Inspection on 16/08/05 for 6 Sadlers Lane

This inspection was carried out on 16th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

6 Sadlers Lane 22/01/09

6 Sadlers Lane 31/01/07

6 Sadlers Lane 31/01/06

6 Sadlers Lane 04/11/04

6 Sadlers Lane 27/05/04

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Dalewood Respite Care

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Fairways

Treloar College

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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 6 SADLERS LANE Winnersh Wokingham Berks RG11 5AY Lead Inspector Susan Cledwyn-Davies Unannounced 16 August 2005 9.15 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. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 6 Sadlers Lane Address Winnersh, Wokingham, Berks, RG11 5AY 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) 0118 9783181 New Support Options Ltd Acting Manager Ms Carol Jeffrey Care Home (CRH) 4 Category(ies) of Learning Disability (LD) registration, with number of places 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4 November 2004 Brief Description of the Service: 6 Sadlers Lane is a care home providing 24 hour personal care to four adults who have learning disability. The current service users are all male and have some additional challenging behaviour. The house is owned and maintained by Maidenhead and District Housing association and New Support options provide the management and care staff. The home is a domestic sized, bungalow situated in a residential part of Wokingham. Each service user has an individual bedroom, one service user has an ensuite bathroom. The garden is easy to access. Shops and local facilities are found in the centre of town, the home has its own transport and access to public transport. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 9.15am and 1.15pm. Included in the inspection was a tour of the home, discussion with the acting manager and staff, conversation with all of service users and examination of the records. All of the service users were present. What the service does well: 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. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 6 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 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 7 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) 1, 2 and 5 Service users have information about the home. Individual service users needs and aspirations are assessed and they each have an individual written contract. EVIDENCE: Service users have a service user guide included in their care plan. The format is not user friendly but factual. The key workers provide information to service users. The statement of purpose was not seen on this occasion. The current service user group have been resident for some years. There are no vacancies in the home. All service users are having an annual review to include a fresh look at their needs and aspirations. See next section. Each service user has a written contract of accommodation. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 8 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 and 9 Service users needs are assessed and reflected in their individual plan. Service users are supported to make decisions about their lives and when taking risks. EVIDENCE: Each service user has an individual care plan. One care plan was seen in detail. All of the plans have been reorganised and risk assessments and information updated. Each service user is having an annual review that includes a total review of needs and personal goals. These are called PATH and look at the future aims and hopes with relatives, home staff and care managers. One of these reviews has taken place and been very positive for the service user involved. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 9 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) 11, 12, 13, 14, 15, 16 and partially 17 Service users have varied activities and opportunities for personal development. Families are actively involved in the lives of service users. Daily routines respect individual rights except in one specific instance. Full records of meals provided are kept. EVIDENCE: Service users have varied activities and leisure opportunities. Holidays have been arranged for three of the service users and the fourth has chosen to have full days out from home. Families are actively involved in the lives of service users and staff maintain good relationships with them. One service user has an ensuite bathroom containing an assisted shower. This bathroom is solely accessed through the bedroom. This bathroom is used for other residents to provide choice. In the main bathroom there is an assisted bath and shower provided. The shower is not working properly therefore staff use the ensuite bathroom instead. This practice does not ensure privacy and respect and should therefore stop. The shower in the main bathroom should be working properly to provide a real alternative to all service users. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 10 A record of meals provided is now being kept on the daily record sheets. The meals were not seen on this occasion. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 11 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) 18 and 19 Service users receive personal support in the way they prefer and health needs are met. EVIDENCE: Annual medical checks are completed for all but one service user. The community nurse completes this check. Medical help is obtained as necessary. During the visit one service user was stung by a wasp. The service user went to the chemist for treatment and a specialist destroyed the wasp’s nest later in the day. The manager and staff provide good proactive support to service users. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 12 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 and 23 Service users views are listened to and service users are protected from abuse. EVIDENCE: There have been no complaints about the home either to the manager or to CSCI. There is a comprehensive complaints policy. There is an awareness of the vulnerability of the service users. The staff ion duty had completed training on the protection of vulnerable adults and the acting manager will be collating all staff training to demonstrate that training on the protection of vulnerable adults has taken place. The new multi agency guidelines for POVA investigations were in place. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 13 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 The home needs upgrading and improvement. EVIDENCE: The house needs some basic maintenance and upgrading. The manager advised that the whole house is due for redecoration and new carpets. The following areas also need to be given attention. • There is an outstanding requirement to change the kitchen. The kitchen has not been changed and continues to deteriorate. There are large holes on the work surface making this an environmental hazard. The cupboards are badly fitting and drawers are breaking. This provides very poor quality storage for food and provides a hazard for staff and service users. • The bedroom with the ensuite bathroom has a damaged carpet. There was a leak from the bathroom and the water has badly damaged a corner of the carpet. There is a strong musty smell form this. • A further bedroom has a damaged wall from possible subsidence. Staff are aware of checks being made and that any subsidence may have been resolved. This needs to be checked and any structural damage repaired. • The driveway is covered with tarmac. This tarmac is now very bumpy and pitted. All of the service users are older and one uses a walking frame. The surface of the driveway needs to be improved. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 14 All of these areas are made a requirement. The home is kept neat and tidy. The carpets are old and in need of replacement. The lounge carpet especially is marked and a requirement is made to have this carpet cleaned. This is in the interim until the carpet is replaced. In the lounge there is an old style fireplace. This has a raised surround covered in ceramic tiles. It is unfortunate this surround protrudes onto the main access corridor. The fire itself is not used. The service users are aging and increasingly physically frail therefore the surround becomes an unnecessary health and safety hazard. It is strongly recommended that this be removed before any accidents can take place. The laundry is separate from the home in the back of the garage. There is a sink with the washing machine. Staff were requested to put in liquid soap and towels for staff use. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36. An effective team supports Service users. The homes recruitment practice was not supported by the records seen. Staff training is taking place but records did not demonstrate this. Staff are well supported and supervised. EVIDENCE: There is sufficient staff available to provide care and good relationships between staff and service users were seen. There are 2 vacancies and existing staff or bank staff covers most of these shifts. Further staff are being sought. The staff recruitment records remain incomplete. This follows a previous requirement to ensure that the minimum records are present. This will be made a requirement again. The new manager is now aware of the problem and will be making sure that records are complete. There is no central staff training record to ensure that all staff receive a minimum of 5 training days a year and have sufficient up to date basic training. This is also a repeat requirement. Staff confirmed that training is taking place. Staff have received individual supervision plus team meetings. Recently a PATH meeting took place for everyone in the home, service users, staff and relatives. This meeting was to look at the whole home and to have ideas to 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 16 improve the home and service users life. A lot of good ideas and enthusiasm for the home came form this and the acting manager and staff are looking forward to introducing new ideas. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 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 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) 37 and 41 There is no registered manager in the home; an acting manager provides daily management. Records are responsibly maintained but secure storage is too limited. EVIDENCE: The manager of the home has now moved to another home within the organisation. This took place last year to help in a home that needed a lot of support. The acting manager has been providing good day-to-day support and has just been appointed as the manager. It is important for the service users, staff and relatives that there is continuity therefore a requirement is made to ensure that there is a registered manager in place. Records of service users seen were well maintained, as noted previously staff records were not so well maintained. The storage used for confidential staff records does not lock properly therefore new storage is urgently required. The manager moved the confidential records to a locking cupboard in another room. 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 18 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 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 2 3 Standard No 31 32 33 34 35 36 Score x x 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 6 SADLERS LANE Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 x x x 3 x x H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 19 Yes 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. 3. 4. 5. 6. 7. 8. Standard 16 24 24 24 24 34 35 37 Regulation 23 23 23 23 23 19 18 8 Requirement That the ensuite bathroom be only for the use of the service user in the attached bedroom. That the lounge carpet is cleaned. That the kitchen be replaced. THIS REQUIREMENT IS REPEATED. That the driveway be made safe. That the defects in service users bedrooms be repaired. That the staff recruitment records be available. THIS IS A REPEAT REQUIREMENT. That a central staff training record be kept. THIS IS A REPEAT REQUIREMENT. That the manager be registered with CSCI. Timescale for action 1.10.05 1.10.05 1.12.05 1.12.05 1.12.05 1.12.05 1.11.05 1.10.05 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. 2. Refer to Standard 24 41 Good Practice Recommendations That the fire surround is removed. That better quality confidential storage be available. H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 20 6 SADLERS LANE 6 SADLERS LANE H52-H01 S51746 6 Sadlers Lane V231944 160805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 2nd Floor, 1015 Arlington Busines Park Theale Berks RG7 4SA 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. 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