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Inspection on 24/08/05 for 58 Hermitage Way

Also see our care home review for 58 Hermitage Way for more information

This inspection was carried out on 24th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service has undergone a period of management change however continuity for service users has been maintained. This is due to the concerted efforts of all staff and management and the support that service users have offered staff in return. Service users are fully involved in all aspects of their lives and are proactive in making suggestions and sharing their thoughts and ideas about the services that they receive. Service users fully support the inspection process and are open and supportive of the process.

What has improved since the last inspection?

58 Hermitage Way is currently deemed to be performing well yet it is positive to note that improvements are still being made. An improved and more person centred appraisal system has been developed and implemented and staff induction has been reviewed.

What the care home could do better:

Although the acting manager and service manager are proactive in identifying improvements to the service there was nothing identified that could be done better at the time of this inspection. No requirements or recommendations were made by the inspector.The inspector would like to thank everyone for their support and hospitality during the inspection.

CARE HOME ADULTS 18-65 58 Hermitage Way Madeley Telford Shropshire TF7 5SZ Lead Inspector Sue Woods Unannounced 24 August 2005 17:00 th 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 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 Stationary 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 E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 58 Hermitage Way Address Madeley, Telford, Shropshire, TF7 5SZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01952 586224 01952 432209 CARE (Cottage and Rural Enterprises Ltd) Ms Jayne Eeles Care Home 7 Category(ies) of Learning Disabily (7) registration, with number of places 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No conditions apply. Date of last inspection 24th January 2005 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 and the registered manager is Jayne Eeles. 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 Home’s 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’. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of 58 Hermitage Way took place during the early evening of 25th August 2005. The inspector spoke with service users, the acting manager and the acting service manager who was working on shift at the time of the visit. The inspector reviewed health and safety records and medication arrangements. The home is currently considered to be performing well and thus warrants the application of a reduced methodology. What the service does well: What has improved since the last inspection? 58 Hermitage Way is currently deemed to be performing well yet it is positive to note that improvements are still being made. An improved and more person centred appraisal system has been developed and implemented and staff induction has been reviewed. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 6 What they could do better: Although the acting manager and service manager are proactive in identifying improvements to the service there was nothing identified that could be done better at the time of this inspection. No requirements or recommendations were made by the inspector. The inspector would like to thank everyone for their support and hospitality during the inspection. 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. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 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 standard(s) These standards were not reviewed on this occasion as there have been no admissions to the home and there are no vacancies. EVIDENCE: 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 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 standard(s) 6,7,8, Service users lead full and active lives while receiving the support they need. Full involvement and robust consultation processes mean that service users are fully in control of their lives and the services that they receive. EVIDENCE: Three service users spoke at length with the inspector in a group discussion and on an individual basis. During the group discussions service users detailed the contents of their care plans and shared details of their personal goals and aspirations. Service users continue to enjoy full and active lives accessing leisure activities independently or with staff support as required. Service users informed the inspector of forthcoming reviews and detailed how these tied into reviews of day activities. It was very evident that service users are fully consulted on all aspects of life in the home giving examples of menu planning, choice of colour for redecorating and the recruitment and selection of staff. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 10 Service users stated that they had been fully informed and consulted during the recent management changes to the home and commented that things are going ‘very well’ at the moment. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 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 standard(s) 13,14,17 Service users are enabled to participate in the community-based activities that they enjoy allowing them a good quality of life. EVIDENCE: At the time of the inspection one service user was preparing a meal for himself and others. The acting service manager commented that the kitchen cupboards were well stocked to meet individual preferences and before leaving the inspector saw one service user preparing a house shopping list. She was aware of what was needed and was carrying out the task independently. Service users and the managers shared stories of their holidays with the inspector and it was evident that a great time was had by all. Service users spoke of numerous recent leisure activities including trips to the cinema and swimming. Some service users have plans to visit family over the bank holiday weekend and people staying at home have planned their activities also. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 12 One service user told the inspector that he was having a barbeque to celebrate his forthcoming birthday. He has already invited family and friends to the event. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 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 standard(s) 19,20 Person centred and flexible support enables service users to feel well supported with health care emergencies and routine appointments. The home has a safe system for storing, handling and recording medication. EVIDENCE: One service user told the inspector of her recent admissions to hospital. It was positive to hear that she is now in good health and that she felt well supported by staff (and hospital staff) during her illnesses. One service user had attended a hospital appointment at the local hospital on the day of the inspection and commented that it had gone well. Another service users is waiting for an appointment for an eye examination. Again service users stated that they receive appropriate staff support. Medication arrangements were reviewed at the time of the inspection. Only one service user receives regular medication and it was stored securely in a locked cabinet in the office. The administration records were seen to have been completed appropriately for the last two days and back dated records were available but were not reviewed by the inspector. The medication cabinet 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 14 contained only minimal stocks and paracetamol-based products seen are supported by a protocol signed by the local GP. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 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 standard(s) 22 The open approach of managers and staff enables service users to feel that their views are listened to. EVIDENCE: Service users who spoke with the inspector in a group discussion stated that they were very confident that their views are listened to. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 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 standard(s) 24,30 The standard of the environment within the home is good, providing service users with a warm, safe and homely place to live. EVIDENCE: Communal areas were seen to be clean and well organised at the time of the inspection. The plans to redecorate the hallway are supported by paint colour patches strategically placed to assist with the decision making process. Bedrooms and bathrooms were not reviewed on this occasion. One service user showed the inspector that he has recently ‘treated’ the fence. He explained how he had used gloves and a mask and the manager later stated that the product used was user friendly and appropriate risk assessments had been carried out. The service user who lives in the flat was out shopping at the time of the inspection therefore her home was not visited. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 Service users benefit from a well supported staff team enabling their needs to be effectively met within the home. EVIDENCE: The acting manager stated that she has maintained a regular supervision programme for staff and added that the acting assistant manager is also assisting in this process. The acting manager detailed how certain tasks have been delegated to experienced staff. Records reflect these arrangements. It was positive to note that despite a difficult period where staffing levels and sickness impacted on the remaining staff team (although not on service delivery) that all staff hours are now covered despite the ‘acting up’ arrangements in place. The acting manager and the acting service manager spoke positively about the changes to the induction process and how these changes have benefited staff. Again, parts of the induction process are supported by existing staff and service users. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 42, 43 An open approach from staff and managers and full consultation enables service users to feel confident that management changes will not affect the quality of the service that they receive. Managers and staff have implemented and maintained systems to safeguard service users. EVIDENCE: Service users told the inspector that they were asked if they were happy with the service that they receive from CARE. They also stated that they were. Regulation 26 visits have started taking place on a more regular basis and summaries are sent to CSCI. Recent temporary management changes have been fully supported by service users and have not impacted upon continuity. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 19 The acting manager feels well supported and the acting service manager, (previously registered manager of Hermitage Way) who has maintained contact with service users and staff. Service users commented positively about these arrangements. The acting manager is currently undertaking the Registered Managers Award and will then commence NVQ level 4 in Care. She already has NVQ level 3. The acting manager has received training in supervising staff and for the Protection Of Vulnerable Adults. The records for fire safety checks were reviewed and found to demonstrate that appropriate checks take place on a regular basis. All incidents requiring notification to CSCI (under Regulation 37) had been acted upon and written records are submitted in a timely manner. 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 4 4 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x 4 4 x x 3 Standard No 31 32 33 34 35 36 Score x x x x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 58 Hermitage Way Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 3 E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 21 NA Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement There were no requirements made as a result of this inspection 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. 1. Refer to Standard Good Practice Recommendations There were no recommendations made as a result of this inspection 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn SHREWSBURY SY2 5DE 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 58 Hermitage Way E56 S20541 Hermitage Way V221518 UAI 240805 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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