Inspection on 10/10/05 for Bluecoats (18)

This inspection was carried out on 10th October 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bluecoats (18) 28/03/08

Bluecoats (18) 25/04/06

Bluecoats (18) 05/04/05

Bluecoats (18) 16/08/04

Bluecoats (18) 18/05/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 18 Bluecoats Thatcham Berkshire RG18 4ND Lead Inspector Tracy McGuire Brown Announced Inspection 10th October 2005 09:30 DS0000011192.V249924.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 DS0000011192.V249924.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. DS0000011192.V249924.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 18 Bluecoats Address Thatcham Berkshire RG18 4ND 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) 01635 874266 New Support Options Limited ***Post Vacant*** Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places DS0000011192.V249924.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th April 2005 Brief Description of the Service: Bluecoats is a purpose built single storey property located in a quiet area but close to the centre of Thatcham.The home has six single bedrooms and provides care and accommodation for up to six people who have learning and physical disabilities. The Service Users are aged between 18 and 65 years of age.The home has a kitchen/ dining area and a lounge; there is a utility room. The rear garden is large and well maintained with a raised garden suitable for wheelchair Users. There is parking and a small-grassed area to the front of the property. There is wheelchair access to the garden. DS0000011192.V249924.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection, which was announced so the Inspector could involve the home in a consultation project. There were 2 Inspectors involved in the inspection. The Inspectors spent some time talking to the Area and Acting Manager about the home and the plans for the future. The inspectors briefly met the residents and the staff on duty. Time was spent examining some records and looking around some areas of the home. What the service does well: What has improved since the last inspection? What they could do better: DS0000011192.V249924.R01.S.doc Version 5.0 Page 6 Staff in the home need to continue work to improve and up date the residents records in the home. The staff team need to work better together as a team. The home is in need of some decoration; some areas are looking very worn. 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. DS0000011192.V249924.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 DS0000011192.V249924.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): These Standards not assessed at this inspection EVIDENCE: DS0000011192.V249924.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 and 9 Service users needs are detailed in individual plans, more information is needed in these plans. Service users have individual risk assessments in place; there is an inconsistency in the quality of these. EVIDENCE: Individual service user records were sampled .The Inspectors found that there had been improvement in the development of Service users plans in a document entitled “individual support package”. These documents are still limited in detail and need to demonstrate that they are reviewed on a regular basis; this will be a requirement of this report. The Inspectors examined risk assessments that were in place on individual service user files. The risk assessments varied in quality of information and some were out of date or did not reflect service users current needs. It will be a requirement of this report that this is rectified. The Inspectors noted there had been some improvement in the format of risk assessments; there were also more risk assessments in place, particularly for the most recent admission. DS0000011192.V249924.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): These Standards not assessed at this inspection EVIDENCE: DS0000011192.V249924.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 Service users receive personal care in the way they prefer and require. Service users’ physical and emotional health is generally met; further improvement in records is needed. EVIDENCE: Since the previous inspection the staff have developed “personal care and day to day routine” documents. These documents detail the daily routines of each service user with personal preferences and needs clarified. The Inspectors examined the healthcare records in place for service users. Records were inconsistent in their format and their organisation. The Inspectors noted there had been a significant improvement in the level of recording and healthcare appointments were all being recorded. DS0000011192.V249924.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service Users feel their views are listened to and acted on. EVIDENCE: The Inspectors viewed the complaints log, which detailed complaints that had been made. The last recorded complaint was dated 30/04/05. Although the action and response had been written in the detail was not sufficient and there was no date. It is essential that the response to complaints is detailed correctly and this will be a recommendation of this report. DS0000011192.V249924.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 Shared space is minimal and needs to be reviewed. EVIDENCE: There has been no formal review undertaken of the shared communal space as required at the previous inspection. Consideration needs to be given to the communal space available in the home as service users needs have changed and more mobility aids are used. This was also a requirement of the previous inspection. One service user has deceased since the previous inspection so there is currently a vacancy in the home. All the service users in the home have mobility issues and there can be problems storing wheelchairs and equipment. The maintenance log was completed and up to date. The decoration in some areas of the building such as the hallway is looking very worn since the previous inspection and would benefit from some attention. DS0000011192.V249924.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 An effective staff team supports Service users. EVIDENCE: Since the previous inspection the formal review of the staffing has been completed, however the detail was not satisfactory and the Inspector has requested some further detail from the current Area Manager. The staff team has increased due to the successful recruitment of new staff to the home. The Acting Manager informed the Inspectors that there are also further staff due to start in the near future. The Inspectors were informed of some issues within the staff team, the organisation and Area Manager and Acting Manager are aware of these issues and are working on strategies to address any issues and improve team building. Staff rotas were examined on the day of inspection and were found to be inaccurate; it will be a requirement of this report that rotas are accurate. DS0000011192.V249924.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,40,41. Service Users benefit from the home generally running well day-to-day. Service users are safeguarded by the homes policies. The homes record keeping has improved to safeguard service users. EVIDENCE: Since the previous inspection an Acting Manager has been in post. The Acting Manager has worked hard to address some of the issues in the home and identify areas where work needs to be undertaken. The Area and Acting Manager informed the Inspectors that the post of a permanent Manager is being advertised in the next few weeks. It will be a requirement of this report that a permanent Manager is recruited to the home. A new Area Manager has also been appointed to the home recently. The Area Manager discussed with the Inspectors plans to develop the records further and to address any staffing issues in the home. A variety of records were sampled during the course of the inspection and there has been some significant improvement in the content and organisation of the records. This work needs to be maintained. The organisation has detailed policies available. DS0000011192.V249924.R01.S.doc Version 5.0 Page 16 DS0000011192.V249924.R01.S.doc Version 5.0 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 x x x x x Standard No 22 23 Score 2 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x 2 x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 x x Standard No 37 38 39 40 41 42 43 Score 2 x x 3 3 x x DS0000011192.V249924.R01.S.doc Version 5.0 Page 18 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 2 Standard YA6 YA9 Regulation 14 &15 13 (4) Timescale for action Service user plans continue to be 31/03/06 improved and are reviewed on a regular basis. Risk assessments are reviewed 31/12/05 on regular basis to reflect current practice and they are consistent in detail. A formal review is undertaken in 31/01/06 respect of the communal space available taking service users current and future needs into consideration. (Previous timescale of 30/09/05 not met) Ensure staff rotas are an 31/12/05 accurate reflection of the rota worked. The organisation recruits a 31/01/06 permanent Manager for the home and C.S.C.I are kept informed. . (Previous timescale of 30/09/05 not met) Requirement 3 YA28 23(2a) 4 5 YA33 YA37 17(2) Schedule 4 8&9 DS0000011192.V249924.R01.S.doc Version 5.0 Page 19 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 YA19 YA22 Good Practice Recommendations Healthcare records are more organised and consistent forms of recording are implemented. It is essential that the response to complaints be detailed correctly. DS0000011192.V249924.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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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