Inspection on 18/04/06 for 330 Westward Road

This inspection was carried out on 18th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

330 Westward Road 29/11/05

330 Westward Road 11/05/05

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 330 Westward Road Ebley Stroud Glos GL5 4TU Lead Inspector Mr Paul Chapman Key Unannounced Inspection 18th April 2006 09:00 330 Westward Road DS0000016335.V290943.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 330 Westward Road DS0000016335.V290943.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. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 330 Westward Road Address 330 Westward Road Ebley Stroud Glos GL5 4TU 01453 823852 01453 823852 jenny.miles@hft.org.uk www.hft.org.uk Home Farm Trust 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) Mrs Jenny Miles Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 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 DS0000016335.V290943.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was completed over a period of 8 hours on a day in April 2006. The manager was present throughout the inspection. The inspector spoke to seven of the service users individually during the day and completed a thorough tour of the accommodation provided. In addition to this the inspector examined the records for three of the service users and other records maintained by the staff as required by these regulations. The inspector wishes to thank the staff and service users for their time and support during the day. What the service does well: The home provides a safe environment with a service that is led by the needs of the service users. The Person Centred Plans produced with the service users make good use of technology that makes them easier to use. The goals that service users have identified were either being achieved with staff support, or had been achieved. Comments from the service users during the day showed that they lead the development of their plans. The service users lead active and varied lifestyles taking part in activities in the community and the home supported by staff or independently. Examination of previous complaints showed them to be appropriately managed and service users confirmed that they were satisfied with the process when they had used it previously. Service users records are well maintained and stored securely. From observations during the inspection the staff team are committed to providing a quality service. The service users benefit from a staff team that are very experienced and in a lot of cases have known the service users for a number of years. The service users spoken with during the day all stated how they enjoyed living at the home. All of the responses from the surveys sent to service users, other professionals and relatives were positive about the service. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 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 DS0000016335.V290943.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 330 Westward Road DS0000016335.V290943.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): 2, 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home has a comprehensive assessment process. The manager must ensure that all of the service users have copies of their contracts with the home. EVIDENCE: No new service users have been admitted to the home since the previous inspection. As the inspector was unable to case track an actual admission to the home the inspector examined the homes admission procedure which was seen to be comprehensive and enable the service users involvement in the process. The inspector sampled 3 of the service users files and found that not all of the service users had individual contracts (2 of 3 contained contracts). When speaking to the service users they were unclear as to whether they had contracts. The inspector spoke to the manager about this shortfall. Whilst the inspector was present the manager spoke to her head office who will supply them with a copy of the contract. See requirement for standard 5. 330 Westward Road DS0000016335.V290943.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): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Person Centred Plans are developed with the service users and staff support them to achieve their goals. Staff support the service users to make decisions but do not make decisions for them. Comprehensive risk assessments were available but these are in need of review. EVIDENCE: The inspector case tracked 3 of the service users care packages (see page 21). The records seen were comprehensive. Of the files case tracked by the inspector none contained a service users guide or a Statement of Purpose. When speaking with the service users they were unaware that these documents existed. The inspector spoke to the manager 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 10 about this, a copy is available from the office in the home, and service users would be able to access them whenever required. Each service user has a needs assessment in the form of the PCP which is reviewed a minimum of six times a year. When talking to service users they confirmed they meet with their keyworkers regularly to review their PCPs . The inspector spoke to the service users about their assessments and their involvement in their completion, service users commented that they enjoyed developing their PCPs with the staff and were able to explain the process followed in developing them. Each of the service users being case tracked by the inspector had person centred plans. Documents showed that service users were involved in their development and comments from the service users included they were allowed to say exactly what they wished in their PCPs. The person centred plans examined by the inspector provided specific, measured, achievable, realistic and time constrained targets and progress towards meeting them was evident. Service users said that the goals/targets they set are achieved to their satisfaction. Regular reviews of these documents were evident with ammendments made where appropriate. Staff maintain daily records for each of the service users. Examination of these records showed them to be comprehensive. The language used in these documents was professional and respectful. Staff collate this information each month and provides a monthly summary of significant events. Examination of the accident records showed that they were recorded properly and that when necessary these had been reported to the CSCI via a regulation 37 notification. 1 of the service users that was case tracked has made a complaint since the previous key inspection. For further information about complaints seen the evidence for standard 22. Service users were able to give the inspector examples of making decisions about their lives both daily and long term, this was supported by observations of the practice of the staff during the fieldwork visit. In addition to this examples were evident in the service users files where staff had supported service users to make informed choices. Surveys completed by the service users also supported this. Risk assessments must be reviewed, a number seen were no longer relevant and others had not been reviewed for over twelve months. Whilst the inspector was at the home the manager added this as an agenda item for the next staff meeting. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 11 All of the relatives in contact with the service users at the home gave positive feedback about the service provided. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 12 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): 12, 13, 15, 16, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Staff support the service users to lead active and varied lifestyles. The meals and food provided at the home is of a high quality and chosen by the service users. EVIDENCE: 7 of the 8 service users living at the home were spoken with. They were able to give numerous examples of accessing the local community and attending college courses. A number of the service users commented on how much they enjoyed these activities. When talking to the service they spoke about holidays to Torquay, a boat trip down the Rhine. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 13 Service users commented that they thought the food was nice and that they were able to choose what they ate. Service users stated that they met on each Saturday when they would decide the menu for the following week. Service users stated that they were involved in preparing the meals. Whilst the inspector was at the home he witnessed the service users making their own lunches of sandwiches, etc. Examination of the menu showed a good variation of nutritious meals that were served daily. Menus used pictures and symbols as well as words to enable the service users to understand them more easily. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 14 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): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Health and personal care needs are addressed appropriately by the staff and other professionals. Medication records must be monitored by the manager to ensure that accurate records are maintained. EVIDENCE: Service users records case tracked by the inspector showed that other professionals were involved in maintaining and addressing their health needs. Currently none of the service users require support with their personal care. The medication storage and medication was examined - only one issue identified where staff had failed to sign for administering medication. This was brought to the attention of the manager and it is a recommendation of this report that the manager monitors this in the future. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The homes complaints procedure empowers service users and when complaints have been made previously they have been dealt with appropriately. Completion of adult protection training by the staff team will raise their awareness of issues surrounding vulnerable adults allowing them to reflect on their practice. EVIDENCE: The last complaint made by a service user was examined as part of the case tracking completed. Records showed that it was handled properly and the manager was able to give an account of the allegation. The service user stated that they were satisfied with the outcome. The inspector spoke to other service users about making complaints. They showed a good understanding of the process they needed to follow. All of the service users stated that when they had made complaints previously that they had been resolved to their satisfaction. The inspector spoke to the manager about staff training in adult protection. They stated that they had recently attended a training course in this topic and as a result have asked the regional training manager to organise training for the staff team. The inspector spoke to the manager about the importance of the staff completing this training. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 16 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 17 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, 27, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is maintained to a high standard and has a homely atmosphere. EVIDENCE: The inspector completed a tour of the premises. The home continues to be maintained to a high standard of decoration throughout and was clean and hygienic at the time of this inspection. The only shortfall identified related to the shower room which although had been painted since the previous inspection paint was already flaking off. As a result it is a requirement of this inspection that this is addressed. Since the previous inspection the kitchen and dining room have been painted. A recommendation of this inspection is for the lighting above the main staircase to be made more effective as it can become a dark area during daylight hours which may lead to accidents. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The process of recruitment and selection of staff is thorough and minimises potential risks to the service users. Training records showed that staff receive training to meet the needs of the service users. Staff training in adult protection will raise awareness and enable staff to reflect on their pratcice. EVIDENCE: No new staff have been employed since the previous key inspection. At that inspection the inspector examined the staff member’s personal file which was found to contain all the information required to meet the regulations. The inspector spoke to the newest staff member about their induction. They stated that they are currently completing this and have found it really useful. Training records for the staff were seen. Well organised records are the responsibility of the deputy manager. records showed that updates are 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 19 completed as necessary with the dates they are required highlighted in the records. The inspector spoke to the manager abour adult protection training. the manager completed the course in February this year and has spoken to the regional training manager about organising the course for other staff. All but one of the staff team has completed an appropriate NVQ. The one staff member yet to complete their NVQ is still completing their induction. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has good systems in place that monitor the quality provided and enables the service users to comment and be involved in the decision making process. Regular health and safety checks are completed and minimise the potential risks to the service users. EVIDENCE: Regulation 26 visits - None have been completed since the previous inspection. It is a requirement of this inspection report that this is addressed and that these visits are completed as prescribed by these regulations. The manager checks monthly service users’ files and finances, and completes regular supervision with the staff team. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 21 Service users and the team meet annually to review the previous year, plan ahead, discuss any issues. Minutes of the previous meeting seen, August 2005. This is a really good practice that allows the service users to feedback and have their say. The manager stated that it was their understanding that HFT would complete quality audits 3 times a year. It appears that this had not been done in a considerable period of time (over 2 years). Completion of these audits would provide further evidence of the quality of the service provided. Health and safety audits are completed by a independent consultant on a regular basis, the last one was completed in October 2005. Staff complete a health and safety check of each room every Saturday and the service users complete checks of their rooms once a month. Hot water temperatures are checked twice monthly. Shower heads are checked and maintained by a qualified engineer every six months (last checked 14/12/05) , and the manager checks and cleans them every month. COSHH has been addressed by the manager thoroughly with chemical products data sheets/assessments divided into green, amber and red sections with instructions for staff to follow in relation to storage and what to do if substance is spilt. All fire equipment is checked at the appropriate intervals. Portable Appliance Testing was completed in March this year. The manager has completed lone working assessments for all of the staff. Gas/landlord certificate renewed on April 19th 2005. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 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 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA5 Regulation 5 Requirement The manager must ensure that all of the service users’ files contain a copy of their care contracts with the home. The manager must ensure that the service users’ risk assessments are reviewed and the assessments that are no longer relevant are archived appropriately. The staff team must complete training in adult protection. The shower room must be repainted. The manager must ensure that regulation 26 visits are completed each month and copy of the completed document is sent to the CSCI. Timescale for action 05/06/06 2. YA9 13(4) c, 05/06/06 3. 4. 5. YA23 YA27 YA39 13(6) 23(2)(d) 26 07/08/06 07/08/06 05/06/06 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 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 24 1. YA20 The manager should monitor the medication administration records to ensure that they are completed at all times. 330 Westward Road DS0000016335.V290943.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Gloucester Office Unit 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. 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