Inspection on 21/07/05 for Bartlett Close 1

This inspection was carried out on 21st July 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 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

Bartlett Close 1 23/02/09

Bartlett Close 1 31/10/07

Bartlett Close 1 09/01/07

Bartlett Close 1 25/07/06

Bartlett Close 1 06/10/05

Bartlett Close 1 21/02/05

Bartlett Close 1 13/05/04

Bartlett Close 1 09/03/04

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Dalewood Respite Care

Orchard,The

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Fairways

Treloar College

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Pinta

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

CARE HOME ADULTS 18-65 Bartlett 1 Bartlett Close Witney Oxfordshire OX28 7FD Lead Inspector Julian Griffiths Unannounced Inspection 21 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 1 Bartlett Close Address 1 Bartlett Close, Witney, Oxon. OX28 7FD 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) 01993 709646 01993 709659 MacIntyre Care Pauline Buckingham Care Home 4 Category(ies) of Learning Disability (4) registration, with number of places Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21 February 2005 Brief Description of the Service: 1 Bartlett Close is home for four adults with learning and some physical disabilities. It is managed by MacIntyre Care . The building is modern and designed with the needs of people with physical disabilities in mind. The support provided enables service users to lead active lives and pursue their interests in and out of the home. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. This means that the home had no prior notice of the inspector’s visit. The inspector was in the home from 2.15pm until 6.35pm and was able to talk with service users, staff and the manager, look at all the rooms, watch staff at work and look at written records. Service users and staff were open and helpful throughout. Overall the inspector found the home to be providing a high standard of support and accommodation, that service users were settled in their home and were enabled to live active and fulfilling lives. Service users appeared confident and at ease, and relationships between them and staff were good. The home clearly makes efforts to find out what service users want and how they want to live their lives, and to provide a service that reflects this. What the service does well: Service users needs and wishes are set out in individual written plans and reflected in their daily lives. Service users are consulted about their daily lives. Service users are supported to take reasonable risks as part of everyday life. Service users have opportunities for personal development. Service users have access to a wide range of social and leisure activities in the home and the wider community. Service users are enabled to keep in contact with friends and family. Service users’ freedom and choice is promoted in their daily lives. Service users are offered food which they enjoy and which reflects their needs and preferences. The home listens and responds to service users’ complaints. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 6 Service users live in a homely, comfortable, accessible and well maintained home. Service users’ private space reflects their individuality and interests. Service users enjoy and are comfortable in the home’s shared spaces. The home is designed and equipped to promote the independence of service users with physical disabilities. The home is clean. Service users are supported by an effective staff team. The home protects service users by making sure that all staff are properly checked. The home provides training to staff to ensure that the quality of support to service users is high. What has improved since the last inspection? 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. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 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 Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 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) No judgements were reached in respect of these outcomes as none of the standards in this section were inspected. EVIDENCE: Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 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, 8 and 9 Service users needs and wishes are set out in individual written plans and reflected in their daily lives. Service users are consulted about their daily lives. Service users are supported to take reasonable risks as part of everyday life. Records need to show that service users’ health and safety is promoted by regular review of risk assessments. EVIDENCE: Each service user has an individual personal plan and the inspector looked at various elements of three of these. They were found to be detailed and comprehensive, and to reflect the way that each person wanted or needed to lead his or her life. They covered such aspects as preferred daily routines, communication needs, healthcare needs, dietary needs and preferences, leisure interests and dreams and aspirations. Review reports were seen which showed that a service user had been present at his formal review meeting. Monthly updates of peoples’ person centred Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 10 plans were seen, which identified to what extent needs and wishes were being met. Records were seen of periodic service users’ meetings. Five such meetings had taken place in 2005. Discussion had included holiday planning, forthcoming inspections and the Commission’s service user questionnaires, contact with friends, menu planning and things that service users wanted to buy. An action plan and other records showed that service users’ wishes were translated into action. Service users’ records showed that assessments were carried out of the risks associated with various aspects of daily life, and action agreed to minimise risk while enabling service users to pursue their chosen activities. Some of the records of these assessments were unsigned and undated, others were unclear as to when they had last been reviewed and what was the outcome of the review. Others were signed, dated and up-to-date. The manager said that all risk assessments had in fact been recently reviewed, however it is recommended that she check through all risk assessment records to make sure they show clearly that they have been reviewed and are up-to-date. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17 Service users have opportunities for personal development. Service users have access to a wide range of social and leisure activities in the home and the wider community. Service users are enabled to keep in contact with friends and family. Service users’ freedom and choice is promoted in their daily lives. Service users are offered food which they enjoy and which reflects their needs and preferences. EVIDENCE: Records seen showed service users engaging in a wide range of activities, with at least one opportunity for a planned activity for each person every day. It showed that on occasions service users exercised their right to decline an activity. There was little evidence of activities being cancelled, for example due to transport or staffing difficulties, and a staff member stated that, whilst Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 12 this did happen occasionally it was not such that the overall programme was undermined. The records seen showed service users engaged in housekeeping activities such as cooking, shopping and cleaning; in classes such as cookery, dance, art and computer skills, and in leisure activities such as sailing, horse riding, drama, swimming and keep-fit. Service users were shown to be using public transport, although the home has its own car which, staff said, all service users could use, and being out in the local community visiting pubs, the library, the swimming pool, eating out and going for walks. On the day of the inspection some service users had been out to a pub. One service user, with support from a staff member, was putting in an album the photographs from his recent holiday, some of which he had taken himself. He said that he had enjoyed the holiday. The manager said that all service users maintained close contact with their families and she described some of the measures taken by the home to promote this, including transporting a service user a considerable distance, and bringing an elderly relative to the home. Records seen showed staff supporting service users to write to their families, visit a friend and send birthday and other celebration cards. Service users were seen to move freely around the home without reference to staff, although access to the kitchen was limited during the cooking of the evening meal, for safety reasons, by means of a low detachable gate placed in the doorway. The manager told the inspector that this measure had been recently introduced as a result of a recorded risk assessment. Whilst bedroom doors were all fitted with appropriate locks to enable service users to defend their privacy, all were wide open throughout the inspection. The manager said in respect of two service users that they preferred to keep their doors open because it made their access easier. However this meant that a service user did sometimes access another’s room without permission and disturbed his possessions. The inspector saw this happen during the inspection. It was clearly difficult to defend the privacy of the service user’s bedroom whilst complying with his wish to keep his bedroom door open, and without maintaining an onerous level of supervision in respect of the service user who was entering the bedroom. Staff members were seen to be attentive to service users’ needs, to ensure that privacy was maintained as needed, to converse and interact with service users and to have a good understanding of individual needs, for example with reference to communication. Staff members’ responses to service users were seen to be consistent with the information given in their written plans. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 13 The inspector was present when service users had their evening meal of cauliflower/broccoli with cheese sauce and potato wedges. All sat down together with staff in the kitchen/dining room and staff were able to give the 1:1 assistance needed by some service users. Some had very specific mealtime needs which were specified in their personal plans, such as to have food pureed, or to be able to get up from the table and return later during a meal, and these were seen to be followed by staff. The meal was of a type that, according to his personal plan, one service user especially liked. Special equipment needed by service users, such as a particular chair, a plate guard or special cutlery, was all available and used. One service user was clearly very tired, and whilst he was encouraged to eat by staff, he ate little and a staff member said that he could have his meal later if he wished. Drinks were seen to be freely available to service users and a staff member was able to say how a service user communicated, non-verbally, that she wanted a drink. A staff member said that snacks, such as fruit or yoghurts, were freely available to service users. The home’s current menu was seen and this showed a suitable variety of dishes, with each service user having something different at lunchtime, according to his or her personal choice. The service user meeting records showed a service user making a specific request with regard to the menu. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 14 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) No judgements were reached in respect of these outcomes as none of the standards in this section were inspected. EVIDENCE: Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 15 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 The home listens and responds to service users’ complaints. Macintyre’s complaints procedure needs to be brought up to date. EVIDENCE: The inspector saw the home’s complaints record. This contained only one complaint which had been made a year before and had been appropriately dealt with. The manager said that she had checked with all service users’ relatives to ensure that they were aware of how to make a complaint, however MacIntyre’s complaints procedure was seen to be out of date, referring to legislation (the Registered Homes Act 1984) that had been repealed over three years before, and giving no details of the Commission for Social Care Inspection, the name, address and telephone number of which it is obliged by law to include in its procedure. It is required that MacIntyre update its complaints procedure and include in it the name, address and telephone number of the Commission. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 16 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, 26, 27, 28, 29 and 30 Service users live in a homely, comfortable, accessible and well maintained home. Service users’ private space reflects their individuality and interests. Service users enjoy and are comfortable in the home’s shared spaces. The home is designed and equipped to promote the independence of service users with physical disabilities. The home is clean. EVIDENCE: The home is a detached house on a modern development. It is in keeping with its surroundings, domestic rather than institutional in character, within easy reach of many amenities and incorporates design features that make it suitable for people with physical disabilities. It is well kept, bright and airy, well decorated and well maintained to a good domestic standard. Some of the floor covering in service users’ bedrooms was being replaced at the time of inspection. A service user expressed his approval of the new flooring. The Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 17 carpeting in the hall however was in a poor state, being badly stained and held together with duck tape. The manager said that it was about to be replaced. Documentary evidence was seen of regular safety checks being carried out, for example fire safety and hot water temperature checks. All door thresholds on the ground floor were wide, flat and level, and all external doorways ramped. Furniture and fittings were of good quality and comfortable. Bedrooms were very individual, comfortable and well furnished. Residents’ possessions and interests were clearly in evidence. Toilets and bathrooms on the ground floor were all designed to meet the needs of people with physical disabilities. A service user who uses a wheelchair was seen to access one of these facilities without difficulty. The home has sufficient WCs and bath/shower rooms on both floors and close to service users’ bedrooms. All were seen to be lockable. The home has comfortable and appropriate shared spaces – a sitting room, a kitchen/dining room and a well kept and well equipped garden. There was a large paddling pool (empty at the time of inspection) in the garden. The manager confirmed to the inspector that there was a recorded risk assessment in place regarding its use. A variety of equipment and adaptations were seen in the home – a hoist, ceiling tracking, a shower seat, a standing frame and handrails. Service users have their own wheelchairs and walking frames. The home was clean and odour free throughout, and the laundry suitably sited, clean and well equipped. Regarding a previous inspection requirement concerning disposal of clinical waste, the manager confirmed that she had sought the advice of the infection control nurse and West Oxfordshire Environmental Health Department and was following their advice. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 18 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) 33, 34 and 35 Service users are supported by an effective staff team. The home protects service users by making sure that all staff are properly checked. The home provides training to staff to ensure that the quality of support to service users is high. EVIDENCE: There were two or three members of staff on duty throughout the inspection. During this time service users were able to go out, to enjoy a meal, to have 1:1 support to do activities in the home and to have their personal care needs met. There was no indication that the staffing level was insufficient. The duty rota for the month of July was seen and it indicated that staffing did not fall below this level. Staff members told the inspector that staffing was sufficient to meet service users’ needs and sustain a busy programme of activity. A senior staff member is rostered on-call at all times. At the request of the inspector a staff member on duty tested the system by calling the on-call senior. This showed that it worked. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 19 A relatively new staff member told the inspector that he had completed a programme of induction training and was undertaking CWPLD foundation training (Certificate for Working with People with Learning Disability – described by the manager as properly accredited and “like LDAF but better”). One staff member spoken to had achieved NVQ (National Vocational Qualification) level 2 and was working towards level 3. Another said that he assumed he would start work on NVQ as soon as he had finished his foundation. At least two other staff were said to be working towards NVQ. A senior staff member was said to have achieved NVQ level 3. A staff member told the inspector that he had done a variety of in-house training courses in core and specialist skills. The inspector looked at the records held by the home in respect of one of the staff members on duty. This included all the information required to be held in the home under Schedule 4 of the Care Homes Regulations and indicated that an appropriate recruitment process with all required checks was followed. Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 20 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) No judgements were reached in respect of these outcomes as none of the standards in this section were inspected. EVIDENCE: Bartlett v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bartlett Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x v240534 h57-h08 s13063 bartlett v240534 210705 stage 4.doc Version 1.30 Page 22 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 22 Regulation 22 Requirement It is required that MacIntyre update its complaints procedure and include in it the name, address and telephone number of the Commission. Timescale for action 30/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations It is recommended that the manager check through all risk assessment records to make sure that they show clearly that they have been reviewed and are up-to-date. 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