Inspection on 23/02/07 for 7a Finborough Road

This inspection was carried out on 23rd February 2007.

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

Other inspections for this house

7a Finborough Road 26/01/09

7a Finborough Road 01/02/06

7a Finborough Road 19/09/05

7a Finborough Road 10/03/05

7a Finborough Road 12/10/04

7a Finborough Road 24/10/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 7a Finborough Road 7a Finborough Road Short Break Service Stowmarket Suffolk IP14 1PN Lead Inspector Tina Burns Key Unannounced Inspection 23rd February 2007 1.00 DS0000036836.V331406.R01.S.doc Version 5.2 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 DS0000036836.V331406.R01.S.doc Version 5.2 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. DS0000036836.V331406.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 7a Finborough Road Address 7a Finborough Road Short Break Service Stowmarket Suffolk IP14 1PN 01449 626205 01449 626205 david.gilbert@socserv.suffolkcc.gov.uk 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) Suffolk County Council Mr David James Gilbert Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places DS0000036836.V331406.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: 7a Finborough Road opened in 1995 as a short break facility for adults with learning disabilities. It is run by Suffolk Social Services and is registered as a care home for 4 adults with learning disabilities. The home is situated in a small cul-de-sac, close to Stowmarket town centre. It has a large driveway with a parking area shared by neighbouring buildings. The house has four individual bedrooms, two on the ground floor and two on the first floor. There is a spacious kitchen/dining room, which opens onto a patio area. The living room leads into a staff sleep in room which doubles as a duty office. A shower room, suitable for wheelchair users, separate toilet and laundry area are also on the ground floor. A wide staircase leads to the upstairs bedrooms, bathroom, toilet, storeroom and manager’s office. There is another patio area behind the laundry room, which overlooks a pond. Towards the front of the building there are views towards the church. DS0000036836.V331406.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which focused on the core standards relating to care homes for young adults. The inspection was undertaken on a weekday and took place over approximately five hours. The report has been written using accumulated evidence gathered prior to and during the inspection. The inspection process included examination of a range of documents including two staff records, two residents care plans and a range of policies, procedures and health and safety records. The inspector also toured the premises, spoke with two care workers on duty and met four service users receiving respite care at the time. Information was also gathered from the homes pre inspection questionnaire, eight service user survey’s and eight relative’s/visitor’s comment cards. The registered manager was present through out the inspection and fully contributed to the inspection process. What the service does well: The home provides a good quality respite service for over forty service users and their families. It is staffed by a committed and established team of staff that know service users well and are familiar with their likes, dislikes and needs. Care plans reflect service users assessments of need and are individual and person centred. Service users are able to continue with their usual day-to-day, routines, activities and interests while staying at the home. Comments from service users and their relatives included “I enjoy going to 7a, it is very clean, friendly and there is always lots to do”, “I like going to 7a” and “It’s an excellent respite home”. Overall service users benefit from a staff team that are competent, well trained and qualified to do ‘the job’. The registered manager and deputy manager have NVQ level four qualifications and 90 of the care staff have NVQ level three qualifications. The home provides a safe, clean and comfortable environment and policies and procedures in place promote and protect service users and staff. DS0000036836.V331406.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. DS0000036836.V331406.R01.S.doc Version 5.2 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 DS0000036836.V331406.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their carers can expect to receive appropriate information about the home. Further more, they can expect to fully participate in the assessment process and have the opportunity for a trial visit before an overnight stay. EVIDENCE: The home had appropriate information available for people interested in respite care including a Statement of Purpose and Service User Guide. Both documents were informative and detailed and met national minimum standards. Records examined also included Service Agreements that had been signed by service user’s representatives. The fees detailed included the charge for overnight stays at £9.24 per night and, where service users were not staying overnight, the charge for meals. Discussion with the manager and service user records examined evidenced that appropriate assessments were undertaken before respite was agreed. Assessments covered a wide range of needs and included manual handling and individual risk assessments and Family/Carers self-assessments. Feedback DS0000036836.V331406.R01.S.doc Version 5.2 Page 9 from service users and their relatives, and records seen evidenced that service users have the opportunity for a trial visit before their first over night stay. DS0000036836.V331406.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to have a detailed care plan in place that reflect their needs, wishes and preferences and safeguards them from risks. EVIDENCE: Records examined evidenced that service users had detailed care plans in place. They included comprehensive guidelines for staff in terms of the action required to meet basic and complex needs such as communication, mobility, eating and drinking and personal hygiene. Records included good evidence of reviews and consultation with service users and their families in the development of the care plans. Feedback from service users and their relatives, records seen and staff spoken with indicated that service users are supported appropriately to make decisions and participate as much as possible in events and routines within the home. One care plan seen for a service user with complex needs and no speech included a detailed communication plan that provided information about how DS0000036836.V331406.R01.S.doc Version 5.2 Page 11 the service user communicated using sound, body language, signs, gestures and facial expressions. The care plan also included the service user’s likes, preferences and dislikes. Appropriate risk assessments had been undertaken before respite care commenced. Risk management strategies had been agreed with the service users representatives and recorded in the service user plan. DS0000036836.V331406.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to engage in a range of activities within the home and the wider community. Furthermore, they can expect to be actively supported to help plan and prepare meals of their choice. EVIDENCE: With the exception of weekends, 7a Finborough Road does not generally provide daytime support and service users staying at the home are expected to continue to attend their usual daytime activities. Records examined included clear details about service users weekly ‘programmes’ so that they could continue with their usual daily routines whilst staying at the home. Records seen, staff spoken with and feedback from service users and their relatives indicated that at other times the home is committed to providing a range of opportunities and activities to service users. Daily records and personal feedback sheets that were completed after each stay included details of DS0000036836.V331406.R01.S.doc Version 5.2 Page 13 activities offered and undertaken both in the home and the wider community. Comments from service users included “Staff suggest different things and I get to try new things” and “There is always lots to do”. Discussion with the manager, records seen and feedback from relatives confirmed that the home works closely with service users families. As service users are only resident for short stays they do not often receive visitors, however eight out of eight surveys completed by relatives said that they were welcome at the home at any time. At the time of inspection the home was providing respite care for a total of forty-four service users with a wide range of needs, including physical, sensory and complex needs. However, the manager confirmed that even where service users were unable to actively contribute to domestic tasks staff would involve them as far as possible in the daily routines. Staff on duty confirmed that the home does not employ a cook and where possible residents are encouraged to participate in planning menus, shopping for food and preparing meals. Care plans examined included service users likes and dislikes, staff training records evidenced that all support workers had undertaken basic food hygiene refresher training in 2006. DS0000036836.V331406.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, the home has appropriate arrangements in place for ensuring that service user’s physical and emotional health needs are met. Further more, medication procedures safeguard service users and staff training in the administration of medicines is likely to improve. EVIDENCE: Examination of records and feedback from relatives and service users indicated that staff work hard to provide support to individuals in the way that they prefer and require. Staff spoken with had a good understanding of service users needs and the care plans examined clearly detailed the action to be taken to meet personal care needs. Records examined included thorough and detailed information regarding the service user’s health needs. Clear guidelines and protocols were in place to ensure staff support was appropriate to their needs. There was good evidence that the home worked closely with relatives and where appropriate other professionals such as GP’s and Community Nurses. DS0000036836.V331406.R01.S.doc Version 5.2 Page 15 Observations made, staff spoken with and records examined indicated that overall the home had appropriate procedures in place for the safe handling and administration of medication. The manager had developed a ‘work book’ for the purpose of staff medication training that seemed suitable, but it had not been checked or approved by a health care professional. Whether or not medication training is delivered ‘in house’ or externally, medication training should be delivered by a trainer that is knowledgeable in the subject and has relevant, current experience of handling medicines. The manager acknowledged the concerns and made suggestions about improving the training. For example, asking the community health team to verify the workbook or deliver the staff training. DS0000036836.V331406.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect their views to be listened to and acted on. Furthermore they can expect to be safeguarded from abuse, neglect and selfharm. EVIDENCE: Discussion with the manager indicated that the home had not received any complaints in the previous twelve months. Feedback from service users indicated that overall they knew how to make a complaint and who to speak to if they were unhappy. Of the eight relatives surveyed six said that they were aware of the complaints procedure and eight said that they had never had to make a complaint. Training records examined and staff spoken with confirmed that the home ensures staff receive training in the protection of vulnerable adults. The manager advised that being a local authority home they worked within the framework of the Suffolk Inter Agency Policy and Procedures for the Protection of Vulnerable Adults. There had been no safeguarding adult referrals during the past twelve months. DS0000036836.V331406.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect the home to be clean, comfortable and well maintained. EVIDENCE: At the time of inspection the home was well maintained, pleasantly decorated, and furnished in a comfortable and ‘homely’ style. The accommodation consisted of four single bedrooms, two on the ground floor and two on the first floor. There was also a communal lounge, staff sleep in room/office, and a spacious kitchen/dining room that opened onto a pleasant patio area. There was a shower room, suitable for wheelchair users, separate toilet and laundry area on the ground floor and an additional bathroom and toilet upstairs. Both the kitchen and laundry areas were clean, tidy and appropriately equipped. Staff confirmed that they had received appropriate training and were aware of food hygiene and infection control procedures. All eight of the service DS0000036836.V331406.R01.S.doc Version 5.2 Page 18 users that completed survey forms confirmed that the home was always fresh and clean. At the time of inspection the home was clean, hygienic and free of unpleasant odours. DS0000036836.V331406.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 24, 25 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to be safeguarded by thorough and robust recruitment procedures. They can also expect to benefit from well supervised, trained and competent staff. EVIDENCE: The recruitment records of two support workers were examined and included all information required. Each of the files included two references, evidence of verification of ID, personal health statements, evidence of satisfactory Criminal Record Bureau Disclosure checks, application forms and evidence of face-toface interviews. Staff spoken with and training records seen indicated that 90 of the homes support workers had appropriate NVQ qualifications. In addition there was good evidence of comprehensive induction programmes and on going training that included areas such as manual handling, food hygiene, health and safety, protection of vulnerable adults and fire safety. Further training included epilepsy awareness, risk assessment management, autism and managing challenging behaviour. Support workers spoken with and records seen also DS0000036836.V331406.R01.S.doc Version 5.2 Page 20 indicated that staff received annual appraisals and regular planned 1-1 supervision sessions. Comments from service users and their relatives included “The staff are friendly, caring and absolutely brilliant” and “In our experience 7a is a model of good practice”. DS0000036836.V331406.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to benefit from a well run home that is committed to promoting and protecting their health, safety and welfare. Further more they can expect to fully contribute to the homes quality assurance procedures. EVIDENCE: In addition to this service the manager is also the registered manager of a small domiciliary service run from the same premises, and temporary acting manager for a small residential home located close by. Discussion with the manager during the inspection confirmed that the homes deputy manager also worked across all three services and shared many of the day-to-day management tasks. Staff spoken with during the inspection indicated that they felt well supported and there was a clear sense of direction and leadership from the management team. They were clearly committed to ‘the job’ and felt valued by the manager; they confirmed that the manager and deputy manager DS0000036836.V331406.R01.S.doc Version 5.2 Page 22 were helpful, supportive and approachable. Their comments were positive and included “We have got a really good management team”. Both the manager and the deputy manager hold NVQ level 4 qualifications. On the day of inspection the manager’s enthusiasm seemed ‘infectious’ and his commitment to providing a good quality service was highly evident. The home had a number of quality assurance processes in place including the ‘friends of 7a ‘ committee, quarterly newsletters, family self-assessments and service users feedback forms. At the time of inspection the home had not produced or published a annual quality assurance report or development plan for 2006/2007, however the manager was keen to start the process. The home works within the framework of Suffolk County Council Social Services policies and procedures. Procedures in place and available to staff on the day of inspection included a wide range of health and safety procedures. Accident records were in place and analysed on a monthly basis to identify any patterns or significant health and safety concerns. Records examined also evidenced that the home had appropriate fire safety procedures in place and an up to date fire risk assessment. Staff spoken with advised that hot water temperatures were checked on a monthly basis and as and when service users were assisted with baths and showers. However, records did not fully evidence this. Although there was no indication that hot water temperatures were excessive the manager agreed to review the homes risk assessment to ensure that procedures in place to monitor temperatures were suitably robust. DS0000036836.V331406.R01.S.doc Version 5.2 Page 23 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 3 3 X 4 3 5 3 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 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 3 X 2 X DS0000036836.V331406.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation Requirement Timescale for action 30/04/07 2. YA42 12(1)(a) The registered manager must 13(2) ensure that staff medication 18(1)(c)(i) training is accredited and/or provided by a suitably qualified trainer. 12(1)(a) The home must review current 13(4) procedures in place for monitoring hot water temperatures to ensure that they are suitably thorough and robust. 16/03/07 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 DS0000036836.V331406.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000036836.V331406.R01.S.doc Version 5.2 Page 26 - 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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