Inspection on 05/07/05 for Amberleigh

This inspection was carried out on 5th July 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 no outstanding requirements from the previous inspection report, but 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 10/01/06

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 OLS Lead Inspector Justine Button Unannounced 5th July 2005 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. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Amberleigh Address 24 Isaacs Close Street Somerset BA16 OLS 01458 840865 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) Somerset County Council (LD Services) Mrs Pauline McLean Molland Personal Care Home Only 6 Category(ies) of Learning Disability (6) registration, with number of places Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users may be admitted who have concurrent sensory and/or physical impairment. 2. Service users are admitted for a maximum of three months. Date of last inspection This is the first inspection done by CSCI 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 on occasions 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 additon there is a conservatory which is used for quite 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 D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service has been running for a number of years however previously it had been unregistered, as it had been wrongly classified under the supported living scheme. This is therefore the services first formal inspection. This inspection was unannounced therefore not all the standards were assessed on this occasion. Any areas not reviewed on this occasion will be reviewed at subsequent inspections. The inspection was completed over the course of one day. The inspector would like to thank the people who were accessing the service and the staff for their help and assistance during the inspection. What the service does well: What has improved since the last inspection? As this is the first inspection this is not applicable. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 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 Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 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) These standards were not assessed on this occasion. EVIDENCE: Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 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, 7,8, 9 10 People who live at the service have a care and support plan, which informs staff on their current care needs. People are supported to make choices and decisions. EVIDENCE: Four plans were viewed on the day of inspection. The plans on the whole reflected the care needs of the person accessing the service. 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. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 Page 10 On the day of inspection service user were seen to be involved in the day to day running of the service. Staff supported the service users to enable them to do this. Service users spoke positively about the daily routine at the home being flexible to meet their needs. Service users also expressed opinions that staff listen to their views and respond pro-actively. It is difficult to ascertain if the service users are involved or contribute to the development of policies and procedures All information held about people was seen to be held in a secure manner. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15, 16, 17 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. For the one person who was placed at the service on an emergency basis this was not the case. This person stated to the inspector that he felt that his views were not being taken into account with regard to his future placements. He stated that he was bored, as he had had to move away from friends and his normal activities and recreational programme. The management need to ensure that all efforts are being made to secure a permanent home for this person in order that they can regain their expected lifestyle. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 Page 12 Lunch was observed during the inspection. Staff were seen supporting people to choose what they wanted for lunch. On discussion with staff it was evident that they were clear about the dietary needs of the individual people who access the service. On the day of the inspection the kitchen was clean and tidy and in a good state of repair. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 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 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 seen to be stored and administered in a safe manner. One Medication Administration chart did not have two signatures for the hand transcribed entries. Staff need to ensure that this is completed to reduce the margin for error. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 Page 14 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) 22,23 People who live at the service are protected by a clear complaints procedure and robust prevention of abuse policies. EVIDENCE: The home’s complaints procedure was included in all service user’s 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. 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 D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 Page 15 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) 24,25,27,28,29,30 The service is suitable for its intended use. 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. All areas were seen to be clean and tidy. Western Challenge currently manages the premises. This has lead to some confusion about who should service and maintain certain areas of the service. This includes the servicing of hoists and electrical safety checks this needs to be clarified as a priority to ensure that health and safety is not compromised. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36. It could not be confirmed if the service has sufficient staff. There is a strong commitment from the staff team in providing a high standard of care and support. EVIDENCE: The staff duty rotas were viewed for the week prior to the inspection. This demonstrated that there are some staff shortages. These are being covered on occasions by agency staff. The manager confirmed that agency has been used but they try to obtain the same staff to offer consistency thus reducing the impact on the care and support provided. 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. 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 commitment to providing an Individualised level of care. Staff stated that they received regular supervision. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 Page 17 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, 38, 42 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 meetings are held regularly. Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 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 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 x 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 2 x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Amberleigh Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 x D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 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 YA24 Regulation 23 Requirement It is required that the management clarify with Western who is responsible for certain areas of the maintainence of the building to ensure that health and safety is not compromised. Timescale for action 30/09/05 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. Refer to Standard YA11 Good Practice Recommendations It is recommended that the management ensure that all efforts are being made to secure a permanent home for the indentifed indivdual in order that they can regain their expected lifestyle and can be accommodated in a suitabe long term placement. It is recommned that all hand transcribed enteries on the Medication Administration Record are checked and signed by two saff. It is recommened that the staffing be reviewed to ensure that the service is adequatly staffed. 2. 3. YA20 YA31 Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier 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. Extracts may not be used or reproduced without the express permission of CSCI Amberleigh D53 - D02 S61823 Amberleigh V235844 050705 Stage 4.doc Version 1.40 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!