Inspection on 03/01/07 for Bushey Hall Road (31)

This inspection was carried out on 3rd January 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

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Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 31 Bushey Hall Road Bushey Herts WD23 2EE Lead Inspector Jeffrey Orange Unannounced Inspection 3rd January 2007 08:15 31 Bushey Hall Road DS0000068401.V325658.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 31 Bushey Hall Road DS0000068401.V325658.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. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 31 Bushey Hall Road Address Bushey Herts WD23 2EE 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) TBC www.caremanagementgroup.com Care Management Group Limited Miss Beth Kahuri Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection This is the first inspection for this service. Brief Description of the Service: 31 Bushey Hall Road is one of a pair of semi-detached houses that have both been converted and adapted for use as residential care homes. Both homes are owned and operated by Care Management Group Limited and currently have the same manager, they are each registered to provide care and accommodation for up to five adults between the ages of 18 and 65 who have a learning disability. The homes are situated in a residential area of Bushey, within easy reach of Watford town centre with its facilities and services and with good local public transport links. There is limited parking available at the front of these homes, on street parking may be available in adjacent roads, subject to local parking conditions. Each house has three floors, with one bedroom on the ground floor together with an office, communal toilet, laundry, kitchen, lounge and dining room; The other bedrooms are located on the first and second floors. All bedrooms are ensuite. The home has a Statement of Purpose and Service User’s Guide that give contact details for the Commission for Social Care Inspection. Current (January 2007) fee levels for the home are approximately £1886 per week for care and accommodation. Additional charges apply for personal toiletries, newspapers and hairdressing, and also for chiropody, dentistry and opticians’ services where these are not available free or subsidised under the NHS. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted in conjunction with that for 29 Bushey Hall Road and took place over a site visit of seven hours, which provided an opportunity to talk with and observe those service users who are now resident, to talk to the joint home manager and a member of the regional management team, together with other members of the staff team present. Key records were also inspected, including those for the administration of medication and the recruitment of staff. The service has only recently been commissioned and this inspection also made use of information obtained during the registration process for both the service and the manager. Although the service is not yet fully occupied, it is understood that the process of assessment and placement of service users up to the maximum number permitted is ongoing, and is expected to be completed soon. Once the service has been fully operational for a reasonable period, service users will be contacted again to ask them for feedback on their experience of living there. What the service does well: What has improved since the last inspection? 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 6 This is the first inspection for this service. 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. The summary of this inspection report can be made available in other formats on request. 31 Bushey Hall Road DS0000068401.V325658.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 31 Bushey Hall Road DS0000068401.V325658.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 & 2 Quality in this outcome area is good. There is a very thorough process of assessment in place, which should ensure that only those whose needs can be appropriately met are admitted to the home. Information is provided to prospective service users in a clear and accessible way, which should ensure that they know what to expect of the service and what will be expected of them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prospective service users are provided with the key information they need in a format that they can understand, for example by using pictures and symbols. A comprehensive pre-admission assessment process had been undertaken in respect of service users who have recently moved into the home. This should ensure that their needs are well understood by those caring for them. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 9 Records seen were very clearly individually focussed and included the information to enable staff to provide care in a way that takes account of service users wishes, aspirations and preferences. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6 7 9 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Care is provided in a way that recognises each service user as an individual. Care needs are recorded and reviewed with the involvement of the service user. Service users are supported to take risks within a robust risk assessment framework, this recognises that taking reasonable risks, having identified and assessed them, is part of developing an independent lifestyle. EVIDENCE: Care plans seen included “Pen Portraits” and “Life Pictures” together with an induction questionnaire and overview of activities. A comprehensive system of risk assessments was seen to be in place within care plan documentation. These were individual to the specific service user and were used to find ways to encourage and enable service users to achieve their 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 11 personal goals and wishes. rather than to dissuade and prevent them from doing so. For example one service user is something of an expert in bus routes and timetables and enjoys taking unaccompanied trips on local buses. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 13 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to access community activities and facilities and to build and maintain social and family contacts. Service users are involved in decision-making about their care and accommodation, including menus and arrangements for meals. EVIDENCE: At the start of this inspection some service users were having breakfast and they were seen to be exercising choice both about what they would have and where and when they would have it. Weekly menus were seen to be prominently displayed in the dining area of the home. Care plan documentation includes details of a range of activities arranged with service users, in line with their preference, goals and interests. These include for example day centres, swimming and trips to local shops. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 13 The involvement of families, where this is in line with the wishes of service users, is recorded in care plans. This can include for example, visits home and holidays with families. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 19 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a genuine focus in this service on the individual service user, their health and social care needs and how they can be met in a way that reflects their individual preference and wishes. Service users have access to the health services that they require in order to maintain their physical and psychological wellbeing. The process of recording medication requires closer monitoring and an improvement in practice in order to ensure service users are properly protected. EVIDENCE: The way that care was seen to be given and the person-centred nature of care plan and other documentation seen, demonstrates a commitment to meet service users’ care needs in an way that respects their individuality. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 15 Service user records include evidence of the involvement of a range of health care professionals, including details of appointments for community health services. Medication records checked were not always accurate so that reconciliation of actual medication amounts against administration records was not always possible. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ views are actively sought and acted upon where that is possible. There is a comprehensive complaints procedure that is provided in a format that should ensure that service users can make any concerns or complaints known. Policies procedures and training for staff is in place that should ensure service users are properly protected from actual or potential abuse. EVIDENCE: Records were available of quality reviews undertaken and feedback received from service users. Policies and procedures are in place in respect of the prevention of abuse and copies of the Hertfordshire County Council policy is displayed. Staff training records seen evidence that training is in place to ensure that staff know what constitutes abuse, how it may be recognised and what to do if it is seen or suspected. 31 Bushey Hall Road DS0000068401.V325658.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. As newly commissioned premises, the overall standard of décor and furnishings is good and provides a pleasant environment for both service users and staff. There is pressure on storage space, which is being investigated to see if it can be improved. EVIDENCE: The overall standard of décor, furnishing and cleanliness was good and there were no obvious problems with odour on the day of the inspection. The central heating was not working following flooding, auxiliary heating was however in place and the hot water supply was not affected. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 18 31 Bushey Hall Road DS0000068401.V325658.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32 34 35 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a robust recruitment process, including appropriate checks, which should give service users confidence in the suitability of those employed to care for them. Staffing numbers appear to be adequate to provide appropriately for the care of the existing service user group and the standard of care observed was good. Staff supervision is good and basic training is adequate, however there was insufficient evidence to show that the specific training in learning disability provided for staff is adequate. EVIDENCE: Although routine basic training has been provided, those records seen and members of staff spoken to did not provide evidence that the staff team as a whole have received specific training in learning disability at an appropriate level. “ I am learning as I go along” was one comment made. Specific accredited training is particularly necessary as many of the the service user 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 20 group have very complex needs and this service is identified as being specifically for service users with a learning disability. Those members of the staff team spoken to felt that they received a good level of support and those supervision schedules seen provide good evidence that regular staff supervision takes place. New members of staff were keen to enrol on NVQ courses and it is understood from the manager that this is being planned to commence this year. 31 Bushey Hall Road DS0000068401.V325658.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37 38 39 42 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ views are key to the operation of this home and their health, safety and welfare are actively promoted and protected by staff working within a well-developed system of risk assessment and associated policies and procedures. There are currently some significant areas where local and regional management appear to disagree. This is unsettling for the management and staff team and could potentially indirectly affect service users. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 22 EVIDENCE: Staff spoken to, records seen and service user comments and feedback all provide evidence that service users care needs, goals, safety and welfare are reviewed and taken into account in the running of the home. Conversations with local and regional management brought to light some significant divergence in understanding of recent events and the action taken as a result. The professionalism and good-will of all parties will hopefully enable this to be quickly resolved, as it must be, in order to prevent any potential adverse affect for the service users and staff team. 31 Bushey Hall Road DS0000068401.V325658.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 2 3 4 5 CONCERNS AND COMPLAINTS Standard No Score 22 23 3 3 X X X 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X 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 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000068401.V325658.R01.S.doc LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 31 Bushey Hall Road Score 3 3 2 X 2 2 3 X X 3 2 Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13(2) Requirement The manager must review practice for the monitoring of medication records to ensure that accurate reconciliation of amounts against records is possible at all times. The registered person must ensure that all staff receive appropriate level, accredited training, specifically in respect of the homes’ principal service user group, to enable them to understand and meet their care needs effectively. The registered person must notify the Commission if the manager is likely to be absent from the home for a continuous period of 28 days or more. Shorter, but significant absences should be notified under regulation 37 (section e) Timescale for action 03/01/07 2 YA32 18(1)(c) 03/01/07 3 YA38 38 (1) 03/01/07 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations A review of the storage needs of the home should be undertaken and appropriate action taken as indicated by that review. 31 Bushey Hall Road DS0000068401.V325658.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 31 Bushey Hall Road DS0000068401.V325658.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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