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Inspection on 13/06/05 for 9 Allenby Road

Also see our care home review for 9 Allenby Road for more information

This inspection was carried out on 13th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users receive a good quality of care from a home which is well managed and has an experienced and competent staff team. The varying needs of the adults who use this respite service are assessed and the support needs are well documented.

What has improved since the last inspection?

There have been a number of improvements since the last inspection. A survey has been undertaken to determine service user`s views about the home and the service provided. The details on file regarding delegated nursing tasks are clearer and there has been a comprehensive training needs assessment carried out for the whole staff team. The complaints procedure has been written in an easy to understand format and there is clearer recording regarding the activities undertaken by service users.

What the care home could do better:

There is a need to ensure that the fire alarm system is serviced on a quarterly basis to safeguard service users. It is recommended that regular meetings with service users are considered and that the Manager records the hours worked at the home.

CARE HOME ADULTS 18-65 9 ALLENBY ROAD Maidenhead Berks SL6 9BF Lead Inspector Lucy Martin Unannounced 13 June 2005, 9.40 am 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. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 9 Allenby Road Address 9 Allenby Road, Maidenhead, Berks, SL6 9BF 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) 01628 781261 Royal Borough of Windsor and Maidenhead Jennifer Olotu Care Home (CRH) 4 Category(ies) of Learning disability (LD) registration, with number of places 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7/12/04 Brief Description of the Service: 9, Allenby Road is a respite care home operated by the Royal Borough of Windsor and Maidenhead. The home is a purpose built bungalow and can accommodate up to four adults with a learning disability, some of whom have additional physical disabilities. The home is situated in a residential area of Maidenhead and is in easy reach of the town centre, local shops and transport. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection which started at 9.40am and finished at 12.20pm. The inspector spoke to the Manager and to one other member of staff individually. Only one service user was at home who receives day care. Records, including service user’s files were seen. What the service does well: What has improved since the last inspection? What they could do better: There is a need to ensure that the fire alarm system is serviced on a quarterly basis to safeguard service users. It is recommended that regular meetings with service users are considered and that the Manager records the hours worked at the home. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 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. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 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 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 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, 3 There is a thorough assessment undertaken on prospective service users and there is good evidence that the diverse needs of the service users are well met. EVIDENCE: The Care Management Team undertakes a new ‘assessment of need’ before a new service user is admitted. The assessments for two new service users were seen and were comprehensive in content. Support and communication needs are well documented and additional information is gained during the homes own admission procedures which include introductory visits. The home meets a diverse range of needs. The needs of service users are assessed and the home considers what is needed to be put in place to support those needs. Extra staff and specialist nursing staff can be provided if required. The home has service user’s with diverse religious and cultural needs. It was positive to hear that the home is planning to introduce a notice board with pictures of different religions/cultures. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 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, 8, 9 Service users have clear individual plans in place which include risk assessments. Some consultation with service users has taken place. EVIDENCE: The files of two service user’s were seen and both had clear plans in place. It was noted that the plans had last been reviewed in October and November 2004 and advice was given that the plans are reviewed at least every six months. The plans should also be signed by service user’s if possible. Risk is assessed prior to admission and the files seen showed good evidence of a range of risk assessments undertaken. Again advice was given that the risk assessments are reviewed at least every six months. It was a requirement made at the last inspection that there is evidence that feedback is sought from service users about the running of the home. A survey to obtain service users views was undertaken and analysed. This is commendable but it is important that action is taken following the results and that service users receive feedback regarding the questionnaires. The inspector was informed that the idea of regular meetings with service users is being considered and this is a recommendation of this report. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 10 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 Service users are able to maintain their usual daytime activities whilst on respite at the home and regular activities in the evenings and at weekends take place. EVIDENCE: Most of the service users attend local Day Centres and arrangements are made for this to continue whilst at the home for respite. On the morning of this inspection two service users had been collected and taken to a Day Centre. One service user attends the home daily from Monday to Friday for day care. This arrangement is currently under review. The home has started to record service user’s activities in one book in order to monitor that activities are regularly taking place. This provides good evidence that the service users go out regularly with the staff on duty. The home has a minibus which can accommodate a wheelchair. There has been a lack of drivers on the staff team but the home is in the process of employing two voluntary drivers which will ease the situation. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 11 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) 19 Service users’ health needs are well met. EVIDENCE: Service users medical needs are documented before admission and risks are assessed. Some service users have complex medical needs that require a qualified nurse to be on duty while they are resident. At the last inspection it was a requirement to ensure that the correct training and delegation arrangements are on file for service users who are PEG or pump fed. This has been done and advice was given for the information to be dated. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 12 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 The complaints procedure is in an easy to understand format for service users. EVIDENCE: The home has a complaints procedure and since the last inspection, this has been developed into an easy to understand format for service users. The complaints procedure is given to service users on admission and is explained at their reviews. The complaints book was seen and it contained no new entries since 2002. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 13 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) None EVIDENCE: 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 14 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) 33, 34, 35, 36 The home has a stable, experienced staff team and there are robust recruitment procedures in place. There is a training and development programme for staff as well as generally regular staff supervision. EVIDENCE: The home has a small, experienced staff team. Since the last inspection, one new member of staff has started work at the home. There is a low use of agency staff and the regular staff team cover gaps in staff cover. This means that some staff regularly work double shifts and advice was given that there continues to be regular monitoring of this situation. Staffing levels remain at a minimum of two staff on duty during the day and a waking member of staff on duty at night. Some service users require additional staff or nursing support which is provided as part of their respite agreement. Staff meetings continue to take place regularly and minutes are kept. The staff rota was seen which was up to date. The hours the Manager works are not included on the rota and it is recommended that the hours worked at the home are recorded. The recruitment information relating to one new member of staff was seen at the home. There was evidence that all the required checks had been carried out. Two references were seen. A medical check and confirmation that a 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 15 Criminal Records Bureau check had been carried out prior to starting work at the home. Advice was given to record the date the member of staff started work in the file. Work has been undertaken updating the training records. It was a requirement made at the last inspection that a training needs assessment is carried out for the staff team as a whole and this has been undertaken. Each member of staff has a training profile in place and it is important that these are maintained up to date. It was evident that regular training is taking place and the staff spoken with confirmed this. The supervision records seen showed that generally staff receive regular supervision at least every two months or six times per year. There were two staff who had not been supervised for four months between January and May 2005 and this was due to the Manager being absent from work because of sickness. There was every indication that regular sessions would take place in the future. The home ensures that a record of supervision dates is kept in the home. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 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 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) 37, 42 The home is well run and the Manager is now successfully registered with the CSCI. Generally, there were up to date health and safety records in place but the home has not had its fire alarm system serviced regularly. EVIDENCE: The Manager has been post since August 2004 and since the last inspection has been successfully registered with the CSCI. The fire records were seen on this inspection. The inspector was informed that the fire deficiencies noted by the Fire Officer in April 2005 had been attended to or were being discussed further with the Fire Officer. There was evidence that routine weekly testing of the fire alarm system takes place as well as regular fire drills. However, there was no information on file to indicate that the fire alarm system had been serviced since February 2004. The Manager had been attempting to rectify the situation but no action had yet been taken by Windsor and Maidenhead. Servicing of the fire alarm system should take place on a quarterly basis. It is a requirement that this matter is attended to 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 17 within 14 days of this inspection to ensure the continued safety of service users. This matter will be followed up in separate correspondence. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 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 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x x x x Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 9 ALLENBY ROAD Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 x H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 19 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 42 Regulation 23(4) Requirement The fire alarm system is serviced on a quarterly basis Timescale for action 27/6/05 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 8 33 Good Practice Recommendations Consideration is given to holding regular meetings with service users. The Manager records the hours worked at the home. 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 1015 Arlington Business Park Theale Berks RG7 4SA 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 9 ALLENBY ROAD H52-H01-S62384-9 Allenby Road-V229816130605-Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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