Inspection on 24/01/06 for 58 Hermitage Way

This inspection was carried out on 24th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 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 01/02/07

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 Announced Inspection 24th January 2006 04:00 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 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) Ms Jayne Eeles Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th August 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. There is currently a vacancy for a registered manager after the existing manager gained promotion within the organisation. 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. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection of 58 Hermitage Way took place during the early evening of 24th January 2006. The majority of information gathered for this report came from in depth discussions with service users, either as a group or on an individual basis. The manager and service manager were both available for consultation and some records were reviewed to support discussions held where appropriate. A visit took place on 02/02/06 to the main site office to review selected staff files. The home is currently considered to be performing well and thus warrants the application of a reduced methodology. This report therefore should be read in conjunction with the report produced at the time of the unannounced inspection of the home in August 2005. What the service does well: What has improved since the last inspection? The home is currently deemed to be performing well. Improvements to staffing levels have been noted and continued involvement in the day to day running of the home demonstrates that service users continue to take a leading role in all decision making processes. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 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. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 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.V271027.R01.S.doc Version 5.1 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): EVIDENCE: These standards were not reviewed on this occasion as there have been no admissions to the home and there are no vacancies. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 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): 9 Knowledge of and involvement in risk assessment processes enable service users to take appropriate risks. EVIDENCE: The inspector spoke with service users who explained that they have full involvement in the development and implementation of risk assessments, both individual and house assessments. One service user stated that she is doing an NVQ at college and this involved a unit on risk assessment. The risk assessment implemented most recently was to support the Home Alone policy. Service users through conversation detailed what the assessment included and how that impacted upon activities they can and can not do while home alone. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 10 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 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. All activities were age appropriate. One service user is standing in the local elections in February 2006 to sit on the Locality Planning Group and stated that she already sits on the Telford and Ironbridge Community Care Group. One service user detailed the results of his recent computer exam. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 11 Everyone stated that they had a good Christmas with visits to friends and family and friends and family visiting the home. One service user has been doing work experience at a local café. She stated that she is enjoying it. Another service user is undertaking paid employment at a local care centre. One service user stated his hobbies include watching ‘the soaps’. One service user stated that personal relationships are supported by staff and friends are welcome to visit the home at any time. One service user attends a relaxation class once a week and enjoys the activity independently. All service users stated that they manage their own money. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 12 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 Person centred and flexible support enables service users to feel valued and well supported with health care appointments. EVIDENCE: Service users stated that they receive good support from staff to attend hospital and other routine health care appointments. One service user is currently awaiting test results following recent ill health. One service user said that she attends chiropody appointments in the local town. When asked service users stated that without exception they feel that they are treated with respect by staff. They all felt that their privacy was respected and communication is good. Interactions seen between the manager and service users at the time of the inspection reflected these comments. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The full involvement with decision-making and assessment processes enables service users to feel that their views are listened to. EVIDENCE: Through discussions service users stated that they felt very safe and protected by the staff team and spoke positively about the use of documents such as risk assessments. Service users participate in the recruitment and selection of staff and stated that if they said they didn’t like a candidate and gave reasons then that person would not be employed. Staff training records demonstrated that one of the two new staff have attended the Adult Protection Training. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 14 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 The standard of the environment within the home is good, providing service users with a warm and homely place to live however safety is being compromised by the lack of response to identified recommendations made by the fire officer. EVIDENCE: The inspector was shown areas of the home that have recently been refitted or redecorated. The upstairs bathroom has had a new bath and a tiling surround. The tiling had been done by a service user. Other communal areas had been painted…again by the same service user. All areas were homely and clean. The flat was not seen on this occasion as the service user who lives there had gone out for the evening. Recommendations made by the fire officer during his visit on 3rd December 2005 have not been fully actioned. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 15 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): 32,34,35 Service users benefit from a well trained and supported staff team enabling their needs to be effectively met within the home. EVIDENCE: During discussions with service users it was stated that all staff are ‘very nice’. Since the time of the last inspection of the home two new staff have been recruited. The inspector made a separate trip to view the staff files as they are kept at the main CARE site. The home has been allocated an additional 40-hour post and the manager was positive that this has impacted positively upon individual support. As the manager was the only staff member on duty at the time of the inspection the inspector was unable to talk with the new staff members. The training plan shared with the inspector demonstrated that all mandatory training is planned for new staff and additional training in subjects relevant to the service user group is also available. For example staff have attended Person Centred Planning and Cultural Awareness. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 16 A review of named staff files demonstrated that appropriate checks are taken up prior to new staff starting with the organisation. The inspector was informed that proof of qualifications were kept by the organisations training coordinator who works closely with the home managers. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 17 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, 41, 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: The acting manager feels well supported by the service manager, (previously registered manager of Hermitage Way) who has maintained contact with service users and staff. Service users commented positively about these arrangements. Interviews for the manager’s post are scheduled to take place shortly. The manager stated that she feels things have ‘calmed down’ over recent months and that there is a ‘good atmosphere’ in the house. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 18 Continuity has been maintained. The minimal records reviewed by the inspector were up to date and there was evidence that risk assessments have been reviewed. It is recommended that staff sign to demonstrate that they have read updated risk assessments. One service user currently shares responsibility of monitoring health and safety arrangements within the home and she stated that she has recently been involved in the development in risk assessments for radiators and has taken a lead role in ensuring everyone is aware of fire evacuation procedures. The manager confirmed this involvement. An issue relating to health and safety was raised by a service user who had had to tell the manager to store securely a product hazardous to health. The manager had complied with his request and this example demonstrates how proactive the service user group is in highlighting health and safety issues. One service user recently used a kitchen stepladder to assist with painting. The risk assessment was seen by the inspector. The service user was aware of the content of the risk assessment and there is evidence that the assessment had been reviewed on 16/01/06. Discussions took place with the manager in relation to the homes budget and greater flexibility is now available. The household budget is managed by an identified member of staff and a service user. The service user detailed her involvement. Regulation 26 visits take place and a summary of these visits are sent to CSCI. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 4 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 X X 4 X X X 3 4 3 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 23(4) (a) Requirement The home must action recommendations made by the fire officer on 3/12/05 Timescale for action 06/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA41 Good Practice Recommendations It is recommended that staff sign to demonstrate that they have read updated risk assessments. 58 Hermitage Way DS0000020541.V271027.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate 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 DS0000020541.V271027.R01.S.doc Version 5.1 Page 22 - 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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