Inspection on 25/11/05 for 87 Church Road

This inspection was carried out on 25th November 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

87 Church Road 14/05/08

87 Church Road 15/07/07

87 Church Road 29/01/07

87 Church Road 30/08/06

87 Church Road 24/06/05

87 Church Road 03/08/04

87 Church Road 27/04/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 87 Church Road Frampton Cotterell South Glos BS36 2NE Lead Inspector Michael Miles Unannounced Inspection 25th November 2005 2.00 87 Church Road DS0000003341.V261796.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 87 Church Road DS0000003341.V261796.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. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 87 Church Road Address Frampton Cotterell South Glos BS36 2NE 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) 01454 250028 0117 9709301 Aspects and Milestones Trust To be appointed Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8), Physical disability (8) of places 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 8 persons aged 18 years and over with learning difficulties who may also have physical disabilities. This may include persons age 65 years and over. 25th October 2005 Date of last inspection Brief Description of the Service: The Home is operated by Aspects and Milestones Trust, a non-profit making organisation. The building is an extended bungalow that can accommodate up to eight residents with learning disabilities and physical disabilities. This may include people 65 years and over. The home is currently accommodating seven residents who are over the age of 55 years. Two residents use wheelchairs in the home. The home is located in a semi-rural area approximately seven miles from Bristol City centre. There are local shops withing walking distance of the home. Transport is required to enable residents to access local facilities. There is home transport but taxis are used for service users who need to travel in their wheelchairs. There is garden on all sides of the house: the larger areas being the front and back. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this unannounced inspection was to monitor progress made to meet the requirements and recommendations made following the announced inspection conducted on 24 June 2005. As part of the inspection staff were consulted and there was examination of records. Due to the timing of the inspection it was not possible to formally consult with service users and this will be a priority at the next inspection. What the service does well: What has improved since the last inspection? What they could do better: All residents would benefit from a review of their care plan and assessment of risk to their personal safety to ensure that it accurately reflects their needs. Ensuring that there are sufficient staff to afford opportunities for going out would enhance their lifestyles. Maintaining accurate medication records would evidence that residents have been given prescribed medication. Reviewing the premises on a regular basis would help to prevent overcrowding in the home and removing a sound monitor in one residents bedroom and replacing it with a sensor alarm that does not intrude upon the resident would enhance that person’s quality of life. 87 Church Road DS0000003341.V261796.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. 87 Church Road DS0000003341.V261796.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 87 Church Road DS0000003341.V261796.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): 1, 3, 5 Staff have the information and knowledge to enable smooth admissions to the home and residents have been given information about their rights as residents. EVIDENCE: The Statement of Purpose has been revised and an up to date copy has been supplied to the Commission. The updated document now has an appendix that details the dimensions of residents bedrooms. There is an admissions policy and procedures that most staff have signed to indicate their understanding. Staff are aware of the procedures to be followed in the event of a new admission. Residents are provided with a residency agreement and records showed that these have been read to existing residents and staff have signed the document on their behalf. 87 Church Road DS0000003341.V261796.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, 10 Residents are being given more opportunities since the introduction of key worker meetings and an increase in staffing. EVIDENCE: A key worker system operates in the home in that each resident is designated a particular member of staff to assist with the management of their care. Since the last inspection the home has introduced ‘key worker meetings’ during which residents are consulted about the opportunities that they would like to pursue. Care files for two residents were examined. These had been reorganised and store information in an orderly way. The files each contain a ‘pen picture’ of the resident that is ‘person centred’ and includes a positive reputation. In addition there are details of needs, essential and important information along with likes and dislikes. In care files that were seen there was detail of communication needs and Care Plans with identified goals that outline the aims, benefits and means of achieving the goal. The care plans for all residents need to be updated. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 10 Staff communicate with each other by the use of a ‘handover’ record sheet that lists the well-being of residents for the day. It was recommended that an individual sheet is used for each person in order to maintain a diary of the person’s well-being. 87 Church Road DS0000003341.V261796.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): 11, 12, 13, 14, 16 Since the introduction of some additional staffing opportunities for going out have increased however, this is limited to only one person at a time. EVIDENCE: Key worker meetings provide the forum for residents to identify opportunities and these are being recorded in ‘Opportunity Plans’. At least one person goes out of the home to pursue some form of activity each morning, afternoon and evening. A record of residents community activities is maintained. There are trips out for shopping and pub meals along with attendance at Church and at the local ‘Joshua Club’. One of the residents attend a local authority Resource and Activity Centre. During one of the keyworker meetings a resident identified that they would like to help clear away after meals by wiping the dining tables and another has stated that they would like to make woollen ‘pom-poms’. There was discussion during the inspection about how residents craft items could be utilised as Christmas decoration for example. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 12 Residents were looking forward to the evening meal that was to be a ‘takeaway’ from the local fish and chip shop. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 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): 18, 19, 20 There has been some improvement in meeting the healthcare needs of residents, however, the home fails to demonstrate safe handling and administration of medication at all times. EVIDENCE: Personal care statements aim to help ensure that residents are assisted in the way that best suits them. Training has been arranged for staff to enable them to be proficient in the administration of rectal diazepam. As part of this resident’s agreement to this support from staff must be sought. Until such time that staff are deemed competent, the risk assessment in place advises staff to call for emergency services to administer the medication. Residents have better protection from the risk of pressure sores now that a policy has been developed in relation to this. It was recommended that this policy is cross referenced in other relevant documents to ensure that staff are guided to it. The medication storage was orderly however there were gaps in the recording of some medication that had presumably been given. It is difficult to know if residents had received the mediation without accurate recording and an 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 14 immediate requirement was made relating to maintaining accurate records. It was noted that where a resident had refused medication that one of the series of codes to indicate why medication had not been given was used. This is consistent with good practice. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: Not assessed as part of this inspection. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 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 the following standard(s): 24, 25, 26, 28 Whilst the house may have been considered suitable for those living there, increased dependence on wheelchairs leads to congestion in certain areas of the home at times. EVIDENCE: One resident has recently moved to another home and the home currently has a vacancy. Discussion with the senior Support Worker considered how it will be essential to ensure that the room has sufficient space for the person being admitted. There is one resident who depends on a wheelchair for mobility whose room is less that 12 sq m. This person is able to transfer independently from bed to wheelchair with no problem and a risk assessment has been completed in respect of this. Physiotherapy involvement has led to an assessment being conducted in early January 2006. At the last inspection it was noted that there was a sound monitor in one bedroom for safety reasons. It was recommended that this should be removed or replaced with a sensor alarm that does not intrude upon the resident. The Senior Support Worker advised that this has been requested from the Facilities Manager for this person and for another however it was still outstanding. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 17 At the last inspection the dining room was noted to be overcrowded and it was required that a risk assessment be completed in relation to the residents safety in this area. This has now been completed and with the re-arrangement of some of the furniture the area now looks less crowded and safer for the residents use. The temperature in the conservatory is an issue during hot weather and has been recorded on the request for maintenance list to ensure suitable ventilation for the residents in the future. Chairs with damaged springs have been reported as damaged to the organisation’s Facilities Manager. One of the residents that expressed a wish to have a key to their bedroom door now has a key. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 The manager is devoted to increasing the staffing at the home to meet the current needs of service users. Some additional staffing has led to increased opportunities for residents. EVIDENCE: The duty rota shows that there are three staff working the early part of the day with three staff working in the evening in addition to the manager. There is one waking night staff member. Additional staffing has had a positive effect on the residents by enabling more opportunities for going out. Following a requirement made at the last inspection that there are additional permanent staff in the home to provide consistency of care and support to residents. A business proposal is to be put to line management to increase staffing to enable residents to have further opportunities. At the time of the inspection there was one full time vacancy. It was not possible to examine records related to the recruitment of staff as the manager who was on leave was holding the key to the cabinet used for storing these. The Senior Support Worker advised that there are plans to obtain another cabinet as part of the office refurbishment and that he will have access to these records in future. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 19 Staff meetings have been held and records of these meetings were in place. The Senior Support Worker advised that there has been discussion about the possibility of having support worker meetings in advance of the full meeting in order to provide this staff group the opportunity for discussion. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 20 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, 38, 41, 42, 43 The home has lacked stable management for some time however the Manager and Senior Support Worker are now striving to make improvements in the home. EVIDENCE: The Manager has been absent from the home for extended periods and staff have lacked leadership during these times. It would be good for there to be a period of stability where there can be a focus on team building that includes all staff. The Manager and Senior Support Worker is currently in the process of reviewing all in-house policies and procedures and when this work has been completed staff will be asked to read and sign to indicate their understanding of the policies and procedures so that they are in a better position to meet the needs of residents. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 21 The home has devised a new ‘Night Duty’ file that has been shared with all staff and is to be amende4d to reflect their comments indicating a consultative and ‘open’ management style. The Filing system has been re-organised and in now more orderly to assist with the storage and retrieval of information. The fire safety risk assessment has been updated and now includes assessments of risk in emergency situations for exale, when using portable heating sources. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 22 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 3 X 3 X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 3 X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 X 2 X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 2 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 87 Church Road Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X 3 3 3 DS0000003341.V261796.R01.S.doc Version 5.0 Page 23 YES 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 YA6 Regulation 15 Requirement Timescale for action 28/02/06 2 YA9 13 3 4 YA20 YA32 13 18 Review care plans for all service users ensuring that they accurately reflect each person’s needs and wishes. Assessments on resident’s 28/02/06 personal safety must be kept up to date and reviewed in context with the person’s daily living/support plan. Outstanding from last inspection. Extended deadline. Ensure accurate records of the 25/11/06 administration of medication are maintained at all times. Ensure that there are sufficient 28/02/06 permanent staff in the home to provide consistency of care and support and provide opportunities for going out. 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 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 24 1 2 3 YA24 YA25 YA33 Ensure that there is a regular review of the premises and to minimise risk associated with overcrowding There was a sound monitor in one bedroom for safety reasons. This should be removed or replaced with a sensor alarm that does not intrude upon the resident. That a regular review of staffing takes place in order to meet the changing needs of residents. 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 87 Church Road DS0000003341.V261796.R01.S.doc Version 5.0 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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