CARE HOME ADULTS 18-65
3, Silverdale Street Kempston Bedfordshire MK42 8BE Lead Inspector
Mr Paul Worthy Unannounced Inspection 23rd January 2006 2:30 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 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.V280063.R01.S.doc Version 5.1 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.V280063.R01.S.doc Version 5.1 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.V280063.R01.S.doc Version 5.1 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. 9th November 2005 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. 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 2.30 p.m. It took place over 7 hours. The inspector met several of the people living at the home and three showed him their rooms. He spoke to one staff member. Records were also seen. At the first inspection for the inspection year all the core standards had been inspected against with the exception of those relating to the environment, staffing and health and safety. All the standards, including the core ones, relating to the environment, staffing and health and safety were inspected against during this inspection during this second and final inspection for the year. What the service does well: What has improved since the last inspection? What they could do better:
As part of the ongoing programme to improve services there was a reviewing of the role of key workers in the home to ensure that their roles were consistent with the bests interests of those living at the home and complemented the involvement of other staff and the other people important to them. 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 Page 6 The shared living spaces were consistent with the provision of a comfortable and homely atmosphere but the manager and staff were aware that they did not leave anything spare for a dedicated activities room. They were also aware that the garden at present did not provide a useful area for those living at the home to use. The plans for the next financial year include looking at these matters and, while it was acknowledged there was limited scope with the building itself, to see if the garden could be improved and provided with a gazebo for activities. 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. 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 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.V280063.R01.S.doc Version 5.1 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): None EVIDENCE: 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 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): None EVIDENCE: 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 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): None EVIDENCE: 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 Page 11 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): None EVIDENCE: 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 Page 12 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): None EVIDENCE: 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 Page 13 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, 25, 26, 27, 28, 29 and 30 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 there 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 in the last year. Those living at the home had their own rooms with a key to them and those that were looked at had been individualised. There was also documented evidence of ongoing planning to ensure the home was maintained in good decorative order, with the manager taking an active roll in drawing up an annual plan. 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 Page 14 It was observed that the home was being kept clean and fresh and that there were appropriate arrangements in place to ensure hygiene and infection control. 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 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): 31, 32, 33, 34, 35 and 36 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. The manager, staff member and a parent confirmed that there were enough staff to meet the needs of those living at the home and ensure that normally they could undertake their activities. The staff records, staff and the manager confirmed that there were good arrangements for induction, including in-house and LDAF induction and foundation training and an ongoing programme of NVQ training. The manager was maintaining very good records to keep track of mandatory training and updating for staff. Talking to the manager and staff member and observing staff provided evidence 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 records also showed that there were regular supervision and team meetings. The records held at the home provided evidence that the safe staff recruitment practices of Mencap were being followed.
3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 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): 38, 39, 40, 41, 42 and 43 The home was well managed so as to ensure that the needs of those living at the home were met. 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 manager and staff and often chose to sit in a companionable way in the office discussing the day or just resting. The manager was seen to have continued consolidating the introduction of a system for monitoring and reviewing the quality of the service being provided and looking at the ways the service could be improved. This included producing an annual development/business plan at the end of the financial year, which would build on the previous one that had been produced. As well as integrating the monitoring systems already in place, including the monthly visits and reports on Mencaps behalf and the Mencap audits of the home, the 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 Page 17 manager plans to further develop the way the service users, relatives and staff are integrated into the process. The excellent Mencap policies and procedures were seen to be being complemented by a useful set of in-house procedures. The records looked at were being well maintained. In particular the service users plans were seen to be very comprehensive, as were the excellent review documents that were being produced and covering all the main areas of the plans. On one of the files the new plans, which were meant to more clearly reflect the person centred planning approach were seen to be in place. Mencap had very comprehensive health and safety policies and procedures. The housing association was ensuring that there would be a quick response to concerns arising from the routine monitoring of health and safety matters within the home. 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. The manager had taken appropriate steps to involve the GP in ensuring that a previously identified concern relating to ensuring that the intrusive administration of medication in emergency circumstances would be done safely and with the correct medical overview. 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 x 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 x 23 x ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x 3 3 3 3 3 3 3 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 Page 19 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. 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. Refer to Standard Good Practice Recommendations 3, Silverdale Street DS0000014969.V280063.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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