Inspection on 11/05/05 for 330 Westward Road

This inspection was carried out on 11th May 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 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

330 Westward Road 18/04/06

330 Westward Road 29/11/05

330 Westward Road 15/02/05

330 Westward Road 26/05/04

330 Westward Road 09/12/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 330 Westward Road Ebley Stroud Gloucestershire GL5 4TU Lead Inspector Paul Chapman Unannounced 11 May 2005 10:00 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. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 330 Westward Road Address Ebley Stroud Gloucestershire GL5 4TU 01453 823852 Not known Not known Home Farm Trust 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) Mrs Jenny Miles Care Home 8 Category(ies) of LD - Learning Disability - Both (8) registration, with number of places 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: no Date of last inspection 15th February 2005 Brief Description of the Service: 330 Westward Road is a three storey detached house with accommodation for eight adults with learning disabilities. The home is conveniently situated in Stroud, which enables service users to access local community facilities. Service users also have access to transport that is provided by the home and this enables them to access facilities in several other local towns. The home is staffed 24 hours a day, seven days a week. Family and friends are welcome to visit the home at any time and service users can meet them in private if they wish to. The service users attend various activities, which include Day services provided by Home Farm Trust at their Frocester Manor site and College courses. Some of the service users are also employed locally. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed over a 4 hour period from 10 am one morning. All of the service users were spoken with and the 3 staff on duty at the time. The manager was not present. Two service user’s records were case tracked to ensure that their assessed needs were being met and other records required by the Care Homes Regulations 2001 (health and safety, training, staffing rotas, etc) were examined. A tour of the home was completed that included seeing the majority of the service users’ bedrooms with their assistance. What the service does well: Service users’ files are well organised and the monthly reports compiled by staff are comprehensive allowing easy access to relevant information about each service user. Service users have taken the lead in developing their PCP’s (Person centred plan’s) on the home’s computer. Staff support service users to make decisions about their lives. Staff empower the service users to lead independent fulfilling lives where they can continue their hobbies and interests. Service users also attend college and some are employed locally. The home has an annual review meeting where staff and service users discuss any issues and plan for the future. This empowers the service users enabling them to have a direct influence on the practices of the home. The home is maintained to a high standard and is clean and hygienic. All staff have completed a minimum of NVQ level two for which the manager and staff are to be commended. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 6 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. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 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 standard(s) EVIDENCE: None of the outcomes were assessed directly on this occasion. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 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 standard(s) 6, 7, 8, 9, 10 Individual needs and choices are identified and respected by staff who support service users to achieve their goals. Risk assessments empower service users to lead independent lifestyles. EVIDENCE: The inspector examined two service users’ Person Centred Plans (PCP) and their associated personal files. Records of annual reviews were present which identified goals they wished to achieve. Evidence was available to show that if the goal had not been achieved already, progress was being made to achieve it. In discussion with the service users they gave examples of the goals stated in their plan. A recommendation would be for the service user to be able to sign their goal sheet/paperwork. Staff had completed a number of assessments of the service users skills, for example personal care, ironing, completing tasks in the kitchen. Some of these documents were missing dates and others needed review. Staff on duty explained that the manager had asked for these to be reviewed recently but due to the staff computer needing repair they had been unable to do this. These assessments will be reviewed at the next inspection. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 10 Staff are supporting service users to develop PCP’s on the home’s computer using Microsoft’s powerpoint program. Examples of these were seen and showed that the service users are taking the lead in their development. In conversation with the service users they gave examples of staff supporting them to make decisions about their lives and the inspector witnessed staff doing this during the inspection. Key workers complete monthly reports about each service user that is collated from their daily notes. This report covers topics such as accommodation, leisure activities, behaviour, finance, health and relationships. Minutes of the service users meetings were seen and showed that they were held regularly and gave service users the opportunity to be involved in the day to day running and planning of the home. In addition to this the home hold an annual review meeting with staff and service users where practices are discussed. The home has comprehensive risk assessments (environmental and personal) that are regularly reviewed by staff that are appropriately trained. The risk assessment for the home’s lounge must be reviewed and the date changed on the risk assessment for the annex to ‘04, instead of ’05. Service users’ information is stored securely in the home’s office. Service users can keep their files in their bedrooms if they wish and some choose to do so. Information shared with the inspector during the information was handled appropriately. Staff complete financial management assessments with all the service users. Where it is judged as appropriate they manage their own finance. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 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 standard(s) 11, 12, 13, 14, 15, 16, 17 The lifestyles of the service users’ are varied and fulfilling meeting their identified needs. EVIDENCE: A number of the service users attend a local church regularly, also service users attend a local college where they are completing various courses. Four of the service users are employed locally. In conversation with them they explained what was involved and how much they enjoyed their jobs. At the previous announced inspection the home had been running a job club to support the service users in gaining employment. Service users’ gave numerous examples of using facilities in the local community either with staff support or independently. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 12 When talking to the service users they were able to give numerous examples of their interests and hobbies, these included; walking, swimming, cycling, camping, steam rally, DJ’ing discos, drawing and painting. The home has developed an art room and staff support the service users to complete various projects. At the time of this inspection one service user was building a model of the Eiffel Tower from match sticks while two others were painting. Service users stated that friends and family are always welcome at the home and details of past visits had been recorded in the house meeting minutes. Service users records gave examples of their rights being respected and the practices observed throughout the inspection supported this. Service users’ are registered to vote. The inspector was able to examine the menus for the home which are written and supported by pictures. Menus showed that a varied and balanced diet was available. The two couples that live in the home compile their menus and are responsible for shopping for the ingredients and cooking their own meals. Staff support service users to do this if it is needed. The other service users choose their menus on a weekly basis each Sunday after the service user’s meeting. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Physical and emotional health needs are met and medication administration is managed effectively. This contributes to maintaining the safety of the service users. EVIDENCE: Service users require minimal assistance with their personal support and assessments have been completed and are due to be reviewed. Comprehensive records were available that showed service users health needs were assessed and addressed where required by other professionals. Records of the medication administration were examined and showed that it was being managed correctly. Some service users manage their own medication, risk assessments are available to support this practice and staff regularly check that the service users are taking their medication. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 Policies and procedures are in place to protect the service users and they understand how they use/initiate the appropriate procedure when required. EVIDENCE: The home has a comprehensive complaints procedure that is accessible to all service users. No complaints have been made since the previous inspection. When complaints have been made previously they have been managed correctly and service users have commented positively about the process. Staff complete update training in the protection of service users from abuse. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 The home is maintained to a high standard and meets the current needs of the service users that live there. EVIDENCE: The home continues to be cleaned to a high standard, and communal spaces in the home are nicely decorated with service users having an input into colours and style. Six service users showed the inspector their bedrooms, one stated their room had been decorated recently and they had chosen the colour scheme. All of the bedrooms were decorated to a high standard reflecting the hobbies and interests of the service users that they belonged to. All of the home’s toilets and bathrooms were seen to be decorated to a high standard and adaptations were fitted where appropriate. Since the previous inspection some extra banisters have been fitted to support service users with increased physical needs. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 16 One shortfall was identified, this was the light fitting in the flat of the couple living downstairs in the home. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 17 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) 31, 32, 33, 35 Staff roles, responsibilities and training ensure that service users needs are met. EVIDENCE: All staff have Job Descriptions provided by the Home Farm Trust. All staff have a minimum of an NVQ level two and the home are to be commended for this. In addition to this staff stated that other training has been completed that includes; medication administration, risk assessment, first aid, infection control, fire safety training and a computer skills course. The home has a settled staff team that have worked with the service users for a number of years and this is reflected in the quality of the care provided. Staff are supervised regularly by the manager who is a qualified Social Worker with an NVQ level four in management. Regular staff meetings are held. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 18 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) 37, 38, 39, 42 The staff team are well managed and this enables service users to receive a high quality service that protects them whilst promoting their independence and rights. EVIDENCE: The Registration certificate and Employer’s liability Insurance certificate were both displayed in the home. During the inspection the staff clearly indicated that the service provided at the home is led by the needs of the service users. From discussions with staff and service users, and from the examination of records, the routines within the home were flexible enough to enable the service users choice and a varied lifestyle. Regulation 26 visits have been completed regularly since the previous inspection. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 19 Health and safety is regularly monitored around the home by the staff team. Records included monthly checks for defects, weekly hot and cold water outlet monitoring, fire alarm tests, use of the food probe and daily recording of fridge and freezer temperatures. A shortfall that was identified related to the hard wiring being tested by a qualified engineer. No evidence was found to show that it had been tested recently. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 20 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 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 4 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 330 Westward Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 2 x D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 21 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 9 24 42 Regulation 13(4)(a) 23(2)c 13(4)(a, c) Requirement The manager must ensure that risk assessment for the homes lounge is reviewed. The light fitting in the kitchen area of a couples flat must be replaced. The manager must ensure a qualified engineer tests the homes hard wiring. Timescale for action 08/07/05 08/07/05 29/07/05 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. Refer to Standard 6 Good Practice Recommendations Service users should be give the opportunity to sign their goal plans. 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 22 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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 330 Westward Road D51_D03_S16335_WestwardRd_V226887_110505_Stage4_U.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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