Inspection on 14/11/05 for 40 Cody Road

This inspection was carried out on 14th November 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

40 Cody Road 08/01/07

40 Cody Road 24/01/05

40 Cody Road 27/07/04

40 Cody Road 27/01/04

Similar services:

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Dalewood Respite Care

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REACH Upton Court Road

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 40 Cody Road Cove Farnborough Hampshire GU14 0DE Lead Inspector Peter J McNeillie Unannounced Inspection 14th November 2005 09:00 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 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 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 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. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 40 Cody Road Address Cove Farnborough Hampshire GU14 0DE 01252 372057 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) sarah.pilgrim@new-support.org.uk New Support Options Limited Mrs Sarah Jane Pilgrim Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2005 Brief Description of the Service: 40 Cody Road is a purpose built bungalow offering accommodation for up to five persons with a learning disability all accomodated in their own bedroom. The home which is managed by New Support Options Ltd. who are also responsible for operating similar services located in the South of England is situated close to Farnborough town centre with access to local amenities and transport.The nearby towns of Aldershot, Camberley, Fleet, and Farnham are all easily accessed using either public or the homes own vehicle. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two annual inspections for 2005/2006. During this inspection which took place between 9:00am and 12:00pm the inspector who was assisted by the registered manager spoke with all of the residents (although communication was difficult) and staff on duty. Evidence was also gathered from a tour of the building, reading records, care plans, previous reports, comments by management/staff and observations. 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. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 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 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 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): 1 and 2 Prospective residents are issued with information they need to make a choice about living in the home which has a well developed system of assessing and identifying residents needs which assures residents safety and assessed needs can be met. EVIDENCE: A satisfactory dual formatted (written and pictorial) statement of purposeand a service users guide was available. A personalised copy of the service users guide is given to all residents /residents representatives on admission and was available in residents bedrooms. Due to extreme difficulties in communicating with the residents the inspector was not able to assess how much the individual residents understood the document. There have been no admissions since the last inspection. Any new admissions are subject to a corporate admissions policy and procedure which involves undertaking a full assessment of needs and risk by the manager or another member of senior staff of all potential service users, first in their current place of abode and later within the home during a visit or overnight stay following which the prospective service user would be invited to be live in the home on a trial basis. A full review of the placement which includes consultation with existing residents and external health care professionals would be made prior to a permanent bed being offered Since the last inspection a corporate assessment and care planning model has been adopted/developed that places a greater emphasis on seeking residents view and taking their opinions, wishes and aspirations into account. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 9 Not all of the current assessments of need viewed included an acknowledgement that the service users or their representatives had been consulted and were involved in the assessment. The manager gave a verbal undertaking the reassessment of all residents needs would be carried out within 28 days and confirmations of their or their representative’s involvement/ consultation included in the records and that she would also inform The Commission for Social Care Inspection (C.S.C.I.) when complete. Records viewed did however include evidence to confirm a wide range of external health care professionals including doctors, district nurses, physiotherapists, occupational therapists and care managers as well as members of the local community disability team and current residents were involved and consulted. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 10 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 and 9 There is a clear and consistent care planning system in place which ensures residents needs are met within a risk management policy that involves residents in making decisions that affect their day to day lives EVIDENCE: As commented earlier in this report, since the last inspection a corporate assessment and care planning model has been adopted/developed that places a greater emphasis on seeking residents views and taking their opinions, wishes and aspirations into account. Not all of the current care plans, which are being reviewed, included an acknowledgement that the service users or their representatives had been consulted and were involved in the assessment. The manager gave a verbal undertaking that a review of all care plans would be carried out within 28 days and confirmations of residents or their representative’s involvement/ consultation included in the records and that she would also inform C.S.C.I. when complete. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 11 Plans viewed, which highlighted areas of special needs and any additional help required also included a dictionary/ list of individual communication methods such as signs, noises and behaviours. New Support Options, (the registered provider) as part of involving residents in the decision making process about the home organises service user conferences and enables residents to serve on the board and take part in staff interviews. The inspector noted that a previous forum developed and agreed a regional evolution path setting out corporate goals for the future. Using this document as a basis for consultation with residents, a similar in house exercise was carried out and resulting in plan a involving common issues as well as topics that affected individual residents. The inspector was shown progress to which was also reflected in individuals care plans. Despite communications difficulties, evidence was seen confirming consultation with residents takes place i.e. menus (which records likes/ dislikes), bedroom décor, activities, etc. also residents meetings are held and minutes kept. Staff spoken to felt residents rights to take risks was fundamental, however it was clear from records, observations and staff comments all residents have difficulty in totally understanding the concept of risk and consequently were unable to fully exercise unrestricted choice and make valid and safe decisions. Any restrictions placed on residents are recorded in the care plan following a risk assessment written copies of which were also available. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 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 and 17 The communication , social activities,family contacts and the provision of varied and nutritious meals were well managed and reflected residents choices. EVIDENCE: Records seen, a programme displayed in the kitchen, comments from staff and observations made during the inspection confirmed that residents were given the opportunity to develop their skills and participate in a range of activities and social opportunities both in house and community based provided by the home, local day centres and individual one to one support programmes. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 13 All activities/programmes are detailed in personal plans and have been arrived at following consultation with the individual concerned. Activities currently available include, cinema, computers, cooking, gardening, trips, walks, shopping, music, sensory rooms, church, aromatherapy and, art. Within individual activity programmes emphasis is placed on going out into the community and accessing community facilities such as, shops, cafes and libraries etc. All of the residents have regular contact with family and external friends who are encouraged to participate in the service users review if agreed by resident. Should transportation be required to assist contact with family and friends, the inspector was informed that this would be provided by the home. Staff were observed to assist service users with eating/feeding in a manner that acknowledged the individuals independence. A varied menu chosen by service users based on personal likes and dislikes was displayed. Following the two previous inspections the inspector noted the displaying of a pictorial menu had lapsed, but this practice has now been reintroduced. Records seen confirmed all residents receive a regular nutritional assessment. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 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, and 20 Satisfactory arrangements are in place, ensuring the personal emotional, health care and medication needs of residents are met. EVIDENCE: 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 15 Residents who are able to access all parts of the home and gardens have all been assessed and provided with personal mobility/living aids following consultation external health care specialists. Currently special chairs, beds, baths, grab rails and hoists are available. Staff informed the inspector any personal care given or examination by a visiting health care professional takes place in the privacy of the resident’s own room the doors to which have all been fitted with a lock. Records seen confirmed residents are free to choose their own doctor and source of any other personal services e.g. dentist, chiropodist etc. Records viewed confirmed a wide range of health care professionals are consulted to ensure residents health care needs are met, including doctors, district nurses, care managers, continence advisors, physiotherapists occupational therapists and the community learning disability team. Other specialists are consulted as required. All drugs are which securely stored are administered disposed of and recorded in accordance with an in house and corporate medication policy and procedure by trained staff. Records of administration and disposal of unwanted drugs and medicines seen were complete and accurate. A pharmacist via a monitored dosage system dispenses all drugs administered in the home also visits on a regular basis to offer support and advice. No service users are self-medicating. Written risk assessment and evidence to confirm consultations as who has responsibility for resident’s drugs and medication was not available. The manager gave a verbal undertaking that risk assessments would be undertaken, and C.S.C.I. informed when completed within 28 days. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 16 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 and 23 The home has clear policies and procedures in place, which ensures residents, are protected from abuse and enable them to complain. EVIDENCE: A personalised dual formatted written, pictorial/symbol complaints procedure that included details on how to contact The Commission for Social Care inspection (C.S.C.I.) was available and forms part of the service users guide. A record of complaints indicated no complaints had been received since the last inspection. Due to extreme communication difficulties the inspector was not able to establish whether residents understood the complaints procedure. The homes corporate adult protection policy and procedure which operates in tandem with The Hampshire County Council policy and procedure was available. Records to confirm all staff had received training in adult protection. Staff spoken with confirmed they were fully aware of the procedure to follow should they witness or suspect the abuse of any resident. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 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): 24,25, 29 and 30. A safe, well maintained, clean and suitably furnished home and accessible garden is provided for service users which meets their needs. EVIDENCE: A tour of the single storey purpose built building indicated it was fit for its stated purpose, accessible, safe, well maintained meeting all residents needs. Furniture was comfortable, homely and in keeping with the décor which service had helped choose. Since the last inspection all of the communal areas in the home have been redecorated. All residents are accommodated in individual bedrooms, which have been fitted with a lock, meet the spatial requirements of the standards and have been decorated and furnished to reflect the resident’s choice. All residents and the building have undergone a specialist assessment to ensure that any equipment and personal aids required are available. Aids currently in use within the home include hoists (various), raised toilets, beds, wheelchairs, special beds and handrails. The garden which has improved considerably over the past 18 months is a 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 18 real asset providing a pleasant area to loo for residents to look at and relax in, however the fence to the front of the property is leaning and would appear to present a hazard to residents and staff. The manager informed the inspector she is currently in negotiations to have this fence repaired. No requirement is being made on this occasion but the inspector made it clear he would expect some repairs to be carried out within the next few weeks. This matter will be reviewed at a future visit to the home. The home was clean, hygienic and free from adverse odours. An infection control policy and procedure was in place. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 19 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): 32,35 and 36 Residents needs are met by sufficient numbers of well trained. stable supported and supervised staff who are recruited and selected using a procedure designed to protect all service users EVIDENCE: Records confirmed all new staff are involved in an corporate/ in house five-day induction programme followed by The Learning Disability Awareness Framework (L.D.A.F.) accredited training (induction and foundation) prior to being involved in a National Vocational Qualification (N.V.Q) training programme. Core training such as fire safety, food hygiene, first aid moving and handling etc is mandatory for all staff. All training needs are reviewed on a regular basis through regular supervision (records available). Records seen confirmed all are recruited in accordance with a corporate selection and recruitment procedure which includes the completion of an application form, the signing of a Rehabilitation of Offenders Declaration an interview and satisfactory Criminal Records Bureau( C.R.B ) Protection of Vulnerable Adults(P.O.V.A)and reference checks. As part of their terms and conditions of employment all new staff agree to participate in an NVQ training programme. Records seen indicated that 55.6 of staff have completed or hold other qualifications in lieu of N.V.Q. which is just in excess of the 2005 target of the standards which expects 50 of staff to be trained. Two further staff are due to start an N.V.Q . training programme shortly. This matter will be reviewed at a future visit to the home. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 20 The inspector viewed the staff rota which indicated that sufficient staff were employed to meet residents needs and that staff numbers and their deployment was varied according to residents programmes, the time of day and any other factors that could affect the service provided. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 21 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 and 42. The management of the home seeks the views and opinions of residents residents representatives, safeguards the health and safety of staff and residents through the implementation of safe working practices. EVIDENCE: 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 22 The home registers manager is qualified at NVQ level 4 in care is due to complete an N.V.Q. level 4 management module by February 2006. Records confirmed a comprehensive corporate quality monitoring system that seeks the views of service users or their representatives has been implemented results from previous surveys which had been sent to C.S.C.I. Results from these surveys have had a direct result in bringing about changes t as demonstrated by the improvements in the system of care planning referred to previously in this report. Monthly visits that are required to be undertaken by a representative of the organisation in accordance with regulation 26 and the forwarding of the subsequent reports to C.S.C.I. are taking place. A corporate health and safety policy was in place as were records of weekly health/ safety checks, the servicing of equipment, staff training in the techniques of moving and handling, first aid, health and safety, the procedures to follow in the event of fire (including evacuation) and accidents. All of the hot water supplies to baths were fitted with thermostatic controls set at 43 degrees centigrade and all radiators and hot pipes were covered. 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 23 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 3 2 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 X 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 40 Cody Road Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 X 3 x x 3 x DS0000011560.V265810.R01.S.doc Version 5.0 Page 24 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 40 Cody Road DS0000011560.V265810.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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