Inspection on 17/01/06 for 7 Eggars Close

This inspection was carried out on 17th January 2006.

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

Other inspections for this house

7 Eggars Close 23/11/06

7 Eggars Close 29/07/05

7 Eggars Close 24/09/04

7 Eggars Close 20/04/04

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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 7 Eggars Close Alton Hampshire GU34 2UX Lead Inspector John Vaughan Unannounced Inspection 17th January 2006 11:30 7 Eggars Close DS0000012064.V277465.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 7 Eggars Close DS0000012064.V277465.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. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 7 Eggars Close Address Alton Hampshire GU34 2UX 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) 01420 80730 01420 80730 H4037@mencap.org.uk Royal Mencap Society Mrs Olwyn Eileen Fielder Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th July 2005 Brief Description of the Service: 7 Eggars Close is a small residential service providing care and support to four younger adults with a learning disability. The care and support is provided by MENCAP and the building is owned by a housing association that is responsible for the maintenance of the property. Staff are provided twenty four hours a day to support the needs of service users. The home is located in a residential estate and is a short distance from the shops in the town of Alton in a semi-rural part of Hampshire. 7 Eggars Close DS0000012064.V277465.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 over three and a half hours and involved the manager of the service. The service users were out at day services or still away on holiday and this meant the inspector had limited direct contact with service users at this visit. The inspector spoke to the manager and had a very brief conversation with the service user when they came home from day services. Records were sampled and the inspector had a tour of the home. What the service does well: What has improved since the last inspection? What they could do better: The manager was asked to look at plans for service users and make sure all of the information is up to date to avoid confusion and make sure staff support the service user correctly. The manager was also advised to complete the service development plan in the home, which looks at how they can improve the service following comments made by service users in their survey forms. The inspector was very concerned that the home did not have a working fire alarm system and this put service users and staff at great risk of injury or 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 6 death. The manager was asked to take steps immediately to keep service users and staff safe. 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. 7 Eggars Close DS0000012064.V277465.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 7 Eggars Close DS0000012064.V277465.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): These standards were not assessed at this visit. EVIDENCE: 7 Eggars Close DS0000012064.V277465.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): 6 and 9 Improvements to the care plans and risk assessments demonstrate that service users are supported with their assessed needs however some reviewing and updating will enhance these plans. EVIDENCE: The inspector examined the care plans for two of the service users living in the home. Each person has a plan, which is intended to document their needs and how to support them. Areas covered within the plan include personal care, health needs, medication and community activities. These plans have been reviewed since the last visit and more detailed information is in place to support each person with behaviour that challenges the service. Through further discussion with the manager and reading information on file the inspector was able to confirm that the home is working with other professionals to support these individuals with their behaviour. The manager stated that additional staffing remains in place to help support service users and provide prompt intervention when required. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 10 The service user’s plans contained risk assessments covering a wide range of activities including bathing, using kitchen equipment, protection from abuse, using public transportation, road safety, using cleaning products and managing challenging behaviour. The manager told the inspector about changes in service users circumstances and current areas that the home is supporting each person with. The inspector noted that the plans have been reviewed since the last visit however in both plans information was out of date and needs a further update. The manager was made aware of these areas and undertook to update this information. Some words used in plans to support a service user with challenging behaviour describe the person as ‘moody’. The inspector advised that this is not appropriate as it can be seen as negative and very vague. The manager agreed that the use of this kind of description would be removed and replaced with a more accurate explanation of the persons need. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 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 the following standard(s): 16 and 17 The practices within the home promote the rights of the service user and support their individual wishes and preferences. Service users benefit from a balanced and varied diet based on their likes and dislikes. EVIDENCE: The plans contain a section on service users rights and information recorded within these sections confirmed that key workers meet with each person and explain their rights and responsibilities. A service user was observed interacting with a staff member, talking about their activities at day services and seeking reassurance for concerns they have. The contact between the staff member and the service user was positive, relaxed and conducted in a way that supported the service user and gave the reassurance needed. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 12 The inspector confirmed that service users have a key to their rooms. People have specific plans to document their day-to-day routines which include getting up and going to bed. The inspector examined a menu plan. This indicated that a varied diet is offered to service users who help to choose, shop for and prepare these meals. Food likes and dislikes are recorded within each person’s care plan and alternative meals are recorded on the menu. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 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 the following standard(s): 20 The improvements made to the medication administration practice in the home demonstrate a suitable and safe system is in place to support service users needs. EVIDENCE: Medication records are in place and are accurate. Medication is stored in a locked medication cupboard and records are kept of all medication received, administered and disposed of. At the last visit the inspector noted that some medication had been changed since it was dispensed by the pharmacy. The manager explained that this changed following the visit of the psychiatrist and a letter was available to confirm this visit. The inspector recommended that the manager keep a copy of any prescription as evidence of authorisation to change medication or dosages during the cycle of the current medication. The manager provided evidence that they now retain information including copies of prescription changes to support changes made on medication records. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 14 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 The practices within the home demonstrate that the views and concerns of service users, their families and representatives are recorded and responded to. Service users are protected by clear policies and procedures to report and respond to allegations and suspicions of abuse. EVIDENCE: The home has a complaints procedure. This is available to all service users their families, representatives and staff. Details of how to contact the commission are contained within the policy. The timescales for responding to a complaint are included in this policy. A more accessible complaints format was available at this visit to the home and a more user-friendly complaints form is in place. A service user has made a complaint. The inspector saw clear evidence of the process being followed through with the service user being supported to make the initial complaint, a record of this complaint and a letter responding to the service user detailing what action has been taken. The home has a policy on the protection of vulnerable adults and a copy of the Hampshire Protection of Vulnerable Adults Policy is also in place. Staff members have training on protecting service users as part of their induction into the home. A service manger also carried out an update course on protection from abuse in the home in December. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 15 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 Service users benefit from a comfortable and well maintained home with minor repairs completed since the last visit to improve the décor. EVIDENCE: The inspector toured the home and found it to be in a good state of repair, clean and tidy and free from any unpleasant smells. The computers have been moved from the dinning room. One belongs to a service user and this has been relocated to their bedroom and the other to the office. This has increased the space available in the room and the manager said that they are still looking to purchase a TV for this room so that an alternative room is available if service users wish to watch television. The redecoration to the ceiling and wall in the utility room has been completed improving the overall appearance of the area. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 16 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 and 34 An established training programme demonstrated that service users are supported by staff who are obtaining suitable qualifications. The practices of the home when recruiting new staff members protect service users. EVIDENCE: Through discussions with the manager, staff members and examining records the inspector was able to confirm that the home has not met the timescales for having 50 of the staff team with a NVQ award. However a programme is established and foundation training is well developed to ensure staff have the underpinning knowledge needed to obtain their NVQ award. Currently the home has one staff with an NVQ 2, one staff member working on their award and a further 3 staff members starting their NVQ award in September 2006. The home has six staff. Staff complete their Learning Disability Awards Framework (LDAF) induction and foundation initially and then are put forward for their NVQ. Three staff are completing their foundation programmes at present. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 17 The inspector looked at four staff records and found these to be comprehensive. Each file has a full application form, two written references and proof of identity, which included photographs, driving licences, passports and birth certificates. The manager provided evidence to demonstrate staff undertake an enhanced Criminal Records Bureau (CRB) check prior to taking up their position in the home. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 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 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, 39 and 42 Service users are supported by a generally well-managed service. The service can demonstrate that an established system is in place to develop the service with views from service users and their families included in this process. However these have not had any impact on the delivery of the service this year. The lack of action to ensure the home has adequate safeguards against fire places service users and staff at high risk of injury or death. EVIDENCE: The manager has experience of managing and working in a senior capacity in a residential service for people with a learning disability. The inspector was told that they are now working through their registered manager’s award as this was delayed by the college who put back the start date of the course. The manager has recently attended training in finance, disciplinary & grievance, assessing needs and performance management training. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 19 The inspector looked at records, which confirmed that service user questionnaires are completed. The feedback from service users was generally positive in these documents. The home undertakes a quality review and service development programme on an annual basis however this was carried out last year and the last improvement plan for 2004/2005 has not been reviewed. Regulation 26 visits are undertaken and a report is sent to the commission. The service user’s surveys raised some areas that needed actions that have not been responded to with an improvement plan, which is the usual practice. The inspector advised the manager that they complete this programme to demonstrate that service users comments have an impact on the development of the service. The inspector saw evidence that hot water temperatures are monitored and guidelines are in place to instruct staff on what action they should take if these temperatures are outside of the acceptable levels. During the inspection the manager informed the inspector that the fire alarm system is not functioning. Following a visit from the service engineer the alarm panel was found to be irreparable and was turned off. The inspection established that the system had been off for five days and no alternative action or safety arrangements had been put in place to maintain the safety of service users and staff in the home. The manager was required to take immediate action to safeguard service users by contacting Hampshire Fire & Rescue’s fire safety officer for advice. The manager made contact with the officer and followed the advice given which included the provision of waking staff at night until the alarm panel is replaced. 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 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 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 3 23 3 ENVIRONMENT Standard No Score 24 3 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 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 3 X 2 X X 1 X 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 21 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 YA42 Regulation 23 Requirement The registered manager must ensure that following consultation with the Fire Safety Officer they take immediate action to safeguard service users and staff from the risk of fire. The registered person must ensure that the fire alarm panel is replaced. Timescale for action 17/01/06 2. YA42 23 17/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 7 Eggars Close DS0000012064.V277465.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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