Inspection on 05/04/05 for Bluecoats (18)

This inspection was carried out on 5th April 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 but made no statutory requirements on the home.

Other inspections for this house

Bluecoats (18) 28/03/08

Bluecoats (18) 25/04/06

Bluecoats (18) 10/10/05

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 BLUECOATS 18 ,Bluecoats Thatcham Berks RG18 4ND Lead Inspector Tracy McGuire-Brown Unannounced - 5 April 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. BLUECOATS Version 1.10 Page 3 SERVICE INFORMATION Name of service Bluecoats Address 18, Bluecoats. Thatcham Berks RG18 4ND 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) Category(ies) of registration, with number of places 01635 874266 New Support Options Learning Disability 6 BLUECOATS Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2004 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. BLUECOATS Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which took place over 5 hours. The Inspector looked around the home, including bedrooms and bathrooms. Residents care records were examined and additional information in the home was also looked at. The Inspector was able to spend some time with each of the 6 residents. Staff on duty were spoken to. The Area Manager who is acting Manager also spent time with the Inspector. The Physiotherapist also spoke to Inspector. What the service does well: 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. BLUECOATS Version 1.10 Page 6 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 BLUECOATS Version 1.10 Page 7 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) 2 and 5 Service Users have a full assessment undertaken prior to admission to the home. Comprehensive information about each Service User is sought prior to admission. Detailed contracts are in place for each Service User. EVIDENCE: The home maintains records for each individual Service User. Records for the most recently admitted Service Users were examined and these included a detailed Care Management Assessment, Health Assessment and consultation with the CSCI Pharmacy Inspector, Occupational therapy, Speech and Language Assessment. Trial visits were recorded and a transition meeting was held with minutes produced. BLUECOATS Version 1.10 Page 8 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) 6,7 and 9 There has been little progress in the development of Care Plans. Little evidence is available to demonstrate that Service Users are involved in decision making. These need to rectified to ensure the good quality consistent care can be maintained for each Service User. Risk Assessments are in place but need to be reviewed. EVIDENCE: Individual care plans are in place but there has been little improvement made on the requirement made to improve the detail of these plans. Plans are very basic in content with little detail about implementation. Plans have not been updated despite some significant care issues in the home previously, such as falls or changes in behaviour patterns. Care practice is good but relies currently on staff’s good working knowledge of the Service Users and good verbal communication. Discussion with staff indicated that there is some work now in progress to address the care plans. The Inspector was shown an example of a new format, which had been worked on, by one of the care staff in the home. This format was of a better quality and provided detailed and comprehensive detail about the Service User. This work needs to completed and implemented for all Service Users as a priority. BLUECOATS Version 1.10 Page 9 Staff were observed communicating well despite some Service Users communication difficulties. Staff spoken to informed the Inspector how Service Users are supported to make decisions about their lives. Some records seen such as “communication passports” demonstrate how decisions are made. Again records need to more consistent in respect of this issue. Risk assessments have been developed for each Service User. There was inconsistency in the detail and not all areas of risk discussed with the Inspector had a current risk assessment in place. A review and update of risk assessments was made a requirement previously. BLUECOATS Version 1.10 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 standard(s) 12, 13 ,15,16, and 17 The home works hard to try to achieve varied and appropriate activities for Service Users who have a range of complex needs. Various day care options are offered. Service User utilise the local community for a variety of reasons and the location close to the town centre makes this easily accessible. Service Users have a variety of leisure opportunities. Service Users are offered a varied and healthy diet with all dietary and feeding needs taken in careful consideration. EVIDENCE: An activity timetable is produced on a weekly basis for each individual example activities were Drama. Gateway club, swimming, day centre and college. Some guidelines were in place for some individuals in respect of activities Daily diaries also detail some activities undertaken. Records indicate Service Users use the local community shops, café, restaurants, GP, and local clubs. 3 of 6 Service Users were observed watching the television on the day of inspection. Daily diaries and Service User files indicate that Service Users have regular contact with family and friends. Regular meetings are held with parent and minutes are produced. BLUECOATS Version 1.10 Page 11 Service Users are supported to access all areas of the home and garden with support if required, this was observed by the Inspector. Service Users were seen being addressed in an appropriate manner and spent time alone and with others upon request. All Meals taken are also recorded on individual daily diaries; this has met the requirement previously made. . Some Service Users went out into the local town shopping and had lunch out on the day of inspection. Menus are varied and well balanced. Individual Service User records indicate that where required dietician BLUECOATS Version 1.10 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18.19 and 20. Personal care records need to more detailed in respect of implementation. Health care records show some improvement but remain inconsistent Medication is generally well managed. EVIDENCE: Personal care record seen on individual Service User files were inconsistent and lacked detail about implementation. With the level of complex needs of the Service User these records need to be improved with urgency, this was a previous requirement. Current personal care is delivered by good support staff who relay on good communication of their long-term knowledge of the Service Users. The Inspector was shown an example of a new format, which had been worked on, by one of the care staff in the home. This format was of a better quality and provided detailed and comprehensive detail about the Service User and the delivery of personal care. Healthcare records have shown some improvement since the previous requirement made. The records remain inconsistent form individual to individual. The Service User files contained detailed and regular assessments in respect of healthcare from a variety of other professionals including, physiotherapy, speech and language, occupational therapy and district nurse. The physiotherapists visited the home and spent some time talking to the Inspector. The physio reported that the Service Users were doing well BLUECOATS Version 1.10 Page 13 but voiced some concerns about the placement of one service User, this needs to be monitored. Staff were observed administering medication, one member of staff administer and another witnesses. The staff member administering noted that there had been an omission in the signing of the mar sheet for the previous day. The staff member immediately took appropriate action to address this matter. Medication is stored securely in a locked cabinet. The home operates a blister pack medication system and all staff are trained in medication. Medication assessments were seen. BLUECOATS Version 1.10 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 standard(s) 22 and 23 The home deals well with complaints and protects Service Users from abuse. EVIDENCE: A recent complaint manner and within and in addition the aid communication was recorded in the log and responded to in an appropriate set timescales. The home has a complaints policy in place organisation has produced a pictorial complaints format to with Service Users. The home works to the Local Authority interagency Vulnerable Adults procedures. Staff receive training in the protection of Vulnerable Adults and a training session was attended in September 2004. BLUECOATS Version 1.10 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 standard(s) 24,25,26,28 and 30 Generally the home, which was purpose built, is well maintained and has a homely feel. The home is clean and hygienic. EVIDENCE: The home is generally in good decorative order throughout. There has been new flooring added in the kitchen. The kitchen table needs replacing and the Inspector noted that the maintenance log was not always used to record repairs needed. Some 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. Storage of wheelchairs and equipment can also be a problem. Service Users rooms are all well decorated and personalised. The home has a suitable separate laundry room with appropriate appliances. The home is clean and tidy throughout. BLUECOATS Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34and 35 The home is still has vacancies for support staff and a Manager. There is a core of experienced staff in the home who have sound knowledge of the Service Users. The home still relies on bank and agency but recognise the need for consistent staff in the home. Recruitment processes are robust Training is ongoing and related to the needs of the Service Users. EVIDENCE: Staffing levels are still low in respect of permanent staff, the home has undertaken some recruitment recently and hopes to fill the vacancies. Some staff have been newly recruited. The Area Manager informed the Inspector that 4 of the 8 permanent staff are also off on sick leave currently (some long term) The home currently has an acting Manager who is also the Area Manager. The home needs to recruit a permanent Manager. The home has admitted a new Service User and the staffing review previously required has not yet been completed. Records for the most recently recruited member of staff were seen. These were detailed and included; an application form, interview details, completed CRB and POVA checks, copies of relevant documents required. BLUECOATS Version 1.10 Page 17 Training profiles are in place for staff and detail training attended and training required. Copies of certificates were seen on file also. A programme of training was detailed on the notice board with the names of staff to attend. BLUECOATS Version 1.10 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 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) 37,39,40, 41 and 42. The home needs a permanent Manager in place to ensure consistency and clear direction. The organisation and the home are working hard to gain Service Users and parent and families views about the quality and development of the service. The home has detailed policies and procedures in place; these need to be in an accessible format at all times. Health and safety checks are in place. EVIDENCE: The Area Manager is currently managing the service and informed the Inspector they are actively seeking to recruit a Manager. This was a requirement at the previous inspection. The home has had several Manager changes, staff and Service Users would benefit from stability in management. The Area Manager informed the Inspector that the organisation has developed a variety of forums and training days parents have been involved in some and Service Users and staff. The staff and Service Users have developed a “path” which is a working document on display in the home. This details a variety of BLUECOATS Version 1.10 Page 19 area to be worked on and includes aspirations, plans and time targets. The home also has a development plan for 2005/6. This was a detailed plan and was well written and linked with the “path”. Detailed policies and procedures are available in the home. Some are in a file and others are stored on the computer. A recommendation was made that all the availability of policies at all times was considered; this has not yet been completed. Records examined in the home were not always consistent and although there has been some improvement this area still needs to be worked on. Health and Safety records were examined including, water, fridge and freezer temperature recording. Records of fire drills, evacuations and testing of equipment were up to date. Servicing of gas, electrical and hoist equipment was detailed and up to date. Regular health and safety checks are undertaken in the home. Some old health and safety records need to be removed if no longer in use to avoid confusion in records. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 BLUECOATS Score x Standard No 22 Version 1.10 Score 3 Page 20 2 3 4 5 3 x x 3 23 ENVIRONMENT 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 2 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 2 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 x x Standard No 37 38 39 40 41 42 43 Score 2 x 3 2 2 3 x BLUECOATS Version 1.10 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 14&15 Requirement That Service User plans contain additional information regarding implementation and are consistant in detail.(Previous timescale of 31/01/05 not met) That all risk assesments are reviewed and updated to reflect current needs..(Previous timescale of 31/01/05 not met) Records in respect of personal care are more detailed in respect of implementation..(Previous timescale of 31/01/05 not met) That Healthcare records are organised and well maintained..(Previous timescale of 31/01/05 not met) That a written review is undertaken in respect of the communal space available taking Service Users current and future needs into consideration. Carry out a review of staffing levels in the home and inform C.C.S.I in writing, including actions to address permanent staffing levels.(Previous timescale of 31/01/05 not met) The organisation recruits a permanent Manager for the home.C.S.C.I to be kept Version 1.10 Timescale for action 31/07/05 2. 9 13 (4) 31/07/05 3. 18 12&13 31/07/05 4. 19 17 31/07/05 5. 28 23(2a) 30/09/05 6. 33 12&18 31/07/05 7. 37 8&9 30/09/05 BLUECOATS Page 22 informed of progress. 8. 41 17 Ensure ALL records are well maintained and organised..(Previous timescale of 31/01/05 not met) 30/09/05 9. 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 24 40 Good Practice Recommendations Ensure all maintainance issues are recorded in the maintainance log to ensure they are attended to. The organisation considers the availability of policies that are currently stored on the organisations intranet. BLUECOATS Version 1.10 Page 23 Commission for Social Care Inspection 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 BLUECOATS Version 1.10 Page 24 - 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. 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