Inspection on 16/01/06 for 52 Winchester Road

This inspection was carried out on 16th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

52 Winchester Road 23/05/07

52 Winchester Road 22/08/06

52 Winchester Road 30/08/05

52 Winchester Road 08/11/04

52 Winchester Road 22/06/04

52 Winchester Road 10/07/03

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Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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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 52 Winchester Road Four Marks Alton Hampshire GU34 5HR Lead Inspector Mrs Pat Hibberd Unannounced Inspection 16th January 2006 09:00 52 Winchester Road DS0000011642.V275719.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 52 Winchester Road DS0000011642.V275719.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. 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 52 Winchester Road Address Four Marks Alton Hampshire GU34 5HR 01420 564028 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) ILIACE Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category LD are only to be accommodated between 18 and 55 years. Date of last inspection Brief Description of the Service: 52 winchester Rd provides care and support to four service users between the ages of 18 and 65 years and who fall within the learning disability service user group. The Home is owned by a private organisation Iliace ltd. Since the last inspection the manager has resigned and a new manager has been appointed. The commission are awaiting an application for registration. The home is a four bedded detached property situated in the rural village of Four Marks a ten minute drive from the town of Alton which has a range of leisure, educational and employment facilities. Alton is also the location of the organisations head office. All service users have their own bedroom, communal space and a large garden that accommodates an indoor heated swimming pool. There have been no changes to the service user group living at 52 Winchester Rd for a number of years. 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over three hours and was the second unannounced inspection of the 2005/2006-inspection programme. The inspector focussed on care provided to service users, discussions with staff, inspection of files and other documentation relevant to this inspection. Eight standards were assessed on this occasion. A number of areas of improvement were identified. All of the core standards for younger adults have now been inspected during the 2005/2006-inspection year. The inspection included a tour of the home and garden. Discussions were held with the Home’s manager and two permanent staff members and one parent who telephoned the Home during the inspection. Time was spent and discussions held with four service users with a view to gaining an understanding of care provided and to observe staff interaction and support as detailed in care plans. A variety of documentation was viewed and contributed to the findings of the inspection of which details are in the main body of the report. What the service does well: Throughout the inspection the manager and staff demonstrated a commitment to ensuring service users are central to all care provided and lead a full and positive life style. The staff team were seen to communicate appropriately with service users using makaton/symbols, objects of reference and verbal communication. The Home is keen to ensure service users are encouraged and supported to identify and pursue individual interests with both in house and community activities provided. The Organisation has an activities team (DAP) who work alongside the Home to provide community activities for individuals. The manager indicated that due to long-term sickness there were times when the DAP team cancelled activities during the latter part of last year. However, service users have new timetables that the Home supplements with additional interests/activities that meet service users’ needs. 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 6 There is a range of training provided and staff confirmed that they receive regular supervision and daily support from the manager of which they find to be of much benefit to their daily practice. Observations of staff interaction with service users indicated that they had a good understanding of their needs, provided choices and care in a respectful and dignified manner. Comments received from one relative included “ I am pleased that my relative has a fuller and more meaningful daily activity programme. However, I hope that the programme is followed as in the past activities have not always taken place”. The relative further commented that they were receiving good feedback from staff and manager in the Home regarding their relative’s care. What has improved since the last inspection? What they could do better: There were a number of areas of improvement identified on this occasion. These include the need for the manager to devise a policy and procedure, which reflects the new financial procedures in place in the Home in relation to the safe keeping of service users’ monies. This should be kept under review and shared with staff. Due to none of the staff team having achieved National 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 7 Vocational Qualifications (NVQ’s) an action plan is required from the Registered Providers as to when training will commence. The manager needs to undertake fire training and adult protection training. Risk assessments are required to be undertaken of all upstairs windows and window restrictors fitted as necessary. 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. 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 8 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 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 9 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): All core standards have been assessed. EVIDENCE: 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 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): 9 Service users care needs are met within a risk management framework. . EVIDENCE: This standard was not fully inspected on this occasion having been thoroughly inspected in August 2005. However an area of improvement was followed up. At the last inspection a risk assessment relating to one service user accessing the community could not be found and was required to be either written or located and accessible to all staff. The risk assessment was available on this occasion. The manager; who has been in post for four months indicated that he is continuing to read individual care plans, discuss needs with service users and /or staff and relatives as appropriate. Risk assessments, whilst in place are being reviewed and rewritten in the new format recently devised by the Organisation. In discussion with the manager it was evident that he had a good knowledge of all of the service users’ needs. From observations of interaction with individuals during the inspection it was evident that he had built positive relationships with service users accommodated. This was further supported from two service users spoken to. 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 11 The manager indicated that Key Workers would undertake all risk assessments in the future. The manager who has undertaken the required training is providing training to all staff. If a new risk is identified the assessment would be written and shared with all staff through team meetings/shift handovers and documentation. 52 Winchester Road DS0000011642.V275719.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): All core standards have been assessed. EVIDENCE: 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 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): All core standards have been assessed. EVIDENCE: Whilst this standard was not accessed on this occasion clarification of medication training was ascertained. Six of the eight staff team members have undertaken the training with two new staff to commence in due course. The manager indicated that there is always a medication trained staff member on duty on each shift. 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 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): 23 Arrangements for protecting service users are satisfactory. EVIDENCE: The Home has a copy of the Department of Health No Secrets document and the Hampshire Adult Protection policy and procedure. Five of the eight staff team members have undertaken Adult Protection training and in discussion with one staff member they demonstrated an understanding of their responsibilities. The manager indicated that he had not attended an adult protection-training course since commencing his post in August 2005. However, during discussions as to the procedures to follow in the event of a disclosure he was able to demonstrate an awareness of his role in the event of an allegation of abuse. It was agreed that the manager would arrange to attend a training course within the next month to ensure he has a thorough understanding of the Hampshire Adult Protection policy and procedures and their application to service delivery. One staff member indicated that they felt well supported by the manager and were receiving guidance as to how to manage behaviours exhibited by service users that “challenge” their practice/service delivery. All staff have undertaken restraint training (SCIP), which is provided by the Organisation’s Training manager .The manager indicated that guidelines as to the approach to be taken or, when restraint should be used were documented in individual service files viewed. However, the manager further indicated that the practice in the Home is to communicate with service users and follow calming techniques and guidance to prevent an individual reaching a stage where they required any physical 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 15 intervention. Observations of the staff and the manager interacting and explaining to service users how they were to be spending their day demonstrated that this approach is being practised in the Home. There have been no allegations of abuse since the last inspection. Inspection of four service users’ monies indicated that there is a satisfactory recording system in place with all money held balancing records viewed. The manager further indicated that the Organisations Finance manager undertook an audit of service users’ monies in September 2005. However, the manager has recently implemented the finance system in place. Whilst it has been verbally shared with staff it has not been formalised and documented as a policy and procedure for the Home. The manager is to ensure the policy and procedure is written and, that all staff have a copy and sign to confirm their understanding. This should be kept under review. 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 16 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): All core standards have been assessed. EVIDENCE: 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 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 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 and 35 The home’s recruitment practices are satisfactory, ensuring service users are protected. Service users benefit from competent staff who would benefit from further training. EVIDENCE: Throughout the inspection staff were observed as interested, motivated and committed to the needs of service users in the Home. They were observed communicating effectively with individuals and demonstrated knowledge and understanding of strategies in place to deal with anticipated behaviours of some service users that may have a negative impact on others. Recruitment practices are thorough with all applicants undertaking a CRB (Criminal Record Bureau) check, having to provide two written references and complete a satisfactory three month probationary period before being con firmed in post. Service users are fully involved in the recruitment procedures. For example prior to an applicant being offered a post they would meet with service users in the Home as part of the recruitment process. Service users views/interaction would be observed and contribute to a decision as to whether the applicant is offered a position in the Home. One staff member recently appointed is awaiting confirmation of their CRB check. However, a Protection of Vulnerable Adults check (POVA First check) has been undertaken and the manager indicated that the individual is not working unsupervised and does not carry out any personal care. 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 18 The Organisation have their own Training Manager who organises training for the Home in conjunction with the manager. At the last inspection training records were not available in the Home. On this occasion all staff training records were held in the office. All staff have their own training and development assessment with one staff spoken to confirming that they receive regular training which is provided on a three weekly basis. Training undertaken by the eight staff team members includes fire safety (6), food hygiene (6), moving and handling (6), fire safety (6), infection control (6) and restraint (SCIP) (6) first aid (4) and person centred planning (6). The Home has recently appointed two new staff members to the team who have undertake or are in the process of undertaking a thorough induction that utilises the Learning Disability Award Framework. Both team members have been instructed as to the fire safety procedures in the Home with one staff member demonstrating their understanding of their role and responsibilities in such an event. However, none of the staff have achieved national Vocational Qualifications (NVQ’s). A discussion was held with the training manager for the Organisation who indicated that an action plan would be compiled in conjunction with the manager and forward to the commission as to when staff would commence the training. 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 19 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 There is an effective manager who is endeavouring to ensure service users views contribute to all developments of the Home and service provided. Practices in the Home generally ensure the health and safety of services users. EVIDENCE: The manager is in the process of applying for registration with the commission having been appointed to the post in August 2005. The manager indicated that he has completed the Registered Managers Award and has undertaken further training that includes food hygiene, makaton foundation, health and safety enhancement/committee course and first aid appointed person. However, the manager has not undertaken fire training and is required to attend a course. In the interim he was able to demonstrate his understanding of fire procedures including evacuation in the event of a fire in the Home. The manager has a range of responsibilities and indicated that these are reflected in his job description and include ensuring the written aims and objectives of the Home are met, policies and procedures are implemented, the 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 20 budget is properly managed and service users are aware of their terms and conditions of residency. From discussions with staff and service users and documentation viewed the manager is demonstrating his ability to ensure systems are in place to achieve and meet his role and responsibilities and, provide effective leadership and management of the Home. Service users were seen to respond positively to the manager who was able to demonstrate throughout the inspection his understanding and knowledge of service users’ needs. The Home has an annual development plan with objectives in place to measure outcomes for service users in respect of their care; staff and environment .The objectives are linked to the Organisations overarching objectives. Service users meetings are held. The manager indicated that staff would shortly be supporting service users to complete a questionnaire as to their views of services within the Home. This follows a pilot of the questionnaire recently completed in one of the Organisation’s other Home’s. Further systems implemented to ensure there is an effective quality assurance and monitoring of service users’ views include a thorough overview of all care plan and risk assessments and monthly visits undertaken by senior managers of which copies of the outcome of those visits are forward to the commission. The manager and staff were observed during the inspection as approachable and willing to listen to service users’ views. Service users spoken to indicated that staff are available, supportive and responsive to their views and needs. Systems in place in the Home to ensure the health and safety of service users were satisfactory. These include monthly risk assessments of the building, regular fire checks and fire training of staff, food hygiene/infection control/moving and handling and COSHH (Control of substances hazardous to health) training for staff and gas and electrical appliance checks. Each service user has a fire evacuation risk assessment. However as previously detailed all risk assessments are being reviewed. Two service users were able to describe their understanding of the fire evacuation procedures. There are smoke alarms throughout the Home. PAT (portable appliance testing) had been undertaken. All food and freezer temperature records were up to date. The Home has an accident/incident book which is crossed referenced with care plans and any regulation 37 notices sent to the commission as required in the event of an incident affecting the well being of a service user. One further area of improvement related to the need for the manager to undertake a risk assessment of all upstairs windows and install window restrictors as required. The risk assessments should be kept under review. 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 21 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X 2 X X 2 X 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 22 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. Standard YA42 Regulation 13 Requirement The Registered Providers must ensure a risk assessment is undertaken of all upstairs windows with window restrictors fitted where a risk is identified. The Registered Providers must ensure the manager undertakes adult protection training. The Registered Providers must ensure the manager undertakes fire safety training. Timescale for action 19/01/06 2. 3. YA23 YA42 10 10 19/02/06 16/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations The Registered Providers must ensure a policy and procedure is devised in relation to financial systems in the Home. This must be shared with staff and kept under review. The Registered Providers must ensure an action plan is produced indicating when staff will commence NVQ training. 2. YA32 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI 52 Winchester Road DS0000011642.V275719.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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