Inspection on 16/10/06 for Baker Street (86)

This inspection was carried out on 16th October 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Baker Street (86) 31/07/07

Baker Street (86) 06/02/06

Baker Street (86) 05/09/05

Baker Street (86) 02/12/04

Baker Street (86) 22/07/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Baker Street (86) 86 Baker Street Potters Bar Hertfordshire EN6 2EP Lead Inspector Mrs Alison Butler Unannounced Inspection 16th October 2006 09:00 Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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 Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Baker Street (86) Address 86 Baker Street Potters Bar Hertfordshire EN6 2EP 01707 642542 01707 642542 FP bakerst@walsingham.com 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) Walsingham Nicholas Martin Jackson Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6), Physical disability (2), of places Physical disability over 65 years of age (2) Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2006 Brief Description of the Service: Baker Street is a residential care home provided by Walsingham. It is registered to provide accommodation for six service users with learning disabilities, two of whom may have physical disabilities. Fees for the service are £890.05 per week (this is correct as of 16/10/06) The building is a large detached house that is situated in a residential area in Potters Bar with easy access to local shops and amenities. The main entrance is to the side of the building, where there is a small parking space. In front of the building is a small lawn. The communal spaces include the lounge and the large conservatory that leads onto the back patio and large garden. The garden is mainly lawn bordered by mature trees. The garden is wheelchair accessible. Opposite the lounge is the spacious kitchen. The laundry room is by the entrance. There are two bedrooms on the ground floor adapted for wheelchair users. The doors are electronically controlled. The assisted bathroom and toilet are nearby. On the first floor there is a small office and four other bedrooms. The bathroom and toilets are nearby. All the bedrooms are for single occupancy. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted during the morning by one inspector. There were 6 residents residing at the home. A tour of the home was conducted and discussions took place with the residents, staff and manager. General observations were made of staff and examine of records took place. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to speed up the conversion of the outbuilding to provide office space and free up the room with the home and provide better sleep in facilities. An alternative door-opening device must be sought to prevent the use of the fire extinguisher, as a resident prefers to have the door open. Staff must remember to copy exact details from the dispensing label when adding additional medicines to the recording sheet and also to ensure they keep internal and external medicines separately within the storage cupboard. Staff information must be available for inspection as per the memo from head office in August 2005. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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 Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs fully assessed prior to admission. EVIDENCE: There have been no new residents admitted since the last inspection but previously comprehensive assessments have been carried out prior to admission. With a thorough admission procedure in place Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are reviewed and updated. Residents are consulted on all aspects of their life. EVIDENCE: Care plans were examined with the individual residents that showed they contained all the required information. The manager is due to review the filing system and archive all old information and make the files are more user friendly. Each resident is allocated a key worker who is responsible for ensuring the needs of the residents are met and the paperwork is kept up to date. Discussions with the residents showed that they are happy with their care and the support provided by the staff. Staff understand the importance of confidentiality and information is held in accordance with the Data Protection Act 1998. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are treated with respect; there are a wide variety of activities on offer. The meals provided are nutritious and balanced. EVIDENCE: The residents were seen to interact well with each or and the staff on duty at the time of this inspection. Their social and leisure activities are varied and arranged to suit the individuals. The residents state that they are able to choose what they would like to do. Residents are encouraged to assist in the preparation of meals. The residents were very happy with the food provided and said they are given choices of what they would like to eat. Resident meetings are held once a week with minutes being held in the office which residents have access to. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive the care and support in a way that they prefer. Medication storage and recording needs some improvement. EVIDENCE: Residents spoken to during the inspection feel they are well cared for and supported in a way they prefer. They each have a key worker who supports them in keeping their care plans up to date. Examination of the medication procedures on the whole was well managed. With the exception of when staff need to hand write details onto the medication records they must be copied as per the dispensing label to avoid errors in administration. All internal and external medication must be stored separately. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are able to complain, and the home responds to these complaints following the procedure. The home protects residents from abuse, neglect and self-harm. EVIDENCE: The home has not received any complaints. The residents were very complimentary about their care at Baker Street. Staff receive training in adult protection and the Hertfordshire County Council Adult Protection Procedure is on display for all staff. Staff are aware of the Whistle Blowing Policy. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Baker Street is homely, friendly, clean and comfortable although some decoration is needed in some areas. EVIDENCE: The premises are need of some redecoration due to general wear and tear. The manager is aware of the need and will be looking into this and a plan will be put in place. The home was clean and hygienic on the day the inspection. There are plans for the out building to be converted into an office, and use the office in the home just as a sleep in facility for staff. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the homes recruitment practices and by appropriately trained and adequate numbers of staff. EVIDENCE: Examination of the file for the newest recruited member of staff showed that the required information was not available as per the memo received from head office in August 2005. This information needs to be available for inspection in the future. There is a rolling training programme in place. The manager has requested that staff receive training in risk assessments to aid the writing and review of risks assessments. Residents were complimentary about the care staff provide and good interaction was observed during the inspection. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run home. Health, safety and welfare of the residents is protected with the exception of a fire door being held open inappropriately. EVIDENCE: Residents and staff confirmed that the approach of the home is open, positive and inclusive. All records required by legislation were well maintained and up to date and were available for inspection with the exception of the staff information. A fire extinguisher was holding open a fire door this practise must cease and an alternative be sought, to protect all people within the home in relation to fire regulations. Risk assessments had been reviewed. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 Page 16 The organisation are due to carry out a service review during November 2006 and the results will be available in the new year to all interested parties. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 Page 17 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 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 Page 18 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 YA20 Regulation 13(2) Requirement Medication must be copied exactly from the dispensing label when being entered on the recording sheet Internal and external medication must be stored separately An alternative door-opening device must be sought for the door that is required to be open. Timescale for action 30/11/06 2 YA42 13(4)(a) 16/10/06 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 YA32 Good Practice Recommendations The manager should arrange for all staff to receive risk assessments training. Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Baker Street (86) DS0000019277.V318788.R01.S.doc Version 5.2 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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