Inspection on 20/09/05 for 26 St Barnabas Road

This inspection was carried out on 20th September 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

26 St Barnabas Road 26/01/09

26 St Barnabas Road 05/02/08

26 St Barnabas Road 21/03/07

26 St Barnabas Road 21/02/06

26 St Barnabas Road 02/02/05

26 St Barnabas Road 22/06/04

26 St Barnabas Road 24/02/04

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Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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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 26 St Barnabas Road Emmer Green Reading Berkshire RG4 8RA Lead Inspector Robert Dawes Unannounced Inspection 20th September 2005 11.45 26 St Barnabas Road DS0000011047.V249676.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 26 St Barnabas Road DS0000011047.V249676.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. 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 26 St Barnabas Road Address Emmer Green Reading Berkshire RG4 8RA 0118 946 1775 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) Milbury Care Services Limited Mr Steve Lacey Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. Service users not to be admitted over 65 years of age. Date of last inspection 2nd February 2005 Brief Description of the Service: 26 St. Barnabas Road is part of Milbury Care Services Ltd. and registered to provide support and care for six adults with learning disabilities, between 18 and 65 years of age. The home is situated in a suburb of Reading. It consists of six bedrooms, lounge/dining room, kitchen, shower room and bathroom. The aims and objectives of the home are to provide a secure and comfortable home; encourage and support residents to make decisions and choices in their lives; support and assist service users to make and maintain satisfying relationships; assist service users to develop their skills; and enable service users to engage in valued day time occupation and use the community facilities. 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the day on Tuesday 20th September 2005. The Inspector toured the premises, spoke with the manager and looked at records. Fifteen of the sixteen standards assessed were met and one was nearly met. Two requirements and two recommendations were made. What the service does well: What has improved since the last inspection? What they could do better: The new manager intends to ensure the home continues to be decorated; the service user plans are regularly reviewed; and a storage facility is provided. 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 6 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. 26 St Barnabas Road DS0000011047.V249676.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 26 St Barnabas Road DS0000011047.V249676.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): Numbers 1 and 2. Prospective service users have the information they need to make an informed choice about where to live. New service users are admitted only on the basis of a full assessment. EVIDENCE: The statement of purpose complies with the requirements of the regulation. A service users’ guide is in place but still needs to be developed into a userfriendly format. No one has been admitted to the home for three years. An admissions policy is in place. 26 St Barnabas Road DS0000011047.V249676.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): Numbers 6 and 7. Every service user has an individual plan which covers all aspects of personal and healthcare needs. The plans must be reviewed at more frequent intervals than at present. Service users make decisions about their lives with assistance as needed. EVIDENCE: All the files are now in a Person Centred Planning format and contained comprehensive information about the service user and good individual support requirements. All service users have key workers. Reviews are taking place but not at the frequency required by the standard. None of the service users maintain their own benefit books or handle their own finances. A representative of the organisation based at the head office is the appointee for the service users’ benefit money. Service users’ benefit money goes directly into individual bank accounts. Two staff signatories are required to withdraw personal money from service users’ accounts if service users do not withdraw their own money. Service users’ personal money is kept in the manager’s safe except for one service user who keeps his money in a locked safe in his room. Records are kept of all deposits and withdrawals. The organisation audits the financial accounts at regular intervals. 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 10 26 St Barnabas Road DS0000011047.V249676.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): None of the above standards were assessed. EVIDENCE: 26 St Barnabas Road DS0000011047.V249676.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): Number 20. Staff follow the procedures for administering, recording, storing, and disposal of the medication. EVIDENCE: Medication records were in order. No controlled drugs are kept in the home. No service user self medicates. A pharmacist visits every three months to check the recording, storage, handling and disposal of the medication. Only staff who have received appropriate training and have been authorised administer the medication. Sufficient staff have been trained to administer rectal diazepam to cover every shift. 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 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): Numbers 22 and 23. Every effort is made to enable service users to communicate their views. Service users are protected from abuse, neglect and self-harm. EVIDENCE: The home has a complaints procedure. Leaflets explaining the complaints procedures have been given to relatives and service users who are able to read the leaflet in its current format. There have been no complaints since the last inspection. The home has adult protection and prevention of abuse procedures. The majority of staff have undertaken protection of vulnerable adults and physical intervention training. Physical intervention guidelines were seen on the files of service users who could be a physical risk to themselves or others. The Inspector recommended that all relevant people, including the service user, sign physical intervention agreements. Any physical intervention is recorded. 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 14 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): Numbers 24 and 30. The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meets service users’ needs in a comfortable and homely way; and is kept clean and hygienic. EVIDENCE: Since the last inspection the carpet in the downstairs corridor and hall has been replaced with vinyl flooring; the hall, downstairs corridor and stairs have been decorated; a carpet in a service users bedroom has been replaced; and the garden has been tidied and is better utilised i.e. service users keep the raised flower beds tidy. The downstairs bathroom and toilet is due to be refurbished and the upstairs corridor decorated after new lighting has been installed. A storage facility for such items as the tricycle, stand aide and shower chair has still to be provided. The home was clean, hygienic and free from offensive odours 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 15 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): Numbers 32, 33, 34 and 35. The staff team is developing stability, experience and competence. There is a good ratio of care staff to service users on duty each day. The organisation operates a thorough recruitment procedure. The home has a comprehensive staff training programme. EVIDENCE: The staff team is developing stability and experience. Four care staff now have a level 2 or above in care. Two staff members will start NVQ training as soon as they have completed the LDAF course. Three care staff plus the manager are on duty during the week. Three care staff are on duty at weekends. Two members of staff are on duty at night (one awake and one on ‘sleep in’ duty). Agency and bank staff are seldom employed. Staff records seen by the inspector confirmed that the organisation was operating a thorough recruitment procedure. Since the last inspection a concerted effort has been made by the management team to ensure the majority of staff received training in the skills and knowledge they require to care effectively for the service users. The new manager places a high priority on training and is continuing to offer appropriate training to his staff. All new staff receive structured induction and LDAF training. 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 16 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): Numbers 37, 39 and 42. Service users benefit from a well run home. Effective quality assurance and quality monitoring systems are in place. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The new manager has only been in post for a month. He was previously the deputy manager of the home for three years. He will shortly start studying for his NVQ4 in care and the Registered Managers Award. Regulation 26 visits take place as required. Staff meetings take place at regular intervals. Service users meetings are shortly to be introduced. A quality assurance audit by a representative of the organisation takes place annually. Satisfaction questionnaires have recently been distributed to service users and relatives. Those who responded commented favourably on the quality of care. An annual development plan which covered all the standards has been produced. 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 17 Records showed the health, safety and welfare of service users is being protected. 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 18 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 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 26 St Barnabas Road Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000011047.V249676.R01.S.doc Version 5.0 Page 19 Yes 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 Requirement Reviews of the care plan must take place at least every six months. Timescale of 30/4/2005 not met. Suitable provision is made for the storage of items such as the tricycle, stand aide and shower chair. Timescale of 31/3/2005 not met. Timescale for action 31/03/06 2 YA24 23 31/12/05 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 YA1 YA23 Good Practice Recommendations The service users’ guide should be developed into a userfriendly format. Specific restrictive physical intervention agreements should be signed by staff, care managers, service users and relatives. 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 20 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 26 St Barnabas Road DS0000011047.V249676.R01.S.doc Version 5.0 Page 21 - 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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