in residents’ bedrooms were covered and water temperatures taken regularly. The inspector found the bathrooms and toilets clean, in good decorative order, ventilated and containing the relevant toiletries. All other shared spaces were clean and tidy. It was noted that some continence aids were left on bedroom shelves or on display. These will benefit from being out of sight to maintain the individuals dignity. There is a stair lift available in the home and the necessary equipment was available to ensure residents’ independence is maximised. Cheddar Grove DS0000020273.V263993.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): 32,34,35, 36 Appropriately trained staff that are adequately supervised, support residents. Residents are protected by robust recruitment practices. EVIDENCE: The staffing records are not kept on the premises but held at the Brandon Trust HQ. The manager holds some copies of personal ID and ensures that CRB certificates and references have been obtained in respect of each staff member. The CSCI will at a later date arrange to visit the personnel department and view staffing records. It was noted that there are appropriate policies and procedures in place regarding recruitment and equal opportunities etc. The inspector saw that there are various training courses available to all staff members. The training is varied and staff members chose training courses to reflect the needs of the resident group. It was noted that supervision sessions take place on a regular basis and there was a supervision timetable displayed on the office wall to inform all staff. Cheddar Grove DS0000020273.V263993.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): 37,39,40,42 The residents benefit from a stable staff team who work under the guidance of the Brandon trust policies and procedures. staff lack the necessary training regarding fire safety. EVIDENCE: The inspector took the opportunity to examine the fire logbook and found all the appropriate fire system checks are taking place. It was noted however that the staff are not receiving the fire training within timescales set by the Avon Fire Service this was discussed with the manager and a requirement made. The manager has almost completed the Registered Managers Award (RMA) and is undertaking the NVQ assessors training. Records show the manager continues to update his knowledge and ensures the team provides a well-run service. The Brandon Trust provides a range of appropriate policies and procedures designed to support the staff in care provision and aims to protect residents. Cheddar Grove DS0000020273.V263993.R01.S.doc Version 5.0 Page 18 The manager explained that resident and relative satisfaction questionnaires are used to gain feedback on service provision. The inspector saw in the minutes of the last meeting evidence to show that residents contribute towards the running of the home by sharing ideas and concerns. Cheddar Grove DS0000020273.V263993.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 X X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cheddar Grove Score 3 2 2 3 Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 X 2 X DS0000020273.V263993.R01.S.doc Version 5.0 Page 20 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 YA6 Regulation 15(2)(b) 13(4)(c) Requirement Update and review care plans on a regular basis. Timescale for action 31/12/05 2 3 4 YA19 YA20 YA42 Ensure a care plan is put in place in order to support residents with the management of their epilepsy. Include an associated risk assessment where necessary. 12(1)(a)(b) Ensure all residents have regular access to all healthcare facilities including the dentist. 13(2) Put in place an epilepsy profile for the administration of PRN rectal diazepam. 23(4)(d) Ensure fire training takes place for all staff at timescales dictated by the Avon Fire Service and National Minimum Standards: 6 monthly for staff on day duties and 3 monthly for staff on night duties 31/12/05 31/12/05 31/12/05 Cheddar Grove DS0000020273.V263993.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 2 3 4 Refer to Standard YA5 YA19 YA21 YA24 Good Practice Recommendations Ensure residents’ contracts are user friendly. Put in place a ‘quick view’ healthcare-monitoring sheet to ensure information re visits is readily accessible. Complete the ‘my wishes in the event of death’ section in the planning for life folders. Ensure all continence aids are stored appropriately out of sight. Cheddar Grove DS0000020273.V263993.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Cheddar Grove DS0000020273.V263993.R01.S.doc Version 5.0 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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