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Inspection on 31/01/06 for 6 Sadlers Lane

Also see our care home review for 6 Sadlers Lane for more information

This inspection was carried out on 31st January 2006.

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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

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

Service users and staff are very welcoming. Service users are comfortable and call the house their home. The staff team is close and many have worked in the home for some years. The staff team is now complete. The manager and staff are working hard to make sure that all records are up to date and accessible.

What has improved since the last inspection?

A lot of work has been completed on the house. The roof and outside walls repaired. The house has been redecorated internally. All of the carpets were cleaned before Christmas and new will be obtained when all the internal work is completed. The manager has registered with CSCI.

What the care home could do better:

The repair to the bathroom shower tray needs to be completed so that a service user`s en suite bathroom remains private, not used by others. The new kitchen also needs to be installed. The driveway is very uneven and needs to be repaired. Health and safety is considered important, Fire training for all staff is needed plus completing a Fire risk assessment. A central training record is important to make sure that all staff receive sufficient training and all mandatory training.

CARE HOME ADULTS 18-65 6 Sadlers Lane Winnersh Wokingham Berkshire RG41 5AJ Lead Inspector Susan Cledwyn-Davies Unannounced Inspection 31st January 2006 9:15 6 Sadlers Lane DS0000051746.V281580.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 6 Sadlers Lane DS0000051746.V281580.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. 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 6 Sadlers Lane Address Winnersh Wokingham Berkshire RG41 5AJ 0118 929 7900 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) New Support Options Limited Mrs Carole Anne Jeffery Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2005 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 DS0000051746.V281580.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 9.15 am and 11.50 am. Included in the inspection was visiting most of the home, conversation with residents and discussion with the manager and care staff member. Some records were also seen. One resident left with the Manager before the end of the visit to meet his relatives. The remaining three residents were in the house. Feedback was given to the Manager. 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 DS0000051746.V281580.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 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 the following standard(s): 1 The statement of purpose and service users guide are available to service users. EVIDENCE: The statement of purpose was seen. The service users guide for each service user is kept in their case file. On looking at these neither document has been reviewed to include the change of manager. This was noted and the Manager will be reviewing both of these documents. 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 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 the following standard(s): The standard when inspected previously was satisfactory and there were no outstanding requirements or recommendations. EVIDENCE: 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 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 the following standard(s): 16 Service users rights are respected and they are encouraged to and do take an active part in the house. EVIDENCE: All of the service users have had recent PATH reviews, when their interests and plans for the future were discussed. Each individual then has future plans and activities arranged. All of the service users are encouraged to help in the house and this was observed. There is an en-suite shower-room that is used by other resident because the main shower is faulty. The manager has reported this and now has a date for the repair. The requirement remains until the en-suite shower room remains for sole use. 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 10 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): 20 Medication procedures are safe. EVIDENCE: Medication administration is by all care staff and the Manager is refreshing medication training. Medication storage is organised and safe. Out of date or unused medication is returned to the pharmacist. Medication administration records are well maintained. Medication front sheets for each service user are being updated and photographs have still to be added to some. Medication guidelines showing side effects to look for are available. Further recent guidelines are being obtained from the local pharmacist. 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 11 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): 22 and 23 Service users views are listened to and acted upon and they are protected from abuse, neglect and self-harm. EVIDENCE: There have been no complaints. There is a detailed complaints procedure. The manager has a positive approach to complaints. Adult protection issues are taken seriously. Most staff have had protection of vulnerable adults training. New staff attend this training as soon as possible. The multi agency guidelines are present in the home. 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 12 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 and 30 The house is homely and safe. There is needed maintenance work and upgrading in the kitchen. The home was clean and fresh. EVIDENCE: Since the last inspection the manager and staff have worked hard to improve the house. All of the carpets were cleaned last year and recently the whole house has been decorated. Service users are very pleased with the new colour in their bedrooms and chose this. Essential repairs have been done to the outside of the building and the roof. The old fireplace that was a trip hazard has been removed. Still to be completed are the putting in of a new kitchen and repairing the drive. There is a date for changing the kitchen shortly. The repairs to the drive do not have a date so remain as a requirement. New carpet will be put into the house once the new kitchen is installed. The furniture is also aging. A new sofa is being obtained for the lounge. The dining table is in good condition but only 2 chairs were usable. One is being repaired and more need to be bought. The manager is arranging for more chairs to be bought. 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 13 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, 33, 34 and 35 Competent and well-qualified staff supports service users. There is an effective staff team and the recruitment practice is safe. Staff training is given. EVIDENCE: Over 50 of the care staff hold NVQ 2 training, one member of staff is now taking NVQ 3. NVQ training is encouraged. There is sufficient staff for the daily running of the home. On each shift during the day there are two members of staff and then one member of staff sleeping in at night. Staff spoke of this being sufficient staff. and this was observed. During 4 days a week there are outside activities arranged for different service users not involving the home staff. Staff recruitment checks are completed. Some of the staff have worked in the home for some years and information is not up to date. The manager is ensuring that each staff member completes the recommended staff information pack from the CSCI web site to update information. Staff training takes place and the inspector was shown evidence of this. There is no central staff training record to ensure that all staff have attended mandatory training and received a minimum of 5 days training a year. It is recommended that this be used. 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 14 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): 31, 39 and 42 There is a registered manager, running the home well. Service users views are the base of the development of the home. The health and safety of service users is promoted. EVIDENCE: The manager is now registered with CSCI. The manager has also completed NVQ 4 in care and management. The manager is working hard to develop the staff team and improve the house. Quality assurance procedures include regulation 26 monthly visits by the area manager to check the quality of care. Residents meetings with staff are held weekly to plan meals and activities. Questionnaires for service users and relatives have taken place but not recently. Relatives and professionals are invited to regular reviews with service users. Staff meetings take place approximately 2/3 monthly to work towards improving care and greater continuity. 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 15 The manager has asked the health and safety representative of the company to visit the home and check the health and safety. This will be taking place shortly. Some of the checks needed were seen during this visit. • • Hot Water temperatures are checked weekly, this is generally expected to be daily with baths. The manager will check this. Fire precautions include checking the system weekly and servicing of the fire safety system. Fire training has not taken place for over a year; the last fire drill was 3 months ago. The manager will be arranging Fire training. This is required. There is no Fire risk assessment and this is required. • 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 16 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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X 3 X 3 X X 2 X 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 17 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 YA16 Regulation 23 Requirement That the ensuite bathroom be only for the use of the service user in the attached bedroom. THIS IS A REPEATED REQUIREMENT. That the driveway be made safe. THIS IS A REPEATED REQUIREMENT That a fire risk assessment be in place. That staff fire training takes place. Timescale for action 01/04/06 2. 3. 4 YA24 YA42 YA42 23 23 23 01/05/06 01/03/06 01/03/06 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 YA35 Good Practice Recommendations That a central training record be in place. 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business 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. Extracts may not be used or reproduced without the express permission of CSCI 6 Sadlers Lane DS0000051746.V281580.R01.S.doc Version 5.1 Page 19 - 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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