Inspection on 11/01/07 for 3, Silverdale Street

This inspection was carried out on 11th January 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

3, Silverdale Street 23/01/06

3, Silverdale Street 09/11/05

3, Silverdale Street 07/02/05

3, Silverdale Street 23/08/04

3, Silverdale Street 02/03/04

Similar services:

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Claremont House

Coopers Mill Ltd

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Bramley Avenue (73)

Paradise Lodge

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Upaya Ananda

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

CARE HOME ADULTS 18-65 3, Silverdale Street Kempston Bedfordshire MK42 8BE Lead Inspector Mr Paul Worthy Unannounced Inspection 12th January 2007 12.15 3, Silverdale Street DS0000014969.V326629.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 3, Silverdale Street DS0000014969.V326629.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. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3, Silverdale Street Address Kempston Bedfordshire MK42 8BE 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) 01234 302432 www.mencap.org.uk Royal Mencap Society Andrew Charles Reeves-Smith Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mr Reeve-Smith must register, for and start work on gaining an NVQ 4 in care and management within six months of the date of this registration. 23rd January 2006 Date of last inspection Brief Description of the Service: The service is provided by Mencap and the property owned and maintained, except for the maintenance of bedrooms, by Jephson Housing Association. 3 Silverdale Street is an extended Victorian semi-detached house in a residential area of Kempston. On the ground floor there is one bedroom, bathroom and the communal space consisting of a lounge and a kitchen/diner. There is an office/meeting room. Seven further bedrooms are on the first floor. The home is in walking distance of a range of local amenities, including shops, pubs, and places of worship, leisure facilities and a park. It is also close to the main bus routes between Kempston and Bedford. The charges were not checked at this inspection. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 12.15 p.m. It took place over 9 hours. The inspector met several of the people living at the home and three parents. He spoke to three staff. He had lunch with two of the service users and the two staff on duty. Records were also seen. What the service does well: What has improved since the last inspection? There had been further changes since the last inspection to the building to facilitate the independence of those living there with some degree of physical disability. The ongoing programme to ensure that person centred planning was being taken forward had progressed in exciting ways, in particular through the use of the new computer and the use of digital photography. A Mencap notice was up in the office stressing that person centred planning was an ongoing process rather than a one-off event. The role of the key worker had become clearer since the last inspection with expectations of regular meetings with service users to monitor and review their plans. There was a very impressive programme already under way for the continuous ongoing improvement of the service, which placed person centred planning at the heart of the approach. A folder was dedicated for the information accumulating as part of this process. The managers monthly reports as part of this programme allowed the identified areas for improvement to be tracked on an ongoing basis. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 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 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was good initial assessment information relating to those living at the home that was kept updated to ensure that their current needs and aspirations could be and were being met. EVIDENCE: There had been no recent moves to the home. The assessment information relating to the last person to move to the home had been noted, in a previous inspection report, as good and consistent with the home being able to meet her/his needs. The records seen showed that there were good arrangements for ensuring that the assessment information was kept up to date to ensure that each service users needs continued to be appropriately met. Talking to staff about the present service users living at the home and seeing the service users during the day of the inspection showed that their needs were being well met. In one persons case the help of outside specialists was being called upon to ensure that her/his needs were met in the best possible way. Modifications to the building had been made to achieve this. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were effective arrangements for identifying the needs and aspirations of those living at the home so that they would be helped to live as independently and fully as possible. EVIDENCE: The files contained comprehensive assessment and planning information. In particular those looked at had individual plans (called Person Plans), which were written in a user friendly way and gave a comprehensive picture of their needs and the plans to meet them. Person Centred Planning (PCP) had been introduced and was playing an important part in involving those living at the home in planning their own lives. Observation on the day and speaking to staff showed that those living at the home were being given as much support as was needed to live lives that were as full and independent as possible. This 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 10 was being done in the context of risk assessments. The Plans were seen to cross-reference to relevant risk assessments. The key worker reviewed the Person Plan with the person living at the home on a monthly basis. Records of comprehensive six monthly reviews involving the service user and all the relevant people involved in supporting her/him were seen. It was clear from what was seen on the day and talking to the staff that those living at the home were fully involved in the planning of their lives and supported to achieve their aspirations. There were regular meetings for the service users so that they could be involved in planning relating to their communal activities within the home. There was extremely good work, including very positive use of the new computer with its broadband connection, to take forward Person Centred Planning, and ensure that the service users direct involvement in the process was helped and the outputs of the process in the form of documents were in a form that the service user could understand and produce or help produce themselves. The use of digital photography was seen to be playing an important part in this. The collages that those living at the home had produced celebrating life there were seen and gave a very positive impression of the home. The PCP was playing an important part in involving those living at the home in planning their own individual lives and being involved in drawing up their own Person Plans. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12, 13, 14, 15, 16 and 17 Those living at the home were provided with the support that they needed to live lives that were as independent and enriching as possible. EVIDENCE: The assessment and planning information showed that those living at home were being supported to be involved in a wide range of activities, including employment. These provided the opportunity for individual development and access to the community. The service users and staff spoke about their activities, including holidays. There was good contact with family and friends and staff supported this as was seen on the day of the inspection. The home was operated in a way that created a group living situation. This was observed to be the case, with those living at the home all sharing in daily domestic activities supported by staff. This was seen to help those living there to 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 12 maintain as much independence as possible and develop independent living skills. There were weekly meetings of those living at the home, which involved them in decisions relating to their daily lives, including meals. Appropriate information relating to service users dietary needs were seen to be contained in their plans and staff were seen to be supporting those living at the home to eat in a healthy way, in particular so that they could pursue their chosen activities. The coming and going of those living at the home on the day of the inspection reflected the diversity of activity. The discussion about the activities of the day and also of holidays and planned activities showed how much they were enjoyed. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff were providing appropriate care and support to those living at the home to ensure that they maintained as much independence and good health as possible. EVIDENCE: There was good assessment and planning information relating to care, support and health needs. The personal support and care provided was seen to be appropriate, although it was predominantly support that was required. Risk assessments were seen to be in place ,when appropriate in both the case of care and support. The assessment and planning information about the medical needs of those living at the home was seen to be up to date and to cover routine, emergency and ongoing medical care. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 14 There were appropriate arrangements for managing medication, which included details of the medication being taken by each of those living at the home. Some of those living at the home took responsibility for their own medication, on a risk-assessed basis. This allowed for appropriate monitoring by staff. Staff confirmed that they had had appropriate training for administering medication. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were effective arrangements for dealing with the concerns and complaints of those living at the home and for ensuring that they were protected so that they felt listened to and safe. EVIDENCE: Mencap has good formal policies and procedures relating to the making of complaints, which were seen to be complemented by a variety of ways for ensuring that service users were supported to make their requests and concerns known to staff and the manager. This included ensuring contact with an advocate, where there was no family support. It was noted that the expectation that key workers would routinely check on these matters during their regular meetings with their service users was an area being monitored through the monthly visits on behalf of Mencap (regulation 26 visits). The regular meetings for those living at the home were also being used to provide them with a opportunity to voice concerns or requests. There had been no complaints since the last inspection. Appropriate procedures were in place to ensure that incidents of abuse would be dealt with effectively and there was evidence that staff were aware of these. A recent monthly visit on behalf of Mencap had noted that there was a need for a round of training relating to the prevention of adult abuse. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation was well maintained and furnished so that it provided those living there with a homely and comfortable environment. EVIDENCE: The assessment and planning information looked at provided evidence that there was an ongoing attempt to ensure that the accommodation met the needs of those living at the home, and in particular helped them maintain their independence and privacy even with the onset of physical disability. The housing association that owns the premises was seen to have provided the special facilities and adaptations recommended by occupational therapists and further work relating to the garden was planned. Staff confirmed that an occupational therapist was due to carry out a further inspection to determine ways of increasing independence within the home. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 17 The public areas of the home were seen to be being maintained in good order so as to ensure their homely and comfortable feel. The home was observed to be being kept clean and fresh. On the evening of the inspection there was rowdy behaviour from a group of young people that led to damage to the front door. Although this was the first time there had been any such incident, the manager later confirmed that he would be talking to the local police to ensure that they are aware that there are vulnerable adults living at the home and to determine a plan of action to involve the police should there be a recurrence. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff were appropriately trained and organised to ensure that all the needs of those living at the home would be met. EVIDENCE: There was a good staff rota that reflected the staffing on for the day and confirmed that acceptable staffing levels were being maintained when service users were at home. There were appropriate arrangements for dealing with sickness including the use of bank staff, which would ensure that staff who knew the service users were called. Staff felt that there were enough staff normally on duty to ensure that those living at the home could be supported to undertake their normal range of activities. The staff confirmed that there were good arrangements for induction, including in-house and LDAF induction and foundation training and an ongoing 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 19 programme of NVQ training. The manager was maintaining records to keep track of mandatory training and updating for staff. Speaking to staff and observing them interacting with those living at the home showed that they had a good knowledge of the service users and their need to be supported to live as independently and fully as possible. The staff confirmed that there were regular supervision and team meetings. A newly recruited member of staff provided evidence that the correct procedures had been followed to ensure that people who could endanger those living at the home were not recruited. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those living at the home benefited from it being well managed so that they could live as independently and fully as possible. EVIDENCE: The home was seen to be operating in an open, positive and inclusive way, which emphasised that it belonged to those living there. It was particularly noticeable how those service users arriving home all came into the office with a cheery word for the staff and often chose to sit in a companionable way in the office discussing the day or just resting. There was a very happy feel in the home and sense of conviviality and mutual support between the service users as well as between them and the staff. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 21 Mencap was seen to have introduced an excellent system for monitoring and reviewing the quality of the service being provided to those living at the home. It included a policy and procedure that detailed a Continuous Improvement Programme. It also included a diagram of the process. The latter made clear how the Person Centred Planning lay at the centre of the process. The managers first monthly reports that form an important component of the process were seen as were the reports of the monthly visits on behalf of Mencap (regulation 26 visits) that had begun to monitor the Continuous Improvement Programme and were seen, themselves, to be an important part of the process. The report of the regulation 26 visits included a summary sheet and a much fuller report. Only the regulation 26 report summary was being sent to CSCI. It was not clear if the intention was to send a copy of the managers regular report to CSCI to conform to regulation 26, which requires reports in respect of any review of the service to be sent to CSCI. It was seen that there continued to be good monitoring arrangements in the home relating to health and safety issues. There was seen to be an appropriate emphasis on a risk assessment approach in respect both of the environment generally and the specific service users. 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 22 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 3 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 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 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 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 x x 3 x 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 23 N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA39 Good Practice Recommendations A decision should be made in the context of the procedures relating to regulation 24 if the managers regular reports as part of the Continuous Improvement Programme constitute a review and a copy should be sent to CSCI, and whether other documents such as the audits carried out by Mencap on their homes will also be considered a review and a copy sent to CSCI. CSCI should be informed of the outcome of these considerations and what review documents they can expect to receive. The full regulation 26 report should be sent to CSCI . 2 YA39 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 3, Silverdale Street DS0000014969.V326629.R01.S.doc Version 5.2 Page 25 - 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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