Inspection on 01/02/07 for 58 Hermitage Way

This inspection was carried out on 1st February 2007.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

58 Hermitage Way 01/08/07

58 Hermitage Way 24/01/06

58 Hermitage Way 24/08/05

58 Hermitage Way 24/01/05

58 Hermitage Way 24/08/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 58 Hermitage Way Madeley Telford Shropshire TF7 5SZ Lead Inspector Sue Woods Key Announced Inspection 1st February 2007 02:00 58 Hermitage Way DS0000020541.V329552.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 Hermitage Way DS0000020541.V329552.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 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 58 Hermitage Way Address Madeley Telford Shropshire TF7 5SZ 01952 586224 01952 432209 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) www.care-ltd.co.uk CARE (Cottage and Rural Enterprises Ltd) Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: 58 Hermitage Way is registered with the Commission for Social Care Inspection as a care home for a maximum of 7 adults with a learning disability. The home is owned by Cottage and Rural Enterprises Limited (CARE). The organisation has recently appointed a home manager who takes up her post on 1st March 2007. The house is purpose built and is situated on a residential estate close to the towns of Madeley and Ironbridge. The building contains a self contained flat. The Homes Statement of Purpose states that The services provided are designed in consultation with the people who live here and respond to the needs of the individual. Information is shared with service users in the service user guide and formally (during house meetings) and informally on a regular basis. Service users are very proactive in the running of the home and all key decisions are taken only after full consultation. Fees range from £429.03 to £499.39 a week. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection of 58 Hermitage Way took place on 1st February 2007 between 2.00pm and 6.30 pm. The inspection reviewed all 22 key standards and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the fieldwork activity the inspector spoke with service users, the newly appointed manager and assistant manager, the staff member on duty at the time of the inspection and the residential services manager for CARE. Records reviewed included care plans, risk assessments and health and safety information. Two staff files were reviewed. As part of the inspection planning process questionnaires were sent to service users, relatives/visitors and health and social care professionals. Written responses were received from all service users, a relative and one health and social care professional. What the service does well: Service users living at Hermitage Way lead very independent and fulfilling lives. They are proactive in the running of the home and are fully consulted in all decision-making processes. Service users feel that their views are listened to. Service users take a lead role in the induction and support of new staff and support each other when health care needs change. Service users always request feedback at the end of the inspection. An excellent example of the effectiveness of training was seen following medication training when the staff member reviewed current work practice and shared concerns with a senior manager (in the absence of the home manager). The responses provided by the relative and the social care professional were both very positive. Three service users replied that they liked living at the home. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 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 Hermitage Way DS0000020541.V329552.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 Hermitage Way DS0000020541.V329552.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): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place that would enable the successful admission of a new service user to the home. EVIDENCE: There have been no new admissions to the home since the time of the last key inspection therefore the judgement made at the time of the last inspection will be carried forward. 58 Hermitage Way DS0000020541.V329552.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6, 7, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are knowledgeable about their individual support needs and how to take assessed risks during everyday life however they may be vulnerable if written plans and assessments are not reviewed and up to date. EVIDENCE: Service users who spoke with the inspector identified what support needs they had and were happy that staff met those needs. The home alone policy was discussed and service users felt it was working well although they noted that one service user is not currently able to stay home alone due to his changing support needs. They discussed the impact this was having on activities. Service users were aware of their own care plans and those of others who live in the house enabling them to also offer appropriate support when required. Service users are well aware of risk assessment processes and gave examples of how they review risk taking on a regular basis. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 10 On the whole care plans are in place to identify individual support arrangements however it was apparent that not all plans and risk assessments are up to date. Service users are consulted in all aspects of the running of the home and were able to share with the inspector numerous examples of how their wishes and opinions are listened to. The most recent being the appointment of the manger when service users sat on the interview panel. Also service users fed back on the induction of the latest member of staff to join the team and what they are doing to help her ‘find her feet’. Service users identified areas of strengths and needs within the home and requested feedback at the end of the inspection. 58 Hermitage Way DS0000020541.V329552.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users lead full and active lives while receiving the support they need. Full involvement means that service users are fully in control of their lives and the services that they receive. EVIDENCE: During an informal group discussion around the dining table service users told the inspector about numerous activities that they participate in on a regular basis. One service user has recently joined the gym and still supports the local self advocacy group. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 12 One service user is working at a local café and one service user has just started work at a local hotel. Others spoke of how they would like full time employment with long-term prospects. The inspector also spoke in private with two service users. All service users stated that they manage their own money. One service user at Hermitage Way stated that she was attending a full day first aid course tomorrow at a local community training venue. Service users stay in touch with family and friends. All service users who spoke with the inspector stated that they enjoy a healthy diet. Everyone has the opportunity to do the cooking and service users can prepare something different if they do not like what is on the menu. Service users take part in food shopping and gave examples to the inspector of what they like and don’t like eating. 58 Hermitage Way DS0000020541.V329552.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 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. Service users benefit from receiving the support they require when they need it. Service users may be at risk of harm as medication recording arrangements are unsafe. EVIDENCE: Service users stated that they are happy with the support they receive from staff and are able to choose who supports them with medical appointments. Records reflected that service users receive regular health care checks and receive appropriate support when their health care needs change. One service user told the inspector of her ill health over the last twelve months and how she is now feeling much better. When asked, service users stated that without exception they feel that they are treated with respect by staff. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 14 Medication arrangements were reviewed as part of the inspection and were found to be disorganised with conflicting information available in relation to one service user. Storage arrangements were found to be satisfactory however administration records were confusing and contradictory. A protocol to support the administration of medication as and when required had not been dated and therefore could not support a recent change of practice. The newly appointed manager cold not find any guidelines for staff in relation to the administration of Olive Oil to one service user. A staff member, who had received training on the day of the inspection in relation to the safe handling of medication had been to see the residential services manager following the training to discuss issues that the training had raised in relation to her work practice at the home. This action is to be commended. By the end of the inspection the member of staff and the newly appointed manager were working towards improving existing arrangements to make them safe. They planned to use a monitored dose recording system for all service users and cease the use of record sheets made up by the home (which on one occasion did not detail the same administration details as the GP had prescribed) 58 Hermitage Way DS0000020541.V329552.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 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 full involvement with decision-making and assessment processes enables service users to feel that their views are listened to however records do not always support processes. EVIDENCE: At the time of the inspection it was evident from discussions with service users that they feel listened to and confident that their wishes will be followed through. Service users knew who to speak to if the had a concern or a complaint. Staff have attended appropriate adult protection training. The complaints book contained reference to one complaint made by a service user. The book recorded how the manager had addressed the issue however there was no evidence of an acceptable outcome. The newly implemented complaints investigation procedure had not been followed to completion. There was no record of an appropriate investigation on the file of the service user who had made the complaint or a written response to the complainant. As the manager was unavailable at the time of the inspection it may be that the missing paperwork was filed elsewhere. This will be reviewed at the time of the next inspection of the home. Staff had been formally asked to feedback their opinions of the new complaints investigation procedure. Feedback had been positive. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 16 Service users continue to manage their own money and all have access to their cash. Risk assessments were seen in place to support the use of cash cards and financial matters had been discussed at the recent review of one service user. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 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 standard of the environment within the home is good, providing service users with a warm and homely place to live. EVIDENCE: Communal areas of the home were seen by the inspector to be well maintained, clean and tidy. The inspector was shown around the wellmaintained flat belonging to one service user. The manager stated that all requirements made by the fire officer at his last visit in 2005 had been actioned and records were seen of up to date fire safety and emergency lighting checks. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 18 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): Standard 32,34 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well trained and supportive staff team enabling their needs to be effectively met within the home. EVIDENCE: Two staff files reviewed as a result of this inspection contained all required information. CARE, locally, has a good reputation for ensuring all staff have appropriate CRB checks. The disclosures were not on site for review by the inspector however disclosure numbers and dates were recorded on files. The manager stated that should any disclosures be identified then she would be fully informed and a risk assessment would be carried out before a decision to appoint was made. Staff who spoke with the inspector were professional and totally committed to providing a good service. The actions taken by the staff member following her training in relation to medication (see standard 20) reflects that staff use training to review and improve performance. Following staffing shortages over recent months, that have affected moral within the home, it is positive to note that the home is now fully staffed. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 19 Staffing at the time of the inspection corresponded with the rota sent to CSCI in preparation for this inspection. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 20 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): Standard 37, 39, 41 and 42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The health and safety of service users is being compromised by a lack of clear management and poorly maintained records. EVIDENCE: The current manager of the home has been in post for over twelve months and has not completed her application for registration with CSCI despite numerous requests from CSCI to do so. In December 2006 CSCI was advised that the manager has resigned and in January 2007 the previous registered manager of Hermitage Way was reappointed much to the pleasure of service users. Service users acknowledge there have been difficulties at the home over recent months and senior managers have been addressing issues. The newly 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 21 appointed manager was at the home at the time of the inspection and has, as a result, begun prioritising tasks for action. Generally health and safety records were available although upon review it was apparent that some have not been completed or reviewed as appropriate. For example manual handling risk assessments were last completed in 2004. Water temperature checks currently take place weekly however there were inconsistencies seen in temperatures recorded. On one occasion far exceeding the safely regulated maximum. There was no note to say that remedial action had been taken to address this issue and this is of concern, as the next check wasn’t carried out until a week later. The manager committed to carry out an immediate review of water temperature monitoring. The residential services manager carried out a Food Safety Inspection in January 2007. The accident book seen corresponded with best practice in relation to the confidentiality of information sharing however it was recommended that individual records should be kept on service users (or staffs) personal files. The Communication book, although demonstrated that comprehensive information is handed over to staff contained personal and private information. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 22 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 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 3 X 2 2 X 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 23 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 2 Standard YA6 YA6 Regulation 15 (2) (b) 14 (2) Requirement Care plans must contain all up to date information to reflect the current needs of service users The changing needs of one service user must not negatively impact on opportunities for others Risk assessments must be reviewed as required and be updated to support changing needs. An immediate review of medication storage and recording arrangements within the home must take place and outcomes be actioned. (Timescale given reflects that manager is already addressing this requirement) The newly appointed manager must apply for registration with CSCI without delay. General records must not contain personal or private information relating to a service user. Health and safety records must be kept and updated as required by the appropriate legislation and home guidelines. Water temperatures must be DS0000020541.V329552.R01.S.doc Timescale for action 27/02/07 27/02/07 3 YA9 13 (4) (c) 23/02/07 4 YA20 13 (2) 23/02/07 5 6 7 YA37 9 17 (1) (b) 17 31/03/07 23/02/07 27/02/07 YA41 YA42 8 YA42 13 (4) (c) 23/02/07 Page 24 58 Hermitage Way Version 5.2 monitored appropriately and actions taken when discrepancies are identified must be recorded. 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 YA41 Good Practice Recommendations It is recommended that individual records should be kept on service users (or staffs) personal files. 58 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Hermitage Way DS0000020541.V329552.R01.S.doc Version 5.2 Page 26 - 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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