CARE HOME ADULTS 18-65
Bailey Close 8 Bailey Close Haverhill Suffolk CB9 0LH Lead Inspector
Helen Fontaine Unannounced Inspection 20th December 2005 03:30 Bailey Close DS0000024329.V274851.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 Bailey Close DS0000024329.V274851.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. Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Bailey Close Address 8 Bailey Close Haverhill Suffolk CB9 0LH 01440 763290 01440 705580 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) Mrs Nemelita Seneviratne Mrs Nemelita Seneviratne Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: Number 8 Bailey Close is a detached house, which is registered under the provisions of the Care Standards Act 2000 as a care home to accommodate a maximum of five people with a learning disability. The home is situated in a quiet cul-de-sac on a residential housing estate that is approximately one mile from the centre of Haverhill. There is a regular bus service within walking distance of the house. The accommodation is domestic in nature, providing five single bedrooms, three on the ground floor and two on the first floor, all with hand washing facilities. The home provides a communal lounge where residents can meet friends and relatives or watch the television. The lounge opens out to an enclosed garden laid to lawn with shrubs and a bird birth, a patio area with seating is also provided. Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection of Bailey Close took place over two and quarter hours and was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. Two requirements were made at the time of the last inspection, one has not been met and has been restated in this report with a new timescale for compliance and an additional requirement was given from this inspection. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. The manager/provider was present during the inspection, all the residents were spoken too and the assistance of everyone in the home was very much appreciated. What the service does well: What has improved since the last inspection?
The manager starts their National Vocational Qualification level four in January 2006, through an organisation that will be able to visit the home to do some of the course work. The home continues to support the residents extremely well and encourages them to be as independent as possible. Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 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. Bailey Close DS0000024329.V274851.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 Bailey Close DS0000024329.V274851.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): These standards were not tested on this visit. However evidence from the last inspection was that, prospective residents can expect that their individual needs and aspirations are assessed and met. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Bailey Close DS0000024329.V274851.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): 8, 9 and 10 People who use this service can expect to be treated with respect and information is kept confidential. EVIDENCE: During the inspection the residents were cooking their evening meal and while a resident were cooking a resident came and joined the inspector in the lounge. The resident talked about what they had done and how they were going to spend Christmas with their family. The resident said that they each have their own room and that they keep their room how they want too. The residents told the inspector that they each had a key to their rooms and that they only entered each other’s rooms, when they were invited or asked to enter. The manager said they were very careful to make sure that the residents decided what they wanted to do. When the resident cooking the meal asked for assistance the manager was heard to ask what they wanted to achieve. The home had a rota on the kitchen wall for domestic tasks and having established who was on the rota, the resident concerned undertook the task. The manager has managed well the balance between taking over and letting the residents undertake things they wanted to do safely. One resident said
Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 Page 10 that they visit their family at weekends and travelled independently by bus to a nearby town. Some of the residents go out into town to do shopping, either for the home or for themselves. The residents all go out to various daytime activities, one works as a volunteer at a café. Others attended the day centres and did various activities such as agriculture. All the residents travel to their daytime activities by organised transport, but the manager when asked did feel they could do this independently. The manager said that the residents come and talk to them about issues and these are discussed in private. The manager said that nothing is discussed with other residents without it being agreed first. One resident said that they were happy that the manager and staff did make sure that everything is kept private. The resident said that they feel safe to discuss anything with the manager or the staff member. All documents are kept in the office upstairs and when there was a discussion with the inspector about a confidential matter the manager shut the door. The residents respected this and did not come into the room until the door was re-opened. Bailey Close DS0000024329.V274851.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 and 15 Residents can expect to have opportunities to personally develop and have friends and relationships. EVIDENCE: Residents have and continue to develop skills in tasks around the home and one resident said that they are going to start doing some cooking. They were very keen to do some baking, including bread as they are on a special diet. The resident also said that they wanted to start handling their own money and talked about the member of staff helping them to do this. During the inspection the manager and a resident were having a discussion about a new pair of shoes. The manager was suggesting various shops where they might get their shoes and the resident intimated that they just want to know where a good shoe shop was. During the inspection, a friend of the residents had come to have an evening meal with them. When a resident was asked about friends, they said that they met lots of people both at their daytime activities and at the café where they worked. Although the residents have lived together for many years and have really good relationships with each other, they talked of other people they
Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 Page 12 knew well and had known for many years. The residents did not all go to the same daytime activities and this allows them to have new friends and make relationships with other people outside the home. Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 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 and 21 Residents can expect to be supported in the way they prefer and have their wishes respected at the time of illness or death. EVIDENCE: During the inspection it was observed that the manager asked the residents what they wanted and how they wanted done. A resident spoken to said that they are able to have support with things they felt they could not manage. The residents said that they are keen to learn how to manage their own finances and the staff have asked them how they would like to do this. The manager said that the residents go out to the shops, but the staff do support them with the heavier shopping or if they ask for help. The manager said that over the years the residents have lived in the home, there have been family deaths and illnesses. The manager said that they have taken the opportunity at these times, to discuss the resident’s wishes around illness and death. The home does have an understanding of whether the residents want to be buried or cremated. Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 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 the following standard(s): 22 Resident can expect to have their views listened and acted on. EVIDENCE: Residents were observed to be free to say what they wanted and when asked if they felt confident about informing the staff of any concerns, they were very clear that they would and that it would be dealt with. The manager said that if any of the residents wanted to talk in private, they are able to and from time to time disagreements do arise. The inspector did ask the residents about differences of opinions and one resident said that the staff sort out any problems. As the home is so small and the residents know each other well, issues are sorted out immediately. The manager said that they did not have any complaints, but if they did it would be dealt with straight away. Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 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 the following standard(s): 24, 28 and 30 Service users can expect to live in a clean, homely and safe environment. Service users can expect to be encouraged to personalise their own bedroom. EVIDENCE: The home is an ordinary residence on an estate, which offers the residents a real homely setting. The house is very comfortable; the residents have lived there for sometime and are happy with its familiarity. The home was very clean and the resident and the staff undertake the domestic tasks. The residents as well as the staff are very conscious of safety issues in the home and whilst the resident was cooking the supper, they warned the manager about open cupboard doors. The home has an open plan kitchen with room for a long dinning room table; the residents spent their time in the kitchen. The home has a lounge and this was decorated in a way that the residents were comfortable with and was decorated with Christmas decorations. One of the residents smoked and they used the patio doors to access the garden, as they did not smoke in the house. Bailey Close DS0000024329.V274851.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): 33, 35 and 36 There are shortfalls with respect to the qualifications and supervisions provided to staff. EVIDENCE: The previous inspection had identified one requirement and one recommendation. The manager is making arrangements for the staff to undertake National Vocational Qualification level two, but cannot proceed with this until some funding has been established. The manager has however arranged with a local pharmacist for the member of staff to have some training around medication. The manager feels that they do give their member of staff supervision and support. However the member of staff was not on duty for the inspector to ascertain if they do feel supported. The manager produced an exercise book, where some brief notes had been made which the manager called supervision notes. This does not meet with the National Minimum Standards and the requirement has been repeated. The manager must make sure that the supervision is structured, documented and signed with a copy for the member of staff. Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 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 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 and 42 Residents can expect a well run home, the shortfall over the qualification of the manager is being addressed. The resident’s health, safety and welfare are not being protected. EVIDENCE: The home received a requirement from the previous inspection, around the issue of the qualification of the manager. The manager said that they are about to start their National Vocational Qualification in January 2006. The manager has been able to secure funding and the manager said that some of the training would be able to be done in the home. There will be a recommendation from this inspection that the manager does complete their National vocational qualification. The homes practices around health and safety were looked at and the manager did produce documentation. However a lot of the sections around safe storage and disposal of hazardous substances and regulation of water temperature were very out of date. The manager said that they do check the temperature
Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 Page 18 of the water when the residents have a bath, but do not check the water temperatures each week or keep a record. It is appreciated in such a small home where the residents are so independent in most of the activities in the home it makes it appear unnecessary, but the home does need to make sure that all the documentation around health and safety are up to date. The home must make sure that they do check the water temperatures regularly and that a record is kept to check the accuracy of the equipment. Bailey Close DS0000024329.V274851.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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X 3 2 X X X X 1 X Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 Page 20 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. Standard Regulation Requirement Timescale for action 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 3. Refer to Standard YA33 YA36 YA42 Good Practice Recommendations The manager undertakes and completes their NVQ level 4 The manager ensures that staff supervision is recorded and retained on their records. The manager ensures that all the documents in regard to health and safety are kept up to date as well as checking the water temperatures. Bailey Close DS0000024329.V274851.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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