Inspection on 05/09/05 for Baker Street (86)

This inspection was carried out on 5th September 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.

Other inspections for this house

Baker Street (86) 31/07/07

Baker Street (86) 16/10/06

Baker Street (86) 06/02/06

Baker Street (86) 02/12/04

Baker Street (86) 22/07/04

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Claremont House

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Sun Court Nursing Home

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Paradise Lodge

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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 Baker Street Potters Bar Herts EN6 2EP Lead Inspector Yoke-Lan Jackson Unannounced 5 September 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. Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Baker Street Address 86 Baker Street, Potters Bar, Herts, EN6 2EP 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) 01707 642542 01707 642542 Walsingham Nicholas Martin Jackson CRH Care Home 7 Category(ies) of LD-6, PD-2, LD(E)-6, PD(E)-2 registration, with number of places Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2 December 2004 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. 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 includes 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 groung floor which have been adapted for wheelchair users. The doors are electronically controlled. There is an assisted bathroom and toilet on the ground floor. 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 I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection (unannounced) for the year 2005. The registered manager was present. The home has 6 service users. The inspection began with a tour of the premises and the surrounding grounds. Some bedrooms were inspected. General observation was made of staff performance and staff interaction with the service users including observation of the teatime routine. Several service users and staff were interviewed. The admission and care plan files, the service records and other documents were examined. The standard of care and services provided continue to be maintained in a positive way. The service users appeared happy and content. Members of staff interacted well with them as they all sat in the lounge relaxing after returning from their respective day centres and outdoor activities. (Please see below the details of the inspection findings). What the service does well: What has improved since the last inspection? The filing system has been revised and is now complete. Documents are easily accessible for inspection. The home has made arrangements for a contract gardener to maintain the garden on a regular basis. Baker Street I52 s19277 Baker Street v245123 050905 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. Baker Street I52 s19277 Baker Street v245123 050905 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 Baker Street I52 s19277 Baker Street v245123 050905 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) 1, 2, 3, 4, 5. Prospective service users are given the information they need to make an informed decision. They are able to visit the home and assess its facilities and suitability. A prospective service user is comprehensively assessed before being admitted. EVIDENCE: The home had two admissions since the last inspection. The individual admission files were comprehensive and well documented. The admission process was thorough. One of the two new service users introduced herself during the inspection. She appeared happy and very settled in the new environment. The other new service user was away visiting his family at the time of the inspection. Feedback from the other service users suggested that he, too, is very happy and settled in the home. Baker Street I52 s19277 Baker Street v245123 050905 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. Service users are given every opportunity to participate in all aspects of the daily routine. Service users are encouraged and supported to lead independent lives. EVIDENCE: It was evident during the inspection that all the service users interacted well with each other and with the staff. One service user was busy ironing her clothes while the others were having social conversation among themselves and with staff. The home has a key-working system to ensure that each service user is consulted regularly on all aspects of life in the home and to ensure that individual needs are being met. Any changing need is identified and appropriate care and support are given. It was evident through conversation with the service users and through general observation that the service users are very content with the personal care they receive and with the service provided by the staff and the registered manager. Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 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) 11, 12, 13, 14, 15, 16, 17. Service users are treated with respect and dignity. They are encouraged to lead an independent lifestyle. The social and leisure activities are varied and arranged to suit individual and group preferences. Service users have good links with their family and friends. The menu varies and the meals provided are nutritious and balanced. EVIDENCE: At the beginning of the inspection, there was one service user present. He had just returned from the garden centre where he works one day a week. In view of his restricted mobility, a review meeting had been held between the service user, the key worker and the management at the garden centre to arrange for one-to-one supervision for his own safety. A placement has been arranged for another service user who will be attending a college for a course in woodwork. Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 Page 11 The home has a variety of social activities to suit the individual service users. Individual and group holidays take place every year. A summer garden/disco party was held recently. Many friends and relatives were invited and the day was a great success for everyone. Members of staff take turns to prepare the meals with the help of individual service users who are able to do so. Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 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 standard(s) 18, 19, 20. Service users receive personal support and care in the way they prefer and require. Appropriate referral to health care professionals is made when necessary. The medication is appropriately administered in accordance with legislation. EVIDENCE: The home has six service users with learning disability, two of whom also have physical disabilities and are wheelchair users. They all appeared well cared for. Only positive comments were received from the service users, who are all very happy and content with the care and service given. This is also reflected in the high number of complimentary letters received by the home from their relatives and friends. There are two service users on medication which is administered by trained member of staff. Proper records are kept in accordance with legislation. Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 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 standard(s) 22, 23. The keyworking system ensures that every service user is given the opportunity to express their views and preferences. They are protected from neglect, abuse and self-harm. Service users are represented on the interview panel for new staff. EVIDENCE: The home has not received any complaints, only complimentary letters from service users’ relatives and friends. A copy of the Hertfordshire Vulnerable Adult Protection Procedure is kept in the office. The registered manager assured the inspector that the staff are constantly reminded of the procedure. The staff are aware of the Whistle Blowing Policy. Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29, 30. Baker Street is a homely, friendly and comfortable place. The communal spaces and facilities provided are adequate for the service users. The staff sleep-in facilities are currently under review by management. EVIDENCE: The premises appeared well maintained both externally and internally. There is an ongoing maintenance programme. The home has made arrangements for a contract gardener to attend to the grounds and garden on a regular basis. There are plans to renovate the attic next to the office to provide sleep-in facilities for the night staff. Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 Page 15 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, 32, 34, 35, 36. The home has an effective staff team. They have good knowledge of the service users’ needs and aspirations. Staff are well supported and they have regular supervision and training. EVIDENCE: The home has recruited two carers to fill the vacant positions. Proper recruitment procedures have been followed. The two carers are currently working as agency workers until the appropriate documentation is in place. The staff development programme includes a half day in the office for each member of staff to read manuals to enhance their knowledge and skills. All the staff interviewed confirmed that they have received appropriate training arranged to meet the changing needs of the service users. Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 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, 38, 39, 40, 41, 42, 43. The home is well managed in a professional yet caring manner. The service users’ health and safety are promoted and protected. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. EVIDENCE: The services and care provided continue to be maintained to a high standard. Staff have access to the policies and procedures and other relevant information for their guidance. All records required by legislation are updated and easily accessible for inspection. Service users and staff interviewed confirmed that the management approach has created an open, positive and inclusive atmosphere to the benefit of the service users. Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 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 3 3 3 3 2 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 1 3 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Baker Street Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 Page 18 None 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 Regulation None 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. Refer to Standard None Good Practice Recommendations Baker Street I52 s19277 Baker Street v245123 050905 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts AL7 3BQ 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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