Inspection on 27/09/05 for 5 Barth Close (Royal Mencap Society)

This inspection was carried out on 27th September 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 Barth Close (Royal Mencap... 12/07/07

5 Barth Close (Royal Mencap... 10/07/06

5 Barth Close (Royal Mencap... 21/06/05

5 Barth Close (Royal Mencap... 16/12/04

5 Barth Close (Royal Mencap... 12/08/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Barth Close, 5 (Royal Mencap Society) 5 Barth Close Great Oakley Corby Northants NN18 8LU Lead Inspector Judith Roan Unannounced Inspection 27th September 2005 15.15 Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.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 Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.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. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Barth Close, 5 (Royal Mencap Society) Address 5 Barth Close Great Oakley Corby Northants NN18 8LU 01536 460718 01536 741204 h2mo77peters@mencap.org.uk 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) Royal Mencap (Housing & Support Services) vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21.06.2005 Brief Description of the Service: The home ‘5 Barth Close’ provides personal care and accommodation for 5 younger adults within the category of Learning Disability. The home is owned by the MENCAP organisation and is located within the Great Oakley residential area of the town of Corby being adjacent to a Health Centre with Pharmacy and close to a National Superstore. The home was newly purpose built and opened in April 2000. All the rooms within the home are for single occupation and without en-suite facilities. The garden is large in comparison with similar private residential properties in the immediate area. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting two service users and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The Inspector also received questionnaires completed by relatives. Questionnaires expressed concern about staff turnover but remained overall positive about the service. A complaint has been received and this is currently being investigated via the providers complaints procedure. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. The inspection took place during the afternoon and early evening over a period of 3.75 Hours. What the service does well: What has improved since the last inspection? A statement of purpose & service user guide is available in an accessible format. Medication is stored in a locked cupboard at the home, with clear records. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 6 Outstanding maintenance has been completed. 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. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.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 Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.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): 1,2,3,5 Information about the home informs service users so they may make an informed choice. The assessment procedure does not clearly identify that the service can meet service users assessed needs. EVIDENCE: The home has produced a service user guide that sets out their aims and objectives in an accessible format. Service users files seen did not include an assessment undertaken by the home. Care management assessments were however included on the file. The home needs to put in place an assessment tool that clearly identifies service user needs and how the home can meet them. A contract between service users and the home were recommended in the December 2004 inspection. The home has yet to develop contracts that sets out clearly the terms and conditions of the service provided with costs. A requirement is now made. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 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): 6,7,8,9,10 Service user care plans reflect need but fail to demonstrate personal goals and how these will be met. Support workers positively assist service users to make daily choices. Records do not fully demonstrate how individual service users are protected from the behaviours of other residents. Service users can be assured that information about them is stored confidentially. EVIDENCE: Care plans viewed generally contained full details but fall short in identifying goals for individuals and how these are to be met. This linked with standard 11 has been a requirement on the last two inspections. Through observation during the inspection it was evident that service users were enabled to make decisions about daily routines and activities. During the meal service users were given options to choose from and asked whether they needed support. Communication with service users was positive and gave them information to make decisions. Service users are supported to have an independent life as possible and support workers are aware of potential risks for individuals. The records however do not reflect this knowledge and need to include specific risk Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 10 assessments in relation to how support workers protect more vulnerable residents from others behaviours that can cause distress and upset. A review of service users files is recommended to identify areas of information shortfall in relation to risk. The main service user file is stored in a lockable cupboard where it is easily accessible to staff who need to find information. Daily working records are kept in the office/sleep in room. This room is in constant use throughout the day by staff. Service users did respect the privacy of information and the need to have the door closed at certain times in the day. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 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 the following standard(s): 11,13,16,17 As personal development goals are not clearly defined it is not possible to track whether this work is achieved. Good support is available for service users to join in community activities. Rights of service users who are vulnerable are not always protected from others living at the home. Service users likes are included within menu planning and the provision of a healthy and balanced diet. EVIDENCE: Two service users files case tracked during the inspection did not have any personal goals identified. Staff did express that there was a need to do more individual work with service users but a lack of staff is preventing this work to be achieved. Staffing levels at the home have only been met by using relief staff. In discussion with the registered manager more appointments have been achieved and these staff will be in post shortly. Service users confirmed that they had good support with activities within the home and were also supported by their families in the community. In reviewing the files it was noted that there had been several incidents between service users. The records do not show that investigations had been Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 12 carried and the home had failed to notify CSCI of the incidents. In discussion with the registered manager it was agreed that there is a need to have clear procedures on what staff need to do in these situations. In one file it did ask for ABC (Antecedents, Behaviour, Consequences) charts to be completed. These have not been carried out. It is important for the Registered manager to investigate all incidents to ensure that individual rights of service users are not impinged upon and that working practices at the home monitor and record the effects of behaviours on others. Service users are assisted to choose meals from a selection of favourite dishes. Support workers have worked positively with service users by developing a file of photographs to aid decisions for service users who find it difficult to communicate their wishes. Support workers ensure that there is a balanced diet that is varied and healthy. When service users attend day services they take a packed lunch. Service users are encouraged to be involved in the preparation and choice of their lunch the evening before. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 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 the following standard(s): 19,20 The staff team work in partnership with primary health care teams to ensure that health care needs are monitored. Service users are protected by a robust medication procedure. EVIDENCE: There is evidence that the care team at the home are proactive in meeting service user health care needs. Joint working with members of the primary health care team to address needs of service users when appropriate. It was noted that referrals have been made in relation to incidents referred to in this report in the Individual Needs/choices and Lifestyle sections. Service user files showed that visits to dentists, optician and other specialist services are recorded. Future appointments are noted in the central diary to ensure they are not missed. The home has developed its procedure for the management and administration of medication. Two support workers ensure that correct medication is given and that records are appropriately signed. Medication is stored in a locked cupboard on the ground floor. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 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 the following standard(s): 22,23 Service users are not fully protected by the protection of adult procedures within the home. EVIDENCE: Recent incidents within the home between service users were not fully investigated at the time. Concerns expressed to the CSCI are now being fully investigated by the provider’s complaints procedure. The provider has been asked to respond to the complainant and the CSCI. The inspector was concerned that instructions to monitor individual’s behaviour have not been consistent. A requirement to review the home policy and procedures in relation to the protection of vulnerable adults is made. The registered manager needs to consider additional training for staff in adult protection issues to ensure that there is consistency in approach from support workers. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 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 the following standard(s): 24,25,26,28,30 The homes environment is comfortable, well maintained, clean and hygienic. The communal space does not fully meet the differing needs of service users. EVIDENCE: During the inspection service users showed the inspector around the home. The inspector found the home to be recently decorated that reflected service users involvement in choosing the colours. Individual bedrooms were lockable and service users were encouraged to keep their rooms clean and tidy with support. Service users are encouraged to personalise their room with favourite items. The home was found to be safe and that support workers had a full understanding of storing potentially hazardous materials appropriately. The present communal space does not provide for service users to undertake various activities. The proposed conservatory will increase the areas available. The considerable delay in providing this facility has a direct impact on meeting the differing needs of service users. The provider needs to give the CSCI a timescale for completion. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 16 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): 33,34,36 The homes recruitment and selection procedures ensure that service users are protected. The support given to the staff team ensure that service users are well supported. The number of staff vacancies at the home has reduced the effectiveness of the staff team in the provision of service to users. EVIDENCE: A new staff member was able to confirm with the inspector that they had undergone a comprehensive recruitment process involving an interview, criminal records bureau check and references taken up. They very positive about their induction programme and the support they had received from the Registered manager. The lack of permanent staff has over time led to less work being undertaken with service users in the community. Two support workers were on duty at the time of the inspection that did not provide for service users to go off site and be supported in community activities. The Registered Manager must make the appointment of staff to current vacancies a priority. Staff recruitment has been a long term issue at the home and the manager is working to appoint sufficient staff to have three staff on duty at identified times in the week to meet service users needs. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 17 Support worker spoken with during the inspection were positive about their working relationship with the manager and had regular supervision. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 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 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): No standards from this section were assessed on this inspection EVIDENCE: Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 19 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 2 X 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 X 2 X 3 LIFESTYLES Standard No Score 11 1 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 20 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 Regulation 14 (1)(a)(d) Requirement The Registered Manager needs to develop an assessment tool identify service users needs and how they can be met within the service provided The Registered Manager must develop fully costed statements of terms and conditions for each service user. Care plans must include personal goals and demonstrate opportunities for personal development. Risk assessments must be in place to guide Staff in the management of specific behaviours. The registered Manager needs to ensure that all staff are fully aware of adult protection issues. The Registered Manager to provide the CSCI with timescales for the development of the additional communal living space. Timescale for action 31/10/05 2 5(c) 31/12/05 3 12 1,2,3 15, Sch 1 13(4) 31/10/05 4 31/10/05 5 6 YA28 13(6) 23(2)(e) 31/10/05 31/10/05 Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 21 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 YA33 Good Practice Recommendations It is recommended that plans to recruit to vacancies and developing the rota to meet service user needs are seen as a priority by the Registered Manager. Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Barth Close, 5 (Royal Mencap Society) DS0000012702.V253590.R02.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!