Inspection on 20/02/06 for 82 Chaucer Road

This inspection was carried out on 20th February 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

82 Chaucer Road 14/05/08

82 Chaucer Road 12/01/07

82 Chaucer Road 01/12/05

82 Chaucer Road 19/10/04

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 82 Chaucer Road Bedford Beds MK40 2AP Lead Inspector Pursotamraj Hirekar Unannounced Inspection 12:20 20 February 2006 th 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 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 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 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. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 82 Chaucer Road Address Bedford Beds MK40 2AP 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) 01234 216319 Caretech Community Services Limited Mrs Karen Elizabeth Barringer Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Number of places: 6 Age: 18-65 years Category: All persons admitted to the home must have Learning Disabilities as their primary assessed need. No service users with additional physical disabilities shall be admitted, unless it can be demonstrated that the home can meet their needs by way of accessible private and communal space and appropriate aids/adaptations. The manager must obtain a qualification to level 4 NVQ in care by December 2005. 1st December 2005 5. Date of last inspection Brief Description of the Service: 82 Chaucer Road was first registered in June 2004 as a care home for up to six adults with learning disabilities. Caretech Community Services Limited who provides a number of homes for people with learning disabilities nationwide owns this home. The stated purpose of the home is to provide care and support to people who have diverse needs associated with their learning disability, such as behaviour that challenges needs on the autistic spectrum and people who require alternative communication systems. The home is not suited to people with mobility problems although ground floor accommodation is available. The home is a refurbished Victorian villa in a residential area on the west side of Bedford. Accommodation comprises of a large lounge, dining room/conservatory, kitchen, laundry room and office on the ground floor. All bedrooms are for single occupancy and have en-suite facilities. There are bathing and toilet facilities on both floors. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out at 12.20pm on 20/02/06 and at 3.55pm on 20/02/06 by Pursotamraj Hirekar over 3 ½ hours. The deputy manager coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with deputy manager and staff, conversation with service users’ and partial tour of the building. What the service does well: What has improved since the last inspection? What they could do better: The home must establish individual procedures and ‘behaviour protocol and specific programme’ including detailed preventive steps for all service users’ with challenging behaviour problems in their respective care plans. The home must ensure proper care and appropriate treatment of service users’ with challenging behaviour and also ensure, in which service users participate are so far practicably free from avoidable risks to health or safety are identified and eliminated. The home must ensure that at all times records specified in schedule-2 are available for inspection. The home must ensure adequate shared space to the service users’ and suitable facilities are provided for service users’ to meet their visitors. The home must ensure that at all times records specified in scheduled-4 are available for inspection. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 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. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 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 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 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): None EVIDENCE: 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 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): 6,7 The home had made arrangements for assessing the changing needs and reflecting in the individual service user’s care plans. However, all service users’ must have comprehensive risks assessments and preventive mechanisms actioned on time. EVIDENCE: The care plans and risk assessments of two service users’ were case tracked. One service user’s six monthly review conducted on 26/08/05 recorded that the service user do not require further personal risk assessment and had not mentioned that the service user was sensitive to loud sounds and noises / voices. A document titled ‘Behaviour protocol and specific programme’ dated 10/02/06 signed by the manager and the deputy manager, detailed that the service user was sensitive, had signs of agitation, projected behaviour; pacific programmes to manage and the need to use NVIC. One more document regarding the same service user, which was signed, by the manager and the deputy manager on 16/02/06 that detailed preventive steps, which need to be taken with the service user as part of his care plan. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 10 There was no information available on this inspection about the preventive steps that were planned and actioned between the 26/08/05 and 10/02/06. Except for the two documents produced dated 10/02/06 and 16/02/06 just one day before and five days after the 11/02/06 incident that had happened with service user. The deputy manager had said that there was one more service user who has had two challenging behaviour incidents in the past. However, ‘behaviour protocol and specific programme’ and detailed preventive steps that may have been planned was not able to be located by staff for inspection. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 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): 15 The home had facilitated service users’ to have appropriate family relations. EVIDENCE: Conversations with service users’ highlighted that they were pretty busy during the daytime at college engaged in various stimulating skill training activities. Service users’ have enjoyed doing household chores and shopping that developed their independent living skills. The home had made appropriate arrangements for service users’ to be in regular contact with their family members and carers’ that promote healthy relationship. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 12 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): 19, 20 The home had made arrangements for administration of medication and needed to make additional effort to prepare behaviour protocol and specific programme for all service users with challenging behaviour to avoid any harm. EVIDENCE: The service users’ have high levels of emotional health needs. The home had prepared care plans for each individual service user, based on the need assessment and have been reviewed as scheduled. On this inspection ‘Behaviour Protocol and Specific Programme’ was not made available for all service users’ who have had challenging behaviour issues, except for one who was party to the incident at home on the 11/02/06. Service users’ do not control and administer their own medication. The home had made arrangement for administration of medication by the trained staff and the medicines were stored in safe place. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 13 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): 22,23 The home had a robust complaints policy and procedures, which ensured that complaints were investigated and reported upon. EVIDENCE: The home had a comprehensive complaints policy and procedures in place. On the 11/02/06 a service user who has challenging behaviour issues had pulled hair and bit on the head of the mother of a service user, who was visiting her daughter near the stairs leading to the first floor. The mother of the service user complained in writing to the home manager about the incident. The manager and the deputy manager have taken appropriate measures to investigate and inform concerned individuals and institutions about the incident. The home manger had also, taken steps to review risk assessments and care plan of the service user who turned violent on 11/02/06. The revised care plan preparation was in progress at the time of this inspection. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 14 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): 24,28 The lack of provision of a private space for visitors to meet service users resulted in increased risk of negative interaction for the remaining service users’ group. EVIDENCE: The home was managed well to keep the premises clean, neat and comfortable for the service users’. However, the recent incident of 11/02/06 at the home advocate to undertake risk assessment of the home’s environment whilst taking into account the safety of the service users’ and their visitors to the home. The home was considering options to provide adequate space for the interaction of the service users’ and their visitors’. The home’s application for variance to include two new rooms constructed for use was in progress. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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): 32,34 Inability of the home to provide personnel records of support staffs that were on duty and witness to the 11/02/06 incident is a cause of concern to the safety of service users’ and their visitors. EVIDENCE: The home had a robust recruitment policy. All the staff employed by the company/home were qualified, experienced and trained. At the time of the incident on 11/02/06 the deputy manager had left the home 2 staff on duty, both from an agency, no information was held on these individuals as specified by regulations regarding agency staff. Therefore, it was not clear whether the staffs were not competent enough to prevent and reduce the impact of incident or the home did not make sufficient arrangements to have appropriate mechanisms and measures in place to work with service users who have challenging behaviour issues, which were violent in nature. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 16 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): 37,41,42 The manager of the home was competent. However, the absence of behaviour protocol and specific programme for all the service users’ with challenging behaviour was a cause of concern. EVIDENCE: In general the home was well managed and in particular, the care plans needed to include the behaviour protocol and specific programme for all service users’ with challenging behaviour. The manager, staffs and service users’ have had good working relations that promote independent living skills and achieve quality of life goals of service users’. The manager had obtained NVQ 4 and registered manager award. The conditions of registration are currently under review. On this inspection there were no records available at the home to evidence about the 11/02/06 incident. The deputy manager informed that all the records about the incident were with the manager, who was on leave and working on incident report using various documents relating the incident. The home must make available all the personnel and complaints records available all the time for inspections. 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 17 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 2 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 82 Chaucer Road Score X 2 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X X 2 3 X DS0000060926.V272142.R01.S.doc Version 5.0 Page 19 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 YA6 Regulation 14(2) Requirement Timescale for action 31/03/06 2. YA19 3. YA34 4. YA28 5. YA41 The home must establish individual procedures and ‘behaviour protocol and specific programme’ including detailed preventive steps for all service users’ with challenging behaviour problems in their respective care plans. 12(b) The home must ensure proper 13(4)(b)(c) care and appropriate treatment of service users’ with challenging behaviour and also ensure in which, service users participate are so far practicably free from avoidable risks to health or safety are identified and eliminated. 19 (2) (3) The home must ensure that at & (4) all times records specified in schedule-2 are available for inspection. 23(2)(i) The home must ensure adequate shared space to the service users’ and suitable facilities are provided for service users’ to meet their visitors. 17(3)(b) The home must ensure that at all times records specified in scheduled-4 are available for inspection. DS0000060926.V272142.R01.S.doc 31/03/06 31/03/06 30/05/06 31/03/06 82 Chaucer Road Version 5.0 Page 20 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 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 82 Chaucer Road DS0000060926.V272142.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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