Inspection on 29/07/05 for 7 Eggars Close

This inspection was carried out on 29th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

7 Eggars Close 23/11/06

7 Eggars Close 17/01/06

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 29 July 2005, 10:00 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 7 Eggars Close Address Alton, Hampshire GU34 2UX 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) 01420 543 495 Royal Mencap Society Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24/09/2004 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 H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four and a half hours and involved the manager and the service user who was at home on the day of the visit. The inspector spoke with the manager and had a very brief conversation with the service user before they went out. 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 has been asked to do more work on service users plans to make sure information is clear on how to support each person with their needs. The home also needs to make the complaints procedure easier to understand. Some small areas of repair are needed to the ceiling in the utility room and the bath panel needs to be redecorated to improve how the home looks. The manager needs to work with a service user and the Fire Safety Officer to make sure all service users are protected from the risk of fire. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 6 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 H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 4 The homes approach to the assessment and orientation of service users means that their needs are acknowledged and documented. EVIDENCE: The inspector had the opportunity to meet a new service user who has moved into the home since the last inspection. Information sampled by the inspector in service user’s files confirmed that appropriate assessments of service user’s needs are obtained prior to admission to the home. The inspector saw a community care assessment and information from the service user’s care manager. Information was also available to confirm that the service supports prospective service users to visit the home, stay for a meal and meet other people living in the home. Diary entries indicated that family members also visited and the service user was able to stay overnight. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 The lack of clear strategies for supporting service users with behaviour that challenges the services provided for them means that the home cannot demonstrate that they are fully able to meet service users needs. Developments in consultation within the home mean that service users are encouraged and supported to make decisions. EVIDENCE: The inspector sampled the care plans in place 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. Some of the information sampled was no longer correct and the inspector discussed this with the manager. Goals and strategies to achieve these goals also need developing for service users. The inspector has been made aware through reports sent to the commission of a number of incidents involving service users who present challenges to the 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 10 services provided for them. Past incidents have required staff to step in to protect other service users and themselves. Through 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 is to be provided to help support service users and they showed the inspector information on the extra one to one support. The home does not have clear strategies for supporting a service user with issues related to their challenging behaviour and the inspector advised that they must have a clear method of approach that staff follow when supporting this person which includes a risk assessment and details of any intervention that is used. The manager has set up regular service user’s meetings, which will work alongside the regular key-worker meetings. These meetings have been difficult in the past and the manager has initially approached it by meeting each person individually with a longer-term goal of a single meeting involving everyone. The minutes were available for reading and each person contributed to this. The service user’s plans did contain risk assessments covering a wide range of activities including bathing, using kitchen equipment, protection form abuse, using public transportation, road safety and using cleaning products. One issue raised by the manager involved the risk of contamination of foodstuffs due to poor hygiene practices of a service user. Discussion had taken place about locking away food to prevent the spread of infection. The manager emphasised that this had not taken place. The inspector advised that if such a decision was to be made evidence of risk assessment and consultation with service users and their representatives must be in place together with a clear rationale for the practice and strategies to ensure these practices do not affect any service users access to food and drink. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Service users benefit from the provision of a well organised activity programme enhanced by contact from families and friends. EVIDENCE: When the inspector visited, three service users were out of the home. Two people were on individual holidays with family members. The other service user was attending their day service groups. An activity board located in the kitchen gave an indication of where each person was and detailed what activities have been planned. Information seen within each of the service user’s files confirmed that service users attend clubs and day services in the local area. One service user attends the gym and goes swimming regularly. The inspector had an opportunity to speak briefly to a new service user before they were supported to go out to do some shopping and have lunch in the local town centre. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 12 The inspector noted information on service users plans that gave details of family contact and details of recent visits to and from families and friends. The inspector has spoken to service users about there contact with families and given the documented contacts within plans and service users being away on holiday with their families it was clear that this level of contact is maintained. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 The home provides support for service users to access health Care professionals to meet their needs. Personal support is given in a way that respects the privacy and dignity of the individual. A good medication administration system is in place and would be enhanced by retaining records to demonstrate how service users changing needs are met. EVIDENCE: 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 14 The inspector sampled records and confirmed that each service user is registered with a GP practice and the home liaises with the surgery on a regular basis. Staff informed the inspector that regular monitoring of service users health needs takes place. The home is working with community nurses, psychiatrists and the service users’ general practitioners on current needs and the inspector saw evidence of regular contact. The home has clear statements on providing support to service users in ways that uphold privacy and dignity. This was observed in the interaction of staff and service users. 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. The inspector noted that some medication has been changed since it has been 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. Homely remedies are used in the home and these are documented in the service users care plan file. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Complaints procedures are in place demonstrating that the views and concerns of service users, their families and representatives are recorded and responded to. This could be improved further by a more accessible format. 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. The home also has a record book for ‘informal complaints’. The manager and inspector discussed the provision of a more accessible format for the complaints policy and they said that they would be developing a new document. The manager told the inspector that a “Red Card” system has been introduced and this involved the provision of small red cards addressed to the regional director. If anyone had a concern they could send these to him to indicate there is a problem in the home. Unfortunately there was no documentation or instruction in the home on how this is used on a practical basis and the manager agreed to obtain this information. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 Service users benefit from a comfortable and well maintained home with only minor repairs needed to improve the décor. EVIDENCE: The inspector toured the home and found it to be in a generally good stated of repair, clean and tidy and free from any unpleasant smells. The manager told the inspector that they are currently looking at where items are stored in the home. The manager intends to move the computers from the dinning room. One belongs to a service user and this could be relocated to their bedroom and the other to the office. This will free up space for service users to possibly have an alternative area to watch TV or listen to music. The bathroom panel was in need of redecoration and the ceiling and wall in the utility room was water damaged from a leak from the above bathroom. The manager had noted these and was making arrangements to have these repaired. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 17 The manager has installed new paper towel and tissue dispensers in response to service users needs, this has improved accessibility and choice and has improved concerns about hygiene. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 18 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) 35 Service users are supported by a well-trained staff team. EVIDENCE: The inspector sampled the training for staff working in the home. The records seen demonstrated that staff have had training in mandatory areas such as Food hygiene, Moving and Handling, First aid and Health and Safety and Medication Administration. The fire training for staff is now due for updating and the manager was advised to arrange for suitable training as soon as possible. Additional training and development is provided with a wide range of courses available including Epilepsy, communication and MAKATON, Bereavement & Loss and Stress Management. The inspector also noted that some staff have had training and attended conferences on supervision and support, assessor training and risk Assessment. No staff were available during the visit to discus their training and development within the home and this would be covered at the next inspection. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 19 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) 42 The lack of clear strategies for managing the propping open of doors and unsatisfactory responses to health and safety checks have the potential to place service users at risk. EVIDENCE: The inspector toured the home and sampled records of maintenance and servicing as part of this inspection. A service users door is propped open and the manager stated that it is difficult to keep this door closed. The inspector advised the manager to contact the Fire Safety Officer at Hampshire Fire & Rescue Service for advice and guidance on what remedial action they need to take to ensure they are adequately protected against the spread of fire. The homes records confirmed that regular maintenance and servicing of equipment is carried out. The fire alarm system was serviced in July 2005, 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 20 weekly checks on the system are carried out. A fire drill was carried out in April 2005. Regular checks are made on the hot water outlets to ensure the present mixer valves are operating correctly. The home responded to a previous requirement on this and a record is in place to show that these checks are carried out. However the inspector noted that over two months the temperature in the shower was much higher than the acceptable limit. This had been documented in the record but no action has been taken to respond to this. The inspector questioned the value of monitoring records if action is not taken when these records indicate a problem and the manager was advised that they must ensure staff are clear on what action they should take to resolve health and safety concerns. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7 Eggars Close Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 22 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 6 Regulation 15 Requirement The registered person must ensure that each person has an up to date care plan which provides clear strategies for support. The registered person must ensure that strategies for supporting service users with behaviour that challenges the service are put in place. The registered manager must ensure that they review the current pratice of propping open a service users bedroom door in consultation with the Fire Safety Officer and take appropriate action to minimise risks. The registered person must ensure that as part of the regular monitoring of the hot water outlets any concerns are followed up in order that remedial action can be taken. Timescale for action 29th October 2005 29th October 2005 29th October 2005 2. 6 15 3. 42 23 4. 42 13 29th September 2005 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 23 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 20 22 Good Practice Recommendations The manager should keep a copy of any precription changes made to medication already dispensed by the pharmacy. The manager should review the format of the complaints policy and ensure it is accessible to service users. 7 Eggars Close H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 24 Commission for Social Care Inspection Hampshire Area 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 H54 S12064 7 Eggars Close V229365 290705.doc Version 1.40 Page 25 - 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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