Inspection on 26/11/06 for Bath House

This inspection was carried out on 26th November 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bath House 21/01/09

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Bath House Links Resource Centre 21 Cromwell Road Eccles Gtr Manchester M30 0QT Lead Inspector Joe Kenny Unannounced Inspection 26 October 2006 1:00 Bath House DS0000066573.V310809.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 Bath House DS0000066573.V310809.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. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bath House Address Links Resource Centre 21 Cromwell Road Eccles Gtr Manchester M30 0QT 0161 707 8856 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) Abbotsound Limited Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of three adults who require personal care only by reason of learning disability and who may also have a hearing impairment, may be accommodated. Date of last inspection Brief Description of the Service: Bath House is a residential care home for three service users with a learning disability and/or hearing impairment. It is located in a building which also provides, day services to people with a learning disability and or a physical disability, some supported living tenancies and a separate registered care home for nine people with a learning disability/physical disability. People living in Bath House can access the day service. The home is situated close to the centre of Eccles, local bus routes and public amenities. The provision is owned by Abbotsound Ltd. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place on 26th October 2006 with a follow up visit on the 2 November 2006. As part of the inspection information held by the Commission was reviewed. During the course of the inspection informal discussions were held with the two residents residing at the home. As part of the inspection a survey document was given to the manager to distribute to the two residents using the service. At the time of writing the report, one form had been returned to the commission. A selection of care plans, medication records, staff records, and maintenance records were examined and a tour of the building was undertaken. In the period since the last inspection the registered manager had left her employment and the deputy manager of the home had been put forward to manage the service. What the service does well: The home continues to provide evidence that daily routines and staffing arrangements are arranged in the best interest of the residents. Staff were engaged in taking residents out to local shops and into Eccles. Each resident has a key worker, who supports them on trips out in the community for social and leisure interests. Staff supporting residents have received or are in the process of receiving training in British Sign Language. The care plans examined were well maintained, with clear daily records, signed and dated by staff contributing to them. . Regular unannounced Regulation 26 visits to the home continue to be carried out and copies of the outcomes of the visits are forwarded to the Commission’s local office. Internal arrangements relating to catering and menu planning are carried out in consultation with residents who are actively involved in menu planning, preparing meals and weekly shopping. The manager keeps a record of training programmes available to staff. Staff had access to training provided by Salford Local Authority, including POVA training. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 6 A designated staff team continues to be assigned to the home. The objective of care and support offered is to enable residents to develop and maintain independence within the home and their local community. 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. Bath House DS0000066573.V310809.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 Bath House DS0000066573.V310809.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures used by the home ensure that resident’s needs are identified and assessed before they move into the home. EVIDENCE: As on all previous inspections of Bath House, there have been no new admissions to the home. The procedures described by the manager in relation to referrals and potential admissions ensure an assessment of needs is carried out, a trial visit is offered and there is a review of the placement within the first six weeks. This enables the home and the person referred to determine if the needs of the individual are being met and whether the home can continue to meet their needs. The manager of Bath House has also management responsibilities for the Hamlet a further residential care facility located within the Links resource unit. The home continues to provide enquirers with informative literature about the services offered at the home. The brochure for the home needs updating to inform the reader about the appointment of the current manager. Bath House DS0000066573.V310809.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident is supported to take part in decision making processes and live as independently as possible. Residents continue to be consulted on life in the home and use of facilities in their local community. EVIDENCE: Information provided by staff and the manager clearly indicated that the home strived to respond to the assessed needs and choices of each resident. The daily records relating to the two residents were viewed and contained daily reports on how each resident was supported on personal care and social interests. Plans contained assessments, care plans, health care records and daily update records. Overall, resident files were well maintained. Records were signed and dated with detailed overviews for each individual resident. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 10 Residents supported at Bath House continue to require the support of staff skilled in British Sign Language. Staff on duty at the time of the two visits were skilled in communication with residents or had the necessary level of communication to work closely with each resident. Residents were free to arrange how they spent their time in the home and can choose to remain in the privacy of their room or come together with staff in the kitchen/dining area or in their lounge. The response by the resident using the comment card was positive and confirmed that staff respected choices and preferences. The member of staff supporting one resident to complete the questionnaire, indicated on the comment card how they had to rephrase the question during interpretation to enable the resident to understand the question being asked. This clearly identified a need for the Commission to develop comment cards to meet the communication abilities and skills of some residents, in terms of the language used and those residents who require another to interpret the questions being asked. This is an issue currently being looked at by the Commission. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to access a range of community-based activities and have unrestricted access to facilities within the home. EVIDENCE: Over the period of the two days residents were observed to freely access community activities with support and to have unrestricted access to communal and private areas. One resident was out in Eccles on the day of the first visit whilst the remaining resident was being supported by staff constructively following an incident at the home. There was evidence that the staff had dealt with the incident appropriately. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 12 On the follow up visit both residents were in the home and a tour of the building was undertaken. One resident was pursuing their own interest in their room and one was sitting quietly in the lounge. Each resident has a weekly plan of activities and staffing arrangements are drawn up to support each resident on such activities. The arrangements for meals continue to be planned in consultation with each resident. Residents are encouraged and supported by staff in the planning, purchasing and preparation of meals. The quantity and range of provisions in the home ensured individual preferences could be catered for. Social and leisure activities also enable residents to eat out at their preferred venue. The home manages its own catering budget for weekly provisions. The manager indicated on some occasions if they were to run short of e.g. milk during the week, staff would purchase such items from their own money. The manager is advised to leave a nominated amount of money/float for such purchase. Discussions were also held with the manager in relation to trips out by residents where they are supported by staff and who is responsible for cost such as meals/transport of the support worker. A number of events attended by residents do not incur a cost to their support worker, however the manager is advised to develop policy and procedures in relation to this matter where there may be a cost to be accounted for by staff supporting residents in certain situations. Residents are supported by staff to maintain contact with relatives and friends. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and health care needs are met by staff working in the home. EVIDENCE: Information held on each residents file contained details of their personal and health care needs. Each resident is registered with a general practitioner and records are maintained when visits are made to other health professionals such as the dentist. Records were found to be up to date and supported by a brief description of the outcome or purpose of health care visits. Medication procedures ensure all medicines are held secure and, administered only by designated staff. The home is advised to include on the medication administration records a sample copy of signatures used by staff designated to administer medication when signing the medication administration records. . Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 14 Staff demonstrated they were familiar with medication procedures and all medications were correct and stored appropriately on the date of the inspection. The home keeps a record of medication received and returned to the pharmacist for disposal. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 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 the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to protect residents from abuse and staff are trained in adult protection procedures. EVIDENCE: The home has an established complaints procedure. Residents using the comment card, with support from staff as interpreter indicated that they knew who to speak to if they were unhappy about the care they received and signed that they would go to ‘LH’ in reference to the manager of the home. No complaints had been received by the Commission in the same period. The manager stated the home uses Salford Local Authorities Protection of Vulnerable Adults procedures and guidelines. In addition staff have attended abuse awareness training provided by Salford social service. The safe keeping of residents’ finances and valuables was also inspected during the visit. Safety procedures were in place to protect residents and staff assisting residents when accessing their money. The procedure used by the home needed to be extended to one resident when using their bank book. This issue was discussed with the manager and a member of staff during the inspection. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 16 The records examined on the date of the inspection were found to be in order. The manager is advised to retain evidence on the residents’ finance records that she carries out regular audits of accounts. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment for residents. EVIDENCE: The home was found to be clean and homely in appearance. Residents indicated they were happy with their own private bedrooms. One resident had relocated to a larger room since the last inspection. The room was decorated in accordance with the residents chosen colours and wallpaper prior to them moving. There was some damp damage in the lounge at the time of the last inspection. This area had been rendered and redecorated. The kitchen and dining area is spacious and new laminated flooring had been laid since the last inspection. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 18 The manager was advised to have loose electrical wiring at two sections of the room secured to the skirting board. The loose wiring presented as a potential tripping hazard/electrical hazard if the wiring was to be dislodged from the appliances. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 19 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): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate staffing arrangements are in place, which ensure residents are supported by appropriately trained staff. EVIDENCE: The manager confirmed that there is a designated staff team assigned to work at Bath House. The arrangements for staff cover were appropriate to meeting the needs of the two residents who live at the home. The rotas indicated up to three staff work at the home each day and are assigned as key worker to residents living at the home. The home continued to maintain recruitment and training procedures which looked at establishing a staff team skilled in British Sign Language. Training programmes cover staff working at Bath House and the Hamlet and included access to abuse awareness and Challenging Behaviour training. Staff records provided clear documented evidence of appropriate recruitment and selection processes. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 20 Staff supervision forms were being reviewed to look at topics covered under standardised and relevant headings. Supervision was carried out by the manager on a 6 to 8 weekly basis. The manager takes responsibility for all aspects of management and administration of the service including management responsibility for The Hamlet a further residential service within the Links Resource Unit. The manager is advised to induct, train and supervise senior staff to support her role through delegation of responsibilities for specified areas of management and administration, such as supervision of care staff, medication procedures. Discussions were held with the manager on this topic during inspection. The manager has completed NVQ level 4 and has applied to do the registered managers award. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by effective procedures for the management and administration of the home. EVIDENCE: The management and administration procedures relating to medication, finances, recruitment, supervision and training demonstrated the home was being run in the best interest of residents. The home had an established programme of self-monitoring through residents and staff meetings, supervision and monthly visits on the conduct of the home (Regulation 26 visits). Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 22 In order to support the work under taken, the home needs to develop quality audit recording systems to evidence consultations with residents about how they perceive the service they receive. There was no evidence of user surveys although residents told inspectors they liked the home and there was evidence of good communication between staff and residents. The home keeps appropriate records, which safeguard the rights and best interests of residents. Staff receive regular fire training and the company maintenance team carry out checks on fire alarms and fire doors. The weekly and monthly tests are carried out at the required intervals for the Links Resource Unit. The manager is advised to retain at Bath House, records of weekly and monthly tests and checks specific to the home as a registered independent unit. Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 3 4 3 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 Sco2re 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 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 3 X 3 X 3 X X 3 X Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 24 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 YA24 Regulation 23 Requirement The loose wiring in the kitchen presented as a potential tripping hazard/electrical hazard and must be secured. Timescale for action 28/12/06 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 2 Refer to Standard YA1 YA14 Good Practice Recommendations The Statement of Purpose needs to be updated to inform the reader about the appointment of the current manager. The manager is advised to develop policy and procedures in relation any cost to resident and staff when on planned external leisure activities. The manager is advised to access a nominated amount of money/float for additional purchases required in relation toot catering arrangements. The home is advised to include on the medication administration records a sample copy of signatures used by staff designated to administer medication when signing the medication administration records. DS0000066573.V310809.R01.S.doc Version 5.2 Page 25 3 YA17 4 YA20 Bath House 5 YA31 The manager is advised to induct, train and supervise senior staff to support her role through delegation of responsibilities for specified areas of management and administration, such as supervision of care staff, medication procedures. In order to support the work under taken, the home needs to develop quality audit recording systems to evidence consultations with residents about how they perceive the service they receive. The manager is advised to retain on Bath house, records of weekly and monthly tests and checks specific to the home as a registered independent unit. 6 YA37 7 YA31 Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Bath House DS0000066573.V310809.R01.S.doc Version 5.2 Page 27 - 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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