Inspection on 14/11/05 for Baldock Core & Cluster

This inspection was carried out on 14th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Baldock Core & Cluster 15/11/06

Baldock Core & Cluster 07/06/05

Baldock Core & Cluster 07/12/04

Baldock Core & Cluster 28/07/04

Similar services:

Claremont House

Chesham House

Argyll House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

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

CARE HOME ADULTS 18-65 Baldock Core & Cluster 17/18 Coach House Cloisters 10 Hitchin Street Baldock Hertfordshire SG7 6AL Lead Inspector Mrs Alison Butler Unannounced Inspection 14th November 2005 10:00 Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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 Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Baldock Core & Cluster Address 17/18 Coach House Cloisters 10 Hitchin Street Baldock Hertfordshire SG7 6AL 01462 490016 01223 576 750 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) Granta Housing Society Limited Anthony Edwards Care Home 30 Category(ies) of Learning disability (30), Learning disability over registration, with number 65 years of age (30), Physical disability (30), of places Physical disability over 65 years of age (30) Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This cluster may also accommodate people with physical disability (when associated with a learning disability) aged 18-65 years or over 65 years. 7th June 2005 Date of last inspection Brief Description of the Service: The scheme consists of six houses in Baldock, five of which are detached properties and one is a semi-detached property. All are within easy walking distance of local amenities. All offer single rooms and some have assisted bathrooms. Each house has a full range of domestic facilities. New Farm has seven bedrooms, 2b Icknield Way has three bedrooms, 12 North Road has five bedrooms, 7 Clothall Road has six bedrooms, 15 Clothall Road has four bedrooms, The Rowans has five bedrooms. The aims of the scheme are to assist service users to explore facilities and integrate them into the local community and to provide an environment for service users to learn, maintain and enhance their capabilities to their limit and in accordance with their wishes. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a Monday morning. Not all the records could be accessed on this visit and therefore the requirements have remained until they can be verified at a further inspection. The inspector checked up on the requirements and recommendations that were made at the last visit. Some of these remain outstanding. See content of the report for further details. A number of records were checked in the individual homes. Resident and staff within the scheme were spoken to during the visit. A new manager has been appointed since the last inspection but was unavailable on the day of this inspection. The two assistant managers were on duty and a discussion took place with them. What the service does well: What has improved since the last inspection? A new manager has been appointed since the last inspection, She has introduced a medication audit form, which is hoped will be carried out in each home on a quarterly basis. This will hopefully reduce errors. The manager has reviewed the care plans and each home is trialling a new format with a view to feeding back any concerns/comments. Some of the decoration has been completed since the last inspection and that these areas look so much more homely. The proprietor has put forward an application for variation and this is being looked into by the Commission For Social Care Inspection for approval. The manager has put appropriate emergency guidelines in place to ensure the safety of both residents and staff. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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 Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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 Residents and/or families receive information about the service, which enables them to make a choice about whether or not, they may wish to live in the home. Resident’s needs are not fully assessed before admission. EVIDENCE: A Statement of Purpose and Service User Guide is available although these documents are not written in a user friendly format and are not individualised to each home detailing what they are able to provide and therefore the earlier recommendation remains in place. A new resident has been admitted into the Rowans in September 2005. No assessment appeared to have been carried out, although the assistant manager confirmed that she had a copy of a social workers assessment in the office. The manager must ensure that a full assessment is carried out on all prospective residents to ensure they are able to meet the individual needs within the scheme/or home. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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, 9 & 10 Resident’s needs are not fully assessed and risk assessments are not in place to ensure they are fully supported to maintain an independent life style. EVIDENCE: Each resident has a care plan and are allocated a key worker to support them with their lives and choices. On examination of the documentation for a newly admitted resident to the Rowans, there was evidence that no assessment was available although the assistant manager confirmed that she had requested a copy to be faxed from the social worker. The manager must ensure that a full assessment is carried out to demonstrate that they are able to meet the needs of individual residents prior to admission. The plan for the individual gave very brief details of their needs. The plan needs to be more comprehensive detailing the full care needs and what support staff need to provide. There were no risk assessments in place or behaviour plans as to how staff should deal with any issues in a consistent manner. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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 the following standard(s): 13, 14, 15, 16 and 17. Residents are able to engage in local leisure facilities ensuring interaction with the community. Individual rights and responsibilities are recognised and supported. EVIDENCE: The scheme has transport available to the residents to allow them to access various activities such as bowling, pub, shops and holidays. They are able to access the local taxis’ and public transport. The residents are supported to maintain links with their families and friends. Families are encouraged to support residents and are invited to the home at any time. The induction programme covers the area of confidentiality and that a knock and wait policy is observed at all times with staff. Good interaction was observed during the inspection between residents and staff. Residents spoken to during the inspection were very much looking forward to meeting Father Christmas and joining in the Christmas festivities. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 Page 11 Residents are provided with three main meals a day. Snacks and fruit are available at other times. Residents are able to choose when and where to eat. Where possible residents are encouraged to assist in the planning, preparation and serving of the meals. Support is received from a dietician for those who require special diets. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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): 20 Policies and Procedures are in place to ensure the correct administration, storage and disposal of medication. This had not been the place in North Road, New Farm, 15 Clothall Road and The Rowans. EVIDENCE: From a sample of records examined during the inspection it was noted that at New Farm that there were a number of missed signatures. The staff member concerned was due to be seen on their return from sick leave to ensure they are clear about the correct administration and recording of all medicines within the home. A check carried out The Rowans noted that a tablet had been dropped and on asking the staff about the procedure for the disposal was informed that it had been put down the toilet. The inspector informed the member of staff that this should have been returned to the chemist for correct disposal and a record made in the disposal book. Medication at North Road revealed that internal and external were not stored separately. The controlled medication records were well kept. A bottle of drops which had a hand written label stated the residents name and “2 drops per day” no information as to where they need to be placed e.g. ears, or the time of administration. The manager has introduced a medication audit form in which it is envisaged that a quarterly review will be carried out in each of the homes. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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): 23 Policies and procedures are in place to protect residents from abuse, neglect and self-harm. EVIDENCE: The Hertfordshire County Council Adults at Risk procedure is on display and staff confirmed they were aware of the whistle blowing procedure. The induction programme also covers this area. No complaints had been received in the project or by the Commission For Social Care Inspection since the last inspection. Protection of vulnerable adults training is provided within Granta’s in house training programme. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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, 27 & 30 The scheme is still in need of redecoration and works to ensure it functions as a homely, comfortable and safe environment for the residents. Individual bedrooms were decorated and individualised to meet the needs of the residents. EVIDENCE: The kitchens at North Road & The Rowans have been decorated. The dishwasher at North Road has still to be installed and has been stored in the residents lounge since mid October this does not provide a homely feel, takes up space and must be rectified. A further requirement has been made. The downstairs toilet and shower room is in need of decoration bring it back into full use. The staff stated that they felt a review should be carried out to look at the seating in the shower. The assistant manager stated that the dishwasher in Icknield Way is waiting installation and should be complete by the end of the week. The office and the kitchen at No 7 are still waiting to be decorated and further requirements have been made. The bathroom at New Farm has been decorated although a new bath panel and flooring is required. The en-suite shower room on the ground floor (New Farm) is in need of redecoration, as the mildew issue appears to have been resolved. The Rowans lounge was in the process of being decorated during the inspection, the Probation Service was carrying this out. The bathroom at The Rowans is in need of replacement due Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 Page 15 to the general wear and tear. The facilities must be reviewed during this process to look at meeting the needs of the residents who are now finding it more difficult getting in and out of the bath. All the homes were cleaned to a good standard and no mal odours were detected during this inspection. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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): 35 The staff are trained appropriately to meet the needs of the residents EVIDENCE: Each staff member has a training and development plan in place. All training is identified annually trough the appraisal process. Where resident’s needs are identified additional training has been sought. Staff have been provided training in Mental Health to meet the needs of an individual resident. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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): 42 The health, safety and welfare of the residents is promoted and protected although risk assessments must be put in place or reviewed as appropriate. EVIDENCE: All records required were available for inspection. In New Farm the fire records were examined and testing had been carried out appropriately. Although a fire drill had been recorded it didn’t list the people present only the number. It would be beneficial if names are recorded and therefore a list would be maintained of any missing members who had not attended a drill during the year as part of their training programme. Any issues should also be recorded for example a resident or member of staff who did not respond and why. Other homes fire records listed names of people who were present at the drill and response times. The new resident that has been admitted since the last inspection had no risk assessments on their individual file although there had been some issues Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 Page 18 identified in their daily record. These must be put into place. Some risk assessments examined at North Road are in need of reviewing. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 2 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Baldock Core & Cluster Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000019278.V265937.R01.S.doc Version 5.0 Page 20 Yes 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 YA2 Regulation 14 (1) Requirement The manager must ensure that a full assessment is carried out prior to admission to demonstrate that they are able to meet their needs. The manager must ensure that where risks have been identified a full risk assessment is completed to try and reduce them and those identified must be reviewed. The manager must ensure that the correct procedure is followed for the recording of medication for disposal (The Rowans) The proprietor must ensure that the kitchen is decorated and brought up to an acceptable standard (No 7) The proprietor must ensure that the office in No. 7 is decorated DS0000019278.V265937.R01.S.doc Timescale for action 14/11/05 2 YA42& YA9 13 (4) 14/11/05 3 YA20 13(2) 14/11/05 4. YA24 23(2)(b) & (d) 31/12/05 5. YA24 23(2)(d) 31/12/05 Baldock Core & Cluster Version 5.0 Page 21 and brought up to a reasonable standard. This has been brought forward from the previous 2 inspection and a new timescale set. 6. YA27 23(2)(b) & (d) 7. YA34 17(2)Sc4&19(1)Sc2 remains, as the inspector was unable to verify, as the manager was not available at this inspection. The proprietor must ensure that the ensuite on the ground floor (New Farm) and the bathroom (The Rowans) is decorated/ replaced and brought up to an acceptable standard. The proprietor must ensure all required information on staff employed by the home is available at all times for inspection. This 31/03/06 14/11/05 8. YA42 13 (3)& 13 (4) (a) The proprietor must install dishwashers to prevent the spread of infection. North Road & Icknield Way. This has been brought forward from the previous inspection. 30/11/05 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. 2. Refer to Standard YA1 YA1 Good Practice Recommendations The proprietor should establish a way of creating the Service User Guide into a user-friendly format. This has been brought forward from the previous inspections. The Service Users Guide should be individualised for each DS0000019278.V265937.R01.S.doc Version 5.0 Page 22 Baldock Core & Cluster 4. 5 YA6 YA42 home as they each provide different support facilities. This has been brought forward from the previous inspections. The proprietor should ensure that all care plans give full details required by staff on how to meet the needs of the individuals. The manager should ensure that a list of individuals who are present at a fire drill are recorded as part of their training updates. Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire 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. Extracts may not be used or reproduced without the express permission of CSCI Baldock Core & Cluster DS0000019278.V265937.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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