Inspection on 07/08/07 for 58 Church Lane East

This inspection was carried out on 7th August 2007.

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

58 Church Lane East 05/08/09

58 Church Lane East 02/10/06

58 Church Lane East 28/02/06

58 Church Lane East 20/12/04

58 Church Lane East 02/08/04

58 Church Lane East 26/02/04

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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 58 Church Lane East Aldershot Hampshire GU11 3HB Lead Inspector Peter J McNeillie Unannounced Inspection 7th August 2007 09:15 58 Church Lane East DS0000012081.V342902.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 58 Church Lane East DS0000012081.V342902.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. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 58 Church Lane East Address Aldershot Hampshire GU11 3HB 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) 01252 311846 www.new-support.org.uk New Support Options Limited Mrs Lyn Grist Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd October 2006 Brief Description of the Service: 58 Church Lane East is a registered care home providing care, support and accommodation for up to five persons with a learning disability. New Support Options Ltd a specialist provider who are also responsible for a number of similar homes across the South of England manages the home. Accommodation is provided in large semi-detached three-storied house situated close to Aldershot town centre and other local amenities, which can be easily accessed on foot or by public transport. All residents are accommodated in their own single bedrooms. Shared /communal space includes a lounge, kitchen/diner, study and garden. Fees currently vary between £1117 and 1182 per week. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report was written after taking into consideration a number of sources of information /evidence including a site visit to the premises, previous reports, examining residents /staff training records, talking with residents, staff, management and responses by the manager to a pre inspection Annual Quality Assurance Assessment. (A.Q.A.A.) During this inspection which took place on 07/08/07 between the hours of 09.15am and 12.30pm and was the first inspection for the year 2007/08 All the designated key standards for younger adult were inspected. As a result of this visit no requirements or recommendations have been made. The results and findings contained in this report will determine the frequency and type of future inspections. What the service does well: What has improved since the last inspection? What they could do better: 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 6 There were no areas of concern noted and any requirements or recommendations made. 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. The summary of this inspection report can be made available in other formats on request. 58 Church Lane East DS0000012081.V342902.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 58 Church Lane East DS0000012081.V342902.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. 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. The home has a system of assessing and identifying residents needs which ensures residents safety and that their assessed needs can be met. EVIDENCE: There have been no admissions to the home since the original registration in 1993. A corporate admissions policy and procedure in place which involves undertaking a full assessment of needs and risk of all potential residents by the manager, first in their current place of abode and later within the home during a visit or overnight stay. The prospective resident would then be invited to be live in the home initially on a trial basis following which a full review of the placement would be made prior to a permanent bed being offered when it has been established all needs can be met As part of the final review existing residents views would also be canvassed. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 9 The files of all of the residents were viewed, all included a detailed assessment of needs and risk, which was current, had been updated by a key worker and monitored by the homes manager. All assessments of need and risk which included an acknowledgement that the resident or their representatives had been consulted and were involved in the assessment had been produced in both a written and alternative format such as pictures or signs to ensure the resident can understand them. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a well-developed system of planning and reviewing care which reflects residents wishes, aspirations and ensures residents needs are met within a risk management policy and involves residents /residents representatives or relatives in decisions that affect them. EVIDENCE: All residents care plans were viewed, and had been produced in a written and alternative format such as pictures and symbols to assist residents in understanding them. All plans are reviewed at least monthly and updated as required following a detailed review/ assessments of the resident’s needs and risks. As part of the care plan which indicated how assessed needs are to be met personal profiles detailing residents likes, dislikes, wishes and aspirations and a dictionary of signs/sounds used by residents with there meanings were also available. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 11 We were informed, and found these personal profiles and dictionaries of great value in understanding and communicating with the residents and are an example of best practice, which can reduce both residents and staff frustration and assist in the elimination of misunderstandings. All of the residents currently being accommodated have high care needs and require constant support and supervision by staff. We were informed that the right of residents to take risks is seen as fundamental, however it was clear from records, observations and talking to residents they would have difficulty in totally understanding the concept of risk and risk taking. Consequently should restrictions be indicated to keep the resident safe by a risk assessment these are reflected in the care plan. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 13,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social activities family contacts and the provision of varied and nutritious meals were well managed and reflected residents interests and choices. EVIDENCE: Records seen confirmed personalised individual programmes of activities / opportunities have been arranged to develop residents skills via a number of external day services, additional one to one personal external support and activities provided by the home. All activities and programmes are detailed in the resident’s personal plan following consultation/agreement with the resident. Activities currently available include, cinema, computers, cooking, gardening trips, walks, shopping, music, sensory rooms, church, aroma therapy and, art. Copies of art produced by the residents were displayed throughout the home. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 13 Within individual activity programmes a great deal of emphasis is placed on going out into the community and accessing community based facilities such as swimming pools, shops, café, libraries and health care resources. All residents have regular contact with family and friends who are encouraged to participate in the residents review if agreed by the resident. Apart from face to face contact, residents are assisted in sending family birthday cards and regular letters. We were informed to ensure family contact is maintained if required, the home would assist with transportation. A colour-coded pictorial menu planning system is in operation that ensures balanced and nutritional meals, which also reflect resident’s choices and personal preferences, are served. Residents are encouraged to assist with the food shopping and preparation of meals, which are displayed in a pictorial daily menu. All meal times are flexible to meet resident’s needs. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements are in place, ensuring the personal emotional, health care and medication needs of residents are met. EVIDENCE: We were informed by staff that any personal examinations of residents by a visiting health care professional would take place in the privacy of the resident’s own room to which the resident has a key. Due to difficulties in communicating with residents we were unable to confirm this. However, in line with the homes policy of ensuring residents feel part of the community, where possible consultations with health care professionals take place outside of the home. Records seen confirmed residents had access to a wide range of health/social care professionals including doctors, district nurses, speech and language therapists, psychiatrists, psychologists, care managers and the community disability team. Other specialists would be consulted as required. Residents are 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 15 free to choose their own doctor or source of other personal services such as dentists chiropodists, optician etc. All residents’ drugs and medicines, which are securely stored, are administered in accordance with an in house and corporate medication policy and procedure. A pharmacist via a monitored dosage system dispenses all drugs, which are administered by staff that had received training in the safe handling and recording of resident’s drugs and medicines. Records of administration and disposal of unwanted drugs and medicines seen were complete and accurate. A policy exists to encourage residents who are able to take responsibility for their own medication. Currently no residents are self-medicating following a risk assessment. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear policies and procedures in place which ensures residents are able to complain and are protected from abuse . EVIDENCE: An in house Adult Protection policy/procedure that operates in tandem with the policy and procedure produced by Hampshire County Council designed to safeguard residents from abuse was available. Records viewed and staff spoken with confirmed they had received training in recognising abuse. All were able to demonstrate they knew what to do should they witness or suspect the abuse of any resident An audit of resident’s monies was undertaken. Cash held reconciled with the detailed records and receipts, which were available for all transactions. We were unable to access residents bankbooks as the manager was unavailable, however we were assured that if a resident needed extra money urgently this could be made available. Daily audits of resident’s money are undertaken on each shift. The homes dual formatted complaints procedure which was also included in the service users guide and the brochure given to all residents on admission included information on how to contact The Commission for Social Care Inspection (C.S.C.I) was seen as was a record of complaints 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 17 One complaint had been received since the last inspection. Records indicated this had been dealt with to the satisfaction of the complainant. Staff spoken with said felt comfortable in raising any concerns they had with the homes management on behalf of any resident and confident any matters raised would be dealt with fairly and promptly. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 18 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. 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. A safe, well maintained, clean and suitably furnished home and accessible garden is provided for residents which meets their needs. EVIDENCE: The Home was well furnished, fully decorated, clean, free from adverse odours and homely. It was evident from discussions with staff and our observations of the residents that the environment meets their needs. The Home has a lounge and separate dining room that provides a suitable environment for residents who were observed to be relaxed and comfortable watching television and listening to music. There is a good size kitchen that was clean, bright and airy. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 19 There is a separate laundry with a washing machine fitted with a high temperature programme and sluicing mode. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all residents. EVIDENCE: At the time of the inspection the number of staff on duty were adequate to meet the residents needs. We were informed staff numbers and the deployment of staff would be reviewed and changed if the need arose. We were unable to view staff recruitment files as the manager was on leave and the other key holder with access to the confidential information was not on site. We did however confirm that in the event of an emergency the records could have been made available within an hour or so. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 21 A corporate policy and procedure was in place that ensures all staff are employed in accordance with a robust recruitment and selection procedure designed to protect residents. This involves the completion of an application form, the signing of a rehabilitation of offenders declaration, an interview, satisfactory Criminal Record Bureau, Protection of Vulnerable Adults and reference checks followed by the satisfactory completion of an in house induction training and probationary period of employment. No new staff had been employed since the last inspection. Confirmation that the procedure is followed was seen at the previous four inspections. Staff supervision records were also not available but staff spoken with confirmed they did receive regular supervision. Staff training records viewed indicated all new staff are involved in an initial in house five-day induction programme followed by an intense corporate five day induction during which core subjects such as fire safety, food hygiene, first aid, infection control and moving and handling training are covered. All staff is expected to be involved in a National Vocational Qualification (NVQ) training programme to at least level three in care. Currently 37.5 of staff has been trained to N.V.Q. level three with a further 12.5 currently on a course. A corporate training calendar is available to ensure that any additional identified training needs can be met. A number of staff have been involved in train the trainer courses which will enable them to cascade training to staff and ensure support and advice is available in house. Apart from day to day training additional staff and management training has also taken place as part of the homes accreditation by The Autistic Society to become a home offering specialist care and support to persons with autism. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home seeks the views and opinions of residents residents representatives, visiting health care professionals and safeguards the health and safety of staff and residents through the implementation of safe working practices. EVIDENCE: The manager Lyn Grist is a very experienced manager and has been in charge of the home for a number of years. Mrs Grist has completed her Registered Managers Award and NVQ Level 4 and is an NVQ assessor. Staff spoken with described internal and external management as, supportive, helpful, available and approachable. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 23 Staff also confirmed they were aware of their role and responsibilities and that of their colleagues. Records confirmed a quality monitoring system that seeks the views of residents; resident’s relatives/representatives and health/social care professionals had been implemented. Results from previous surveys had been sent to C.S.C.I. All residents were due to be canvassed again for their views in the near future. Views expressed in these surveys are taken into consideration when corporate and in house plans affecting the future of the home and residents are made. Visits by a representative of the registered person as required by regulation 26 are taking place. Reports made following these visits were available. A corporate health and safety policy that is designed to protect both residents and staff has been implemented this includes the practice of strict infection control procedures such as using protective aprons, gloves and washing hands in antiseptic soap. Records seen confirmed of weekly health and safety checks undertaken and that all staff had received 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 an. All radiators and hot pipes were covered. The records of servicing equipment used within the home were available. 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 24 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 3 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 X 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 25 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 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 58 Church Lane East DS0000012081.V342902.R01.S.doc Version 5.2 Page 27 - 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. 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