Inspection on 22/08/06 for 52 Winchester Road

This inspection was carried out on 22nd August 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 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 4 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 16/01/06

52 Winchester Road 30/08/05

52 Winchester Road 08/11/04

52 Winchester Road 22/06/04

52 Winchester Road 10/07/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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 Craig Willis Unannounced Inspection 22nd August 2006 10:00 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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.V305030.R01.S.doc Version 5.2 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.V305030.R01.S.doc Version 5.2 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 Mr Keith Jackson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: 52 Winchester Road is registered to provide care and accommodation to four people between the ages of 18 and 65 years with learning disabilities. The home is owned by Iliace ltd and is a four bedded detached property situated in the village of Four Marks, a ten minute drive from the town of Alton which has a range of leisure, educational and employment facilities. All service users have their own bedroom, communal space and a large garden, which accommodates an indoor heated swimming pool. The manager reported following the inspection on 5/10/06 that the range of fees at the home is £1178.94 to £1560.19 per week, depending on the needs of the service users. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report was gained from a site visit to the home on 22nd August 2006. CSCI did not receive the pre-inspection questionnaire or any comment cards from service users or relatives prior to the visit. During the site visit the inspector spoke with two of the service users, care staff on duty and the manager. A tour of the building was made and observations were made of the way staff were supporting service users. Documents relating to the running of the home were inspected during the visit. What the service does well: What has improved since the last inspection? Action has been taken to fit window restrictors to upper floor windows. The manager has undertaken fire safety training. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 Page 6 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. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems to assess the needs of service users before they move into the home. EVIDENCE: The files of three service users were inspected during the visit. Each contained an assessment of their needs that was completed before they moved into the home. This assessment covers the individual needs of service users, including communication and personal care needs. No new service users have moved into the home since the last inspection. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has care planning and risk assessment systems, however, failure to keep these documents regularly reviewed may result in the needs of service users not being fully met. Good support is provided to help service users make decisions about their lives. EVIDENCE: The personal files of all three service users were inspected during the visit. Each service user had a care plan that was developed from their initial needs assessment, however, these had not been regularly reviewed and contained some guidelines dating back to 2004 and 2005. The manager reported these were not now being used as he felt they could be used as a punishment and said that he was in the process of reviewing all of the care plans with service users. Service users spoken with said that staff know what support they need and staff were observed providing appropriate support to service users. Care plans contain details of how service users should be supported to make decisions. Staff were observed supporting service users to make decisions 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 Page 10 about activities they took part in during the visit. This support was provided in a sensitive and friendly manner. Risk assessments were in place for all three service users whose files were inspected. These documents set out the assessed hazards to service users and action to minimise the risk of harm. The risk assessments had also not been regularly reviewed, with review dates set for October 2005 but no evidence that this review had taken place. The manager reported that he was in the process of reviewing all of the risk assessments. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides support for current service users to take part in suitable activities, although staffing levels have not always been sufficient to provide this support. Good support is provided for service users to maintain relationships with family and friends and the home provides good food. EVIDENCE: Service users are supported to take part in a range of educational and leisure activities. Service users spoken with said they like to go to local pubs and on trips out. Service users’ files contained details of activities they had taken part in, including attending an outdoor activity centre, college courses and local day trips. Two of the service users have been supported to obtain local jobs. The manager reported that he was looking to develop a training programme for service users in job skills. One service user has recently moved out of the home and the manager reported that they were not always able to provide the support necessary for this person to take part in their planned activities, due to staff support that was required. The manager said that the needs of any 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 Page 12 potential service user would be fully assessed to ensure that there was sufficient support to enable them to take part in suitable activities. Service users are supported to keep in touch with family and friends, with one service user being supported to arrange a visit to relatives during the visit. Service users spoken with said that staff maintain their privacy and treat them well. Details of the support service users need to complete household jobs, such as cleaning and cooking, are detailed in their care plans. The home has a planned menu that takes into account the likes and dislikes of service users and provides a varied and balanced diet. Service users spoken with said the food was good and they could always have something different if they wanted to. Mealtimes are flexible to fit in with service users’ activities. The kitchen was well stocked with a variety of good quality food. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides good support to meet the personal care and health needs of service users. The medication recording systems in the home are not being fully completed and do not protect service users. EVIDENCE: Details of the personal care support service users need are set out in their care plans. Service users spoken with said that staff provided support in the way they wanted it and treated them well. Records are maintained of service users’ visits to health services, including GP, dentist and optician. The records kept included details of any advice given by the practitioner. Service users spoken said they were supported to see their doctor when they needed to. Medication was stored in a locked cabinet in the office. Currently, only one service user was prescribed creams, which they were self-administering following an assessment that this was safe. Due to the service user administering their own medication, the manager reported that staff were not completing the medication administration records. The manager said he was looking to introduce a system where the service user signed to say they had used their prescribed creams. The provider’s regulation 26 report of July 2006 reported that this was not in line with the organisation’s policy and procedure 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 Page 14 and instructed the manager to rectify this. Staff have received training in the administration of medication. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are confident their complaints will be taken seriously and acted upon. The home has good adult protection systems, which help to keep service users safe, although this would be enhanced by training for the manager. EVIDENCE: The home has a complaints procedure available, which sets out who will deal with a complaint and how long the provider will take to respond to a complaint. The procedure has been supplied to all service users in an accessible pictorial format. Service users spoken with said they know what to do if they want to make a complaint and were confident that it would be taken seriously. No formal complaints have been received since the last inspection. The home has an adult protection policy and a copy of the local authority adult protection procedures. Staff have undertaken adult protection training and those spoken with demonstrated a good understanding of abuse and action to take if abuse was reported or suspected. The requirement made at the last inspection that the manager must undertake adult protection training has not been complied with and the manager was unable to say when he would be completing it. The manager reported that records of money held for service users had been audited following a recent adult protection strategy meeting. The manager also said that care managers had been invited to check the money, which was one of the recommendations of the strategy meeting, although none had taken up this invitation. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a safe, homely environment for service users. EVIDENCE: A tour of the communal areas of the home was made during the visit. The home is well maintained and decorated throughout. Furnishings were domestic and of good quality. The home has an enclosed rear garden, which service users are able to access. There is a covered, heated swimming pool in the garden, which service users are able to access with support. The manager reported that the provider has a maintenance team and he has no problem getting work done when it is required. The manager reported that he has complied with the requirement in the last inspection to fit window restrictors on first floor windows. Restrictors were seen on windows viewed during the inspection. The home has a domestic washing machine in the kitchen. There are infection control procedures in place to prevent laundry being taken through the kitchen whilst food is being prepared or eaten. There are hand-washing facilities in the kitchen, bathrooms and toilets. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has good systems to protect service users and meet their needs through the staff training programme however, action is required to demonstrate that recruitment procedures are sufficiently robust. EVIDENCE: The manager reported that one of the eight staff employed have achieved the National Vocational Qualification (NVQ) at level two or above, and two have applied to start the qualification. During the visit, staff were observed interacting with service users in a friendly and respectful manner. The manager reported that one new member of staff has been employed since the last inspection in January 2006. The recruitment records of this member of staff were inspected and did not contain written references or an enhanced disclosure from the Criminal Records Bureau. The manager said that these records were being held at head office, although was unable to confirm this as he could not contact the appropriate person during the visit. Staff spoken with said that they received good training. A record is kept of all training that staff have undertaken. Training staff have completed includes first aid, medication administration, food hygiene, fire safety, health and safety, infection control, adult protection, autism, challenging behaviour, deep water safety and crisis intervention and prevention. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run by a qualified manager who promotes the health, safety and welfare of service users and staff, however, action is needed to ensure that all of the supporting documentation is in place. The implementation of the home’s quality assurance audit will help to ensure that the service improves. EVIDENCE: The manager has completed the Registered Manager’s Award and has been in post for approximately one year. The manager said he receives good support from the senior management staff and is able to speak with them whenever he needs to and has regular supervision meetings with the area manager. The manager said Iliace were in the process of introducing a new quality assurance system to gain the views of service users and their relatives. The home has a set of objectives, although the manager reported that they were out of date and needed to be rewritten. Senior managers from Iliace visit the home each month to review the service quality. Reports of these visits contain actions that are required to improve the service. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 Page 19 The home has a fire risk assessment and regular checks are made of the fire warning system and the equipment. The manager has complied with the requirement in the last inspection report to undertake fire safety training. The manager was unable to find the home’s gas safety certificate, although said the checks had been completed and he had requested the certificate from Iliace head office. Assessments are completed for chemicals used in the home, which are stored in a locked cupboard. The temperatures of the fridge and freezer are taken daily and recorded. These records indicated that during August 2006 there were 8 occasions when the freezer was over minus 18 Celsius and 5 occasions when the fridge was over 8 Celsius. The manager said that the fridge and freezer have been checked by the maintenance team who think the problem is being caused by the door being left open. The manager said he will continue to monitor the temperatures and ensure that food is stored at the correct temperature. Accidents and incidents to service users and staff are recorded and reported where necessary. 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 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 2 X 2 X X 2 X 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 Page 21 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 YA6 Regulation 13 (4) and 15 Requirement The registered person must ensure that care plans and risk assessments contain current information and are regularly reviewed. The registered person must ensure that accurate medication administration records are maintained. The Registered Providers must ensure the manager undertakes adult protection training. This requirement is repeated, as the previous time-scale of 19/02/06 was not complied with. The registered person must ensure that Criminal Records Bureau disclosures and written references are available for all staff employed in the home. Timescale for action 31/10/06 2. YA20 13 (2) 30/09/06 3. YA23 10 31/10/06 4. YA34 19 (1) 30/09/06 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 Page 22 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 52 Winchester Road DS0000011642.V305030.R01.S.doc Version 5.2 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.V305030.R01.S.doc Version 5.2 Page 24 - 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!