Inspection on 25/04/06 for Bluecoats (18)

This inspection was carried out on 25th April 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 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

Bluecoats (18) 28/03/08

Bluecoats (18) 10/10/05

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 Unannounced Inspection 25th April 2006 09:15 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 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 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 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. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 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 bridgette.edwards@newdimension.org.uk www.new-support.org.uk New Support Options Limited ***Post Vacant*** Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 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. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service was inspected over a period of 4 days between 19th April and 2nd May with a visit to the establishment taking place on 25th April between 9.30am and 2.45 pm. The Inspector spoke to service users, a relative, staff ,a health proffesional and management. Resident files and care plans were seen. Information from providers, other proffessionals and inspection records were used. The Inspector toured the building and observed practice throughout the visit. What the service does well: What has improved since the last inspection? There have been many significant improvements since the previous inspection. A permanent Manager has been appointed, this was a requirement which has now been met made at previous inspections Staff and residents were positive about the Manager, one staff member commented that the “the Manager is brilliant and easy to approach” another commented that the Manager has implemented “positive change”. A service user stated, “I like her” Service user plans have been improved and updated so care for service users is clear and consistent. This was commented on in the local authority accreditation visit undertaken in March 2006. This was also a requirement, which has now been met from previous inspections Risk assessments have been reviewed and updated and support the care plans that are in place for 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 6 individual service users. This again was a requirement, which has now been met from the previous inspection. Records sampled have improved in content and organisation and staff report that this has helped the home to run more efficiently and effectively. Activities offered have improved and service users informed they were “doing cooking today” another service user was going to a local day centre. There is an activity board in place with removable pictures to enable service users to demonstrate their activities and choices. 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. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 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 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 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): 2 Quality in this outcome area is good. EVIDENCE: There have been no new Service users admitted to the home since the previous inspection. Previous inspection information indicated that Service users all have full assessments undertaken prior to moving to the home. The Manager informed the Inspector that they have had referrals for the current vacancy and have received assessment detail on prospective Service users proposed. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 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. EVIDENCE: Service users records were case tracked and since the previous inspection support plans have been developed which detail each individual service users care and support needs taking into consideration their personal choices and preferences. Staff reported to the Inspector that these records were “better, up to date and easy to follow” The Inspector observed practice on the day of inspection which was detailed as in care plans. As part of the case tracking process risk assessments were also assessed these were updated and reflective of needs identified in the care plans. Alongside support plans are records detailing, “how I communicate with you” which explain communication methods of individuals to ensure they are enabled to communicate their feelings, wishes and choices effectively. Service Users spoken to are aware of their key workers. Staff spoken to were clear about the role of the key worker and informed the Inspector that they are involved in the development of support plans and risk assessments, working with service users to ensure their preferences are recorded. The Manager informed the Inspector that regular keywork meetings are being implemented and form part of the staff meeting agenda. One Service user in the home has an advocate. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 10 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 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): 12,1,3,15,16 and 17. Quality in this outcome area is good. EVIDENCE: Since the previous inspection an activities board has been added in the hallway, this has removable pictures and each service users day activities are detailed on the board. Service users can remove or add activities if they wish or the board may be used to communicate preferences or changes to the day’s activities. Activities included craft, nail care, drawing, cooking, out shopping, singing, Tree Tops, college, some of these activities are in house and others are external in the local community. Service users informed the Inspector that they like attending Tree tops. Staff informed the Inspector they provide support for this activity. One service user was enthusiastic about “going cooking in the afternoon and attending college.” A relative stated the home offers opportunity for activities, which were not available at a previous establishment Service user records and daily records seen indicate that service users regularly access a variety of community resources including, G.P, shops, restaurants and cafes. The Inspector spoke to a relative who was very positive about the home and informed the Inspector that they are welcome to visit on a regular basis. One 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 12 Service user informed the Inspector about a planned visit to see “mum and dad” at the weekend. Daily records and support plans seen demonstrate that service users are supported to maintain and develop positive relationships with friends and relatives. Staff were observed on the visit to the establishment working with service users in a positive and professional manner. Staff were observed asking service users before a care or support task was undertaken and were seen to explain the task e.g. prior to personal care for the morning. Despite complex needs service user support plans detail how they are involved in the daily routines of the home. Personal preferences are detailed on support plans. Service users have a varied menu and are offered choices, copies of the menu plan were supplied. The Inspector observed breakfast and lunch choices during the visit to the establishment. Service users said the food “was very good” The Manager is planning to develop the menu in a more service user-friendly format and to aid choice and planning. The Manager showed the Inspector the format that has been accessed via an NHS professional and this is on the agenda to be discussed at the next staff meeting. Some service users require assistance with feeding and this was detailed in support plans, this practice was observed during the visit and was professional and sensitive. Mealtimes in the home are a sociable occasion. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 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. EVIDENCE: Service users have detailed support plans in place, which are developed with service users needs and choices taken into consideration. Healthcare records have improved since the previous inspection. Samples of healthcare records were seen during the case tracking exercise, these were up to date, clear and organised. The Inspector also spoke to a healthcare professional,( physiotherapist) who visits the home on a regular basis. The Physiotherapist commented that there have been some improvements in the home, there are still some issues in respect of specific healthcare issues for some individuals and these will be addressed directly with the home as part of the ongoing care. Staff in the home have medication training, certificates were seen in staff files. The Inspector observed the lunchtime medication administration undertaken by 2 staff. Medication records seen were satisfactory. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 14 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. EVIDENCE: The home has a detailed complaints process in place. Staff, service users and a relative spoken to were clear about whom they would approach if they have a complaint. The complaints log was viewed and there were 7 complaints, there was detailed action and outcomes noted. Staff have received vulnerable adults training and those spoken to had satisfactory knowledge of vulnerable adults processes. Robust policies are in place to protect service users. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 15 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): Quality in this outcome area is good. EVIDENCE: The Inspector noted on a tour of the building that the hallway, lounge and office have been decorated; there was also new carpet in the hallway and lounge. Service user told the Inspector that they like the home. The home was clean and tidy throughout .The building is homely, clean, safe and comfortable. The Manager sends the CSCI regular audit reports which detail property issues and maintenance being undertaken. The Area Manager informed the Inspector that a discussion had taken place in respect of a review of the space available; there are no immediate plans to extend the space at present. This review was a requirement of the previous inspection. Service users in the home informed the Inspector that they like the home and feel comfortable. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 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): 32,34 and 35 Quality in this outcome area is adequate. There have been improvements and service users benefit from a more stable staff team. EVIDENCE: The Inspector discussed staffing with the Manager and Area Manager of the home, a relative and professional were also consulted for their comments. Since the previous inspection there have been further changes in the staff team. Some staff have left and there are some newly recruited staff, including a permanent Manager. There has been improvement in working on the issues that existed in the staff team and some team building exercises have been planned, including being involved in a local crafty raft race and fund raising exercise. There are still some vacancies in the home and these are currently filled with regular bank or agency staff to ensure consistency. A relative commented, “the difficulties of recruiting staff were understood but that the home has a regular rota of experienced and familiar staff.” A visiting professional felt that there had been improvement but was also concerned that consistency of staffing and care planning needs to continue to be improved. The home had a training profile and plan in place but there are some gaps in training, this was also identified in the local authority accreditation report. The Manager has arranged for most of the outstanding training to be addressed. Samples of staff training records seen were satisfactory. The Inspector discussed the staffing complement for the home and raised concern that the driver/handyperson post was included in the total care hours 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 17 allocated for the home and not separated. The Inspector was informed this issue has been raised and is to be addressed by the organisation. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 18 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. EVIDENCE: Since the previous inspection the organisation have successfully recruited a permanent Manager. The Manager has several years experience in residential and supported loving work and has gained relevant qualifications. The Manager is currently completing the application process to become the Registered Manager. The Inspector spent some time talking to the Manager who was able to demonstrate the improvements made to the home e.g. records and care plans. Staff, a relative, service users and a visiting professional were complimentary about the Manager and the changes that have been implemented. The Manager was also able to demonstrate work in progress to further improve the care and support offered to service users e.g. a more userfriendly menu planning format and more structured key work sessions. The Manager has continued to develop the “Quality assurance path system” in place. A meeting was held earlier in the year and service users parents and other professional were invited to take part to comment on Quality issues and plan for the future development. The “path plan” is on display in the hallway 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 19 and demonstrates the input from everyone involved. In addition the “10 Big Questions “ quality check has been undertaken with each individual service user and these are on file, communication aids are used to assist service users. The local authority accreditation report also commented on this as a meaningful tool for service user participation. The home has detailed Health and Safety records in place, the Manager commented that these files are in need of some updating and reorganisation and plans to undertake this task soon. 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 20 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 x 2 3 3 x 4 x 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 Score 24 3 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 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI 18 Bluecoats DS0000011192.V290256.R01.S.doc Version 5.1 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!