Inspection on 10/01/06 for Amberleigh

This inspection was carried out on 10th January 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Amberleigh 18/09/08

Amberleigh 14/11/06

Amberleigh 05/07/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Amberleigh 24 Isaacs Close Street Somerset BA16 0LS Lead Inspector Justine Button Unannounced Inspection 10th January 2006 09:30 Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 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 Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 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. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Amberleigh Address 24 Isaacs Close Street Somerset BA16 0LS 01458 840865 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) Somerset County Council (LD Services) Mrs Pauline McLean Molland Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users may be admitted who have concurrent sensory and or physical impairment Service users are admitted for a maximum of three months Date of last inspection 5th July 2005 Brief Description of the Service: Amberleigh is a service for residential short breaks which caters for service users in the Younger Adult Category. Two of the six beds are used for emergency or assessment purposes. All the rooms are for single occupancy. There are a number of communal areas including sitting and dining space. In addition there is a conservatory which is used for quiet time. The service has a very small garden area to the rear this is accessible to the people who live at the service. There are an adequate number of adapted bathrooms. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day between the hours of 09.30 am – 3.30 pm. A number of people were residing at the home on the day of the inspection and spoke to the inspector, as did a number of staff. The manager Mrs Molland was available for part of the inspection. The inspector would like to thank the residents and staff for their time and hospitality shown to the inspector during her visit. What the service does well: What has improved since the last inspection? What they could do better: A number of areas were raised on the day of inspection with the manager. Western Challenge currently manages the building. This has given rise to some issues with regard to the maintenance of the building. Clarification is needed to Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 6 confirm who is responsible for which aspects of the building. Although the service was in a relatively good state of repair some of the paintwork particularly around doorways is in need of remedial works. The staff at the service also provide staffing for two satellite services. It was therefore difficult to ascertain if the staffing levels at Amberleigh are adequate. It would be positive for all parties if separate staffing arrangements for the services were in place. The service does not currently have it’s own transport. Provision of transport would increase the availability and frequency of social and recreational opportunities. A number of people who access the service need support from staff in moving and handling. Staff currently have training in this area at three yearly intervals. In order to conform to good practise guidance the frequency of this training should be increased. 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. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 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 Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 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, 2, 3 & 4. People who access the service have the information they require prior to their first stay. EVIDENCE: The statement of purpose and the service user guide were on display in the home. Both of these documents are available in Somerset Total Communication. This would allow the majority of people who are considering having their short breaks at Amberleigh to make an informed choice about the services that are provided. The manager stated that people are able to visit prior to staying at Amberleigh. Opportunities to stay for a period of time e.g. the afternoon or evening are made available Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 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, 8, 9 & 10. All people who live at the service have a plan which informs staff of their individual care and support needs. It could not be assessed if the people who visit the service are involved in the development or review of their plan. People who visit the service are involved in the day-to-day running of the home. Information is stored in a secure manner. EVIDENCE: Three plans were viewed on the day of inspection. Somerset County Council have informed the CSCI that they are currently reviewing the care planning documentation. This move will be welcomed. The people who live at service have a range of care and support needs and these were reflected in the plans. None of the plans or aspects of the plans are in an accessible format to the people whom they relate to. It is therefore difficult to clarify if people are involved in the development and review of their plans. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 10 The manager stated that the plans were reviewed with the person or their main carer prior to each admission to ascertain if there had been any changes to care needs. Staff confirmed that they were made aware of any changes and stated that they felt that the care notes were adequate and informed them of the needs of individuals. Service users are supported by staff to make choices and decisions. Communication systems are widely used through out the service. Pictures and symbols are used to inform service users of such things as the menu for the day or activities that will be available on that day. Staff were observed reinforcing verbal communication with signs. All information held about people was seen to be held in a secure manner. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 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, 15 & 16. People who access the service are supported by staff to continue their “normal” routine and life style EVIDENCE: People who live at the service stated that they found the staff supportive and helpful. A number of people were out on the day of inspection. These people were accessing their “normal” routine for that day which for most included attending day services. A number of staff and people who were accessing the service stated that activities and social opportunities were sometimes not available at weekends and evenings due to the lack of transport. Consideration should be given to provide accessible transport at the service. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 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): 18, 19 & 20. People’s healthcare needs are met. EVIDENCE: People visit the GP if and when required, staff give support when needed. People are supported by staff to attend any pre-arranged healthcare visits. All visits to all services are well documented in the service user plan. Staff confirmed that all personal care is conducted in privacy. Staff were observed dealing with issues of personal hygiene in a sensitive manner using appropriate communication methods. Medication was viewed during the inspection. Medication is stored and administered in line with good practise guidance. The recommendation made at the last inspection has been met. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 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. People who live at the service are protected by a clear complaints procedure. The procedures to protect people from potential abuse are robust. EVIDENCE: The home’s complaints procedure was included in all service users’ care plans and management confirmed that parents or guardians were issued a copy of the Council’s complaints procedure. The information on how to complain is also available in pictorial form, or a video is available. This is commendable. Service users spoken to, where able, confirmed that they felt comfortable raising issues of concern to staff and management. One complaint has been received since the last inspection. This complaint had been dealt with appropriately by the management team. Staff are aware of the vulnerable adults and whistle blowing policies. In addition to this training there is in place a policy for the two areas. The policies complied with the Public Disclosure Act and the DOH Guidance No Secrets. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 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, 25, 26, 27, 28, 29 & 30. The service is suitable for its intended use. Some areas are in need of remedial repair. There is sufficient specialist equipment. EVIDENCE: A tour of the building was conducted during the inspection. All rooms have furniture and fittings to meet the need of the service user group. Service users are encouraged to personalise their bedrooms during their stay. All bedrooms have a lockable space and TV. The service has a sufficient number of adapted bathrooms to meet the needs of the people who visit the service. Shared space at the home includes a large lounge and a separate dining area. The kitchen is roomy and provides good storage and cooking facilities. Evidence was seen of daily fridge/freezer temperature recordings. The laundry provides good equipment for washing of clothes and machines enable Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 15 programmes to heat to a degree to manage infection control measures. All chemicals are stored in a locked cupboard. All areas were seen to be clean and tidy. Amberleigh has limited accessible outdoor space. Western Challenge currently manages the premises. A number of areas have peeling paintwork and missing plasterwork. This reduces significantly the overall ambience of the environment. Somerset County Council are currently discussing with Western Challenge remedial works required. These works however have been outstanding for a significant period of time and now require urgent attention. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 16 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): 31, 32, 33, 35 & 36. There is a dedicated staff team in sufficient numbers to meet the needs of the people who access the service. It could not be confirmed if all staff had received all necessary training. EVIDENCE: The duty rotas were viewed on the day of inspection. These demonstrated that there are sufficient staff employed. Minor shortfalls due to sickness are covered by the use of agency staff. The service currently staffs two other services. It is recommended that these areas have their own staff team to reduce the effect that this has on Amberleigh. This would enable the management team to focus their efforts on the staffing issues at Amberleigh. Staff stated that staffing levels are increased dependant on the needs of the people who are using the service at the time. This is to be commended. The staff team are supportive of each other and obviously work well as a team. All staff spoken to during the inspection expressed how happy they were working at Amberleigh. Staff stated that they felt well supported and that they had the necessary skills to support all the people who currently access the service. Discussions with the staff demonstrated that they all had a strong Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 17 commitment to providing an individualised level of care. Staff stated that they received regular supervision. A number of people who access the services provided by Amberleigh are wheelchair users. Staff currently receive moving and handling training once every three years. In order to comply with good practise guidance the frequency of this training should be reviewed. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 18 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. The service is well managed and run. EVIDENCE: Staff and people who access the service stated that Mrs Molland provided clear leadership and that her open door policy was welcomed. All stated that they felt able to approach her if they had any concerns. Staff meeting are held regularly. Mrs Molland prior to the inspection had been on an extended period of sick leave. Although satisfactory interim managerial cover had been arranged the CSCI were not informed of this absence as per Regulation 38 (3) of the Care Home Regulations. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 19 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 3 4 3 5 x 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 1 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 X X X X x Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 YA24 Regulation 23 Requirement It is required that the management clarify with Western Challenge who is responsible for certain areas of the maintenance within the building. An action plan is to be submitted to the CSCI detailing the timescales for repair to the damaged plasterwork throughout the service. Timescale for action 01/03/06 2. *RQN 38 (3) This requirement is outstanding from the previous inspection with a timescale 30/09/05 It is required that any absence of 30/04/06 the registered manager in excess of 28 days be reported to the CSCI by the registered person. 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. Refer to Standard YA31 Good Practice Recommendations It is recommended that consideration be given to DS0000061823.V278565.R01.S.doc Version 5.1 Page 21 Amberleigh 2. 13 (5) separating the staff groups who work at Amberleigh and the satellite services. It is recommended that the frequency of moving and handling training be reviewed in order to comply with good practise guidelines. Amberleigh DS0000061823.V278565.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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