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Inspection on 18/07/05 for 31 Vauxhall Drive

Also see our care home review for 31 Vauxhall Drive for more information

This inspection was carried out on 18th July 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff within the home enables and supports residents within decisionmaking. Clear pathways are in place to help residents reach their full potential and a key worker system in place enables the residents to be fully informed and involved in the review of their care plans. A resident informed the inspector that she had a key worker and said, "she is very nice". The resident showed the inspector her health book and said she did not like visiting the hospital, and was able to demonstrate her full awareness of what her records contained in meeting her health and social care needs. The residents are fully involved in menu planning and assist with the preparation of meals that they have chosen. Menu plans offer choice as areas within the menu plan are altered to suit the needs and tastes of the residents.

What has improved since the last inspection?

The home has made improvements to the back garden and has seating provided for the residents. The home continues to develop and improve the residents care plans to ensure the residents are fully involved and informed.

What the care home could do better:

Management could do better in ensuring the home is safe and clean by reviewing and completing the maintenance decor and repair program in place. Management could reduce the storage of items by returning items not required to health care professionals, and look at the storage availability within the home, this would clear items from the communual three areas that should be available for the residents use. The home must ensure staff adhere to medication policy and ensure staff recruitment records are in place.

CARE HOME ADULTS 18-65 31 VAUXHALL DRIVE 31 Vauxhall Drive Woodley Berks RG5 4EA Lead Inspector Yvonne Souden Unannounced 18 July 2005 09:30 th 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 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 Stationary 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. 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 31 Vauxhall Drive Address 31 Vauxhall Drive Woodley Berks RG5 4EA 0118889448896 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) New Support Options Mr Timothy David Holland Care Home only 6 Category(ies) of Learning disability (LD) registration, with number of places 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 2 Service users may also have a physical disability Date of last inspection 18 January 2005 Brief Description of the Service: 31 Vauxhall Drive is a care home providing twenty-four hour care and accomodation for up to six young adults who have a learning disability. The home is a six bedroomed detached house and is situated in a residential road within walking distance to Woodley shopping precinct, sports centre and doctors’ surgery; amenities within Reading town are within a ten minute drive, and public transport is available. Car parking spaces are available at the front of the property. There is a secluded garden to the rear and side of the building with a patio and seating. 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that observed a secure, relaxed and homely environment for the residents who live there, and observed that the staff team have a full awareness of the needs of the residents and have a positive friendly approach towards residents and visitors to the home. There has been some requirements and recommendations made at this inspection in relation to medication, recruitment and the environment. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 1-5 were not assessed at this inspection. EVIDENCE: 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Service users are fully involved in the planning of their health and social care needs, and are supported within a risk management framework to reach their full potential in life. Service users and involved in the decision-making of the home. EVIDENCE: It was evident from discussions with a very enthusiastic service user that the person centred plan, recently implemented, supports them to make decisions on how their health and social care needs will be met, and that this was centred around the service user as opposed to the service. Discussions with the service user and documentation in place show that a key worker system is in place to ensure the service user is fully involved in the review of their health and social care and needs, and that they are supported by health and social care professionals. Observation of interaction between staff and service users demonstrate that service users are involved in the decision making on all aspects of life within the home. Detailed risk assessments are in place that supports a service user to have an element of risk in their life whilst supporting them to meet their full potential; action plans are in place to minimise risk. 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 9 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 standard(s) 16 & 17 Service users are supported within their daily routine that promotes their independence and choice. Weekly planning of the meals promotes independence and respects individual taste and dietary needs. EVIDENCE: Service users are encouraged to plan and be involved in the menu planning and preparation/cooking of meals. On the day of the inspection a service user went with a member of staff to purchase the weekly groceries, having firstly been involved in the planning of the shopping list. Nutritionally balanced weekly menu plans consider the tastes and needs of all, and offers an alternative should the chosen meal within the menu plan be unsuitable to a resident. Staff interaction with service users who have verbal and non-verbal communication skills was positive, and essential life plans support and respect the privacy and decision making of the service user. 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 10 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 standard(s) 19 & 20 Service users physical and emotional health care needs are met, but they are not strictly protected by the homes policies for dealing with medicines. EVIDENCE: Service users are supported to access health care professionals for example dentist, chiropodist, GP, optician, psychiatrist, and records are maintained to ensure future appointments or review dates are recorded. A service user is supported within a risk framework assessment to self administer medication, and staff administer medication to service users using a monitored dosage system (MDS) as dispensed by the pharmacist, but have not received training from the pharmacist on the MDS in place. Staff have received medication training that has been developed by New Support Options, in line with their medication policy and the Royal pharmaceutical Society guidelines on the administration of medication in care homes, but despite training in place the inspector observed two identical prescribed tubes of ointment in use for a service user, one of the tubes was out of date, as was other prescribed creams. 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 11 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 standard(s) Standards 22 & 23 not assessed at this inspection. EVIDENCE: 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 12 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 standard(s) 24 & 30 Service users live in a comfortable safe environment with systems in place to promote infection control, however some cleaning/décor/repair is required for the home to meet the minimum environmental standard. EVIDENCE: The home had no offensive odours and was generally comfortable and homely; some areas within the home have evidently undergoing a programme of repair and décor but there is a need to extend the repair and décor programme to other areas within the home as detailed within the home’s maintenance Plan dated December 2004, for 2005/06, and previous CSCI requirements. Areas in need of attention to make them safe from becoming a trip hazard or harbouring infection is the laundry where minimal work is required, the cleaning or replacement of the hall/stair carpet, replacement of the downstairs toilet flooring, redecoration of first floor bathrooms and cleaning/replacement of a service users bedroom carpet. Items were being stored in the conservatory that prevented it from being used as a communal area, and the acting manager informed the inspector that plans were underway to clear the room and make it habitable. Paper towels were not available to staff to ensure infection control. 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 13 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 Service users have not been strictly supported and protected by the homes recruitment policy and practices. EVIDENCE: The files of members of staff recruited since the last inspection show that management has followed their recruitment procedure in place to ensure the safety of the service users, and have obtained CRB disclosures on those staff. The home has not complied with the requirement made at the previous two inspections to obtain the personal records that would demonstrate all safety checks have been obtained on a member of staff who transferred from a New Support Option home to Vauxhall Drive, and some staff files do not contain a photograph/clear photograph to identify the staff member. 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 14 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Systems are in place to promote and protect the health, safety and welfare of the service users. EVIDENCE: Fire records demonstrate weekly safety checks are maintained and that staff receive fire awareness training. Water temperatures are monitored and radiators covered to protect the service users from burns and scalds, and records of fridge/freezer temperatures are maintained. The home has health and safety policies and procedures in place, and cleaning items stored demonstrate that the home follows COSHH procedure. Records show that servicing of equipment is maintained. The homes Management Audit Report and Regulation 26 reports sent to the Commission for Social Care Inspection, demonstrate that management takes the safety of the home seriously within their continual monitoring of systems in place. 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 15 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 x x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x x x x x 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 31 VAUXHALL DRIVE Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 16 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 34 Regulation 19 & Sch 2 Requirement The registered person must ensure that the recruitment selection procedure is compliant with standard 34, and that all information specified in schedule 2 of the Care Homes Regulations is obtained in respect of all staff.(Previous timescale 31/03/05 not met) The registered person must ensure a monthly audit of service users medication to ensure prescribed medication that is out of date is not used and is returned as details within medication policy/guidelines set. The registered person must review and update the homes maintenance plan and send a copy to CSCI. The report must detail the anticipated timescale that would be within 2005, to meet the shortfall within the environmental standard and safety of the home as identified within standard 24 of this report. Timescale for action 31/08/05 2. 20 13.2 31/08/05 3. 24 23 31/08/05 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 17 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 20 Good Practice Recommendations Mangement should liaise with the homes pharmacist to arrange training on the MDS system used by those staff who administer medication to service users to ensure precision within the system used. Management should provide staff with paper towels in areas where hand washing facilities are provided, and where personal care is provided to service users to ensure good practice within infection control procedures. 2. 26 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Berkshire 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 31 VAUXHALL DRIVE H52-H01 S11381 Vauxhall Drive 31 V226592 180705 Stage 4.doc Version 1.30 Page 19 - 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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