Inspection on 05/03/07 for Chace Dene

This inspection was carried out on 5th March 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chace Dene 16/02/06

Chace Dene 06/09/05

Chace Dene 08/02/05

Chace Dene 12/10/04

Chace Dene 22/01/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Chace Dene 4 Heath Road Southend Bradfield Berkshire RG7 6HQ Lead Inspector Sally Newman Unannounced Inspection 5 March 2007 08:55 th DS0000011180.V328751.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 DS0000011180.V328751.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. DS0000011180.V328751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chace Dene Address 4 Heath Road Southend Bradfield Berkshire RG7 6HQ 0118 974 5062 0118 974 5074 geth.davies@atlas.plus.com 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) Atlas Project Team Limited ***Post Vacant*** Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000011180.V328751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 Brief Description of the Service: Atlas Project Team Ltd are the registered provider for Chase Dene, and provide care and accommodation for three young adults aged 18 to 65, who have a learning disability with associated challenging behaviour. Chase Dene is an extended detached three-bedroom bungalow. The home has a large garden with table and seating provided. Chase Dene is situated within a semi-rural residential area within the village of Southend Bradfield. Limited off-road parking is available at the front of the house and village shops are within walking distance. The towns of Newbury and Reading are within a 20 to 30 minute drive from the home. Fees for this service range from £1700.84 to £2003.72. DS0000011180.V328751.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted over the course of three days and included a visit to the service of 4 ½ hours duration. The inspector was ably assisted by the manager who was working on shift in the home when the inspector arrived. Three area managers arrived shortly after the commencement of the visit in order to provide support to the manager, however, one of the three left soon after arrival. Staff and service users were spoken with and a range of records was seen. In addition a tour of the communal areas, the garden and two bedrooms were seen. Information held by the Commission and a completed questionnaire provided by the service was used in the completion of this report. A range of surveys was sent and one was completed and returned by a professional visitor to the service. The results of this survey provided positive responses in relation to the home. This service provides a high quality of care for the service users where their needs and preferences are the driving force in the home. Care plans, risk assessments and the personal support provided to individuals was considered to be excellent. There were no outcomes where significant shortfalls were found. One requirement was made in respect of consultation with the Fire Authority to seek guidance specifically in relation to the fire doors in the home. The provider has a range of polices and procedures relating to equality and diversity. Care plans have been designed to take account of individual needs and cultural and religious choices. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service that meets the needs of individuals of various religious, racial or cultural needs. What the service does well: Provides a high quality of care for the service users. DS0000011180.V328751.R01.S.doc Version 5.2 Page 6 There is a consistent and dedicated staff team who are knowledgeable and sensitive to service users needs. Staff training is of a good standard and includes induction that is specific to the home. Staff support throughout the organisation is good. The home is particularly competent and skilled at addressing challenging behaviours. What has improved since the last inspection? What they could do better: The home will need to consolidate improvements and maintain the high standards. Continue to promote independence. DS0000011180.V328751.R01.S.doc Version 5.2 Page 7 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. DS0000011180.V328751.R01.S.doc Version 5.2 Page 8 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 DS0000011180.V328751.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users would have their individual aspirations and needs assessed prior to a service being offered. EVIDENCE: There have been no new admissions to the home since the last inspection. However, the organisation have policies and procedures in place which provide comprehensive guidance to ensure that a thorough assessment of needs is undertaken prior to a place being offered to a new service user. DS0000011180.V328751.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans are completed to a high standard and clearly reflect the changing needs of service users. Service users are supported to make decisions for themselves and to take managed risks where appropriate. EVIDENCE: Evidence was obtained from perusal of two care plans, a range of risk assessments together with supporting documentation. Discussion was held with the manager, senior managers and staff and observations were made of interactions between staff and service users throughout the course of the visit. Care plans contained comprehensive but concisely presented information which provided the reader with a clear overview of the individuals’ needs. Goal setting is undertaken on a regular basis together with the service user where appropriate. Goals are closely monitored and adjusted where necessary. Daily records contained detailed information, which clearly stated what the service DS0000011180.V328751.R01.S.doc Version 5.2 Page 11 user had done and how they had been. There was clear information regarding the interventions to be adopted for a service user who on occasions challenged the service. In consultation with behavioural specialists and a closely monitored programme of interventions the number of incidents involving this individual had greatly reduced over the pre-ceding six months. There was sound evidence that comprehensive reviews are undertaken at least annually and include relatives and the purchasers of the service. In addition, internal reviews are held between the key worker and the manager on a regular basis. The inspector was advised that it is the responsibility of key workers to ensure that documentation is kept up to date. This is monitored by the manager. All documentation seen was clearly dated and appropriately completed. It was apparent from all the evidence obtained that the care plans within this home are working documents which support the service provided to the individuals living there and were of a high standard. It was apparent from discussions held with the manager and staff and from observations undertaken during the visit that service users in this home are supported to make decisions for themselves wherever possible. Examples where individuals could not make appropriate decisions for themselves were provided and written evidence was seen within care plans. One example involved a service user who smoked and needed support to restrict this activity to an acceptable level in the interests of their own health and wellbeing. The home adopts a healthy approach to risks where they are viewed as essential to development but must be assessed and appropriately managed. There were comprehensive risk assessments contained within the care plans seen which were individually focussed and were reviewed on a regular basis. An example provided involved a service user who had recommenced car travel with a reduction of staff from two to one. Although in the early stages this was proving to be successful. DS0000011180.V328751.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to participate in appropriate activities, the local community and maintain personal and family relationships. Service users are respected and are offered a healthy and enjoyable diet. EVIDENCE: Discussion was held with the manager and a range of documentation was seen including care plans and information provided by the service prior to the visit. Each service user has an individually tailored programme of activities some of which are planned and regular such as day centre attendance, cooking and computer sessions. In addition, all service users receive aromatherapy sessions conducted within the home by a visiting professional and staff provide stimulation through arts and crafts and game sessions. Spontaneous activities also occur such as pub and cinema trips, rambling and sports centre visits. All service users are able to attend a holiday each year which meets their individual needs and there was evidence within documentation seen that plans DS0000011180.V328751.R01.S.doc Version 5.2 Page 13 were being made for later this year. All activities are designed to take account of service users’ educational and recreational needs and are provided both within the home and outside to ensure participation in the community. Those service users who have contact with relatives are supported to visit them on a regular basis and to receive visitors into the home. It was apparent from discussion with service users, from observation by the inspector and from a range of records that the rights of service users are upheld. Service user’s responsibilities are also understood and encouraged through support with domestic duties and behaviour. There has been a change in the provision of food since the last inspection. Service users can choose breakfast and lunch and then plan evening meal menus from a range of healthy recipes. All main meals are made from fresh produce and service users are supported to participate. The result of this change has meant that all three service users have lost a considerable amount of weight and their health has improved as a result. DS0000011180.V328751.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users personal support, physical and emotional health needs are met to a high standard. Arrangements for medication are robust and protect service users. EVIDENCE: Evidence was obtained from discussion with the manager, staff and senior managers. Care plans and associated documentation was seen. The inspector observed interactions and practice during the course of the visit. Personal support is provided according to service users’ preferences, which are clearly documented in care plans. Bedtimes, baths and meals are flexible and the inspector observed that one service user liked a gradual start to the day, which included a leisurely bath. These particular preferences were well understood by staff and adhered to. There were communication tools in evidence that were particular to individuals. It was reported that implementation of these aids had impacted positively on service users DS0000011180.V328751.R01.S.doc Version 5.2 Page 15 confidence and in conjunction with other intervention techniques had reduced the incidence of challenging behaviour overall. There was comprehensive evidence within care plans and from discussion with the manager that consultation with a range of health care professionals is instigated by the home to ensure that service users’ health care needs are met. Staff know service users so well that any signs of distress or illness are acted upon and medical intervention is sought without delay. All service users received regular checks with dentists, audiologists, speech and language therapists and psychiatrists where appropriate. The morning medication administration routine was observed. This is always undertaken by two staff and on this occasion involved the manager and a support worker. Interruptions by service users was well managed to ensure that appropriate attention was paid to the task. All medications are double signed for following administration and each stage of the process is shared between the two staff. The storage arrangements were seen and were considered to be appropriate. It was noted that some medications not currently being used were being stored in case they were required. The inspector understood that swift access to these medications might be needed. However, the manager is invited to consider whether the amount currently held is either required or appropriate. DS0000011180.V328751.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): 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. Service users are protected from abuse, neglect and self-harm. EVIDENCE: There is a robust complaints policy and procedure, which is provided to service users in a readable format. Information provided by the service and confirmed in the complaints record stated that three complaints had been made about the service since the last inspection. These complaints were from neighbours and in two cases involved inappropriate parking by staff. Appropriate action was taken and the outcomes were accepted by the complainants. No complaints have been received by the Commission about the service since the last inspection. The organisation has an internal policy to guide staff in the event of an allegation or suspicion of abuse. Following discussion with senior managers present during the visit the organisation are invited to consider whether the process is sufficiently clear to all levels of staff to ensure that the appropriate authorities are informed at an suitably early stage. The manager produced an up to date copy of the inter-agency procedures for protecting vulnerable adults and confirmed that she had attended training. The manager confirmed that all staff are expected to attend training which is currently provided by West Berkshire Council. DS0000011180.V328751.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service provides a safe and homely environment for service users and is maintained in a clean and hygienic manner. EVIDENCE: A tour of the premises was undertaken and included the communal areas of the home, the garden and two service users bedrooms. The manager confirmed that all rooms within the home had been redecorated and two windows had been replaced. Throughout the home was decorated and furnished in a homely fashion and provided comfortable accommodation for the service users. Both bedrooms seen had been decorated and furnished with the occupants tastes and needs in mind. Outside the garden area provided space for relaxation, there was a pond and the manager advised that an area was being prepared for growing vegetables. The maintenance record demonstrated DS0000011180.V328751.R01.S.doc Version 5.2 Page 18 that repairs are reported promptly and the inspector was advised that the new landlord had proved to be efficient when addressing maintenance issues. Though out the home was clean and tidy. The kitchen and laundry areas were well organised. A legionella audit had been commissioned by an outside contractor and a range of checks had been implemented by the manager as a result of the findings. DS0000011180.V328751.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a competent and qualified staff team and they are protected by the home’s recruitment procedures. Service users’ needs are met by well trained staff. EVIDENCE: The files for the two most recently recruited staff were seen. Discussion was held with the manager and staff. The training record and supervision plan were seen. Observations undertaken throughout the course of the visit confirmed that staff are competent in their roles and it was apparent that they understood the needs of service users. The staff spoken to felt well supported and valued. Of the nine staff currently working in the home five have already achieved an NVQ qualification. Two staff files were seen and were used to test the recruitment procedures operating in the home. All staff files are kept in a locked cabinet to which only the manager and senior managers have access. All required documentation DS0000011180.V328751.R01.S.doc Version 5.2 Page 20 was in evidence and in addition it was noted that recruitment checklists, which monitor the process and detailed interview records were used. Copies of the General Social Care Council codes of conduct, supervision records and staffs own notes were kept on a separate file which was accessible to staff. The home has a training and development plan which is kept on the wall of the office. This is used to identify when staff need to attend refresher training and provides an overview of all training undertaken by the staff team. The organisation has a dedicated training co-ordinator who assists managers in accessing training for their staff. It was noted from information provided by the home prior to the visit that planned training includes fire, 1st aid, health & safety, food hygiene, SCIP, learning disability award, communication and protection of vulnerable adults. The NVQ programme will also continue with additional staff commencing this year. DS0000011180.V328751.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home which is run in their best interests. Service users are protected by the health, safety and welfare practices of the home. EVIDENCE: The manager was appointed in June 2006 and is currently part way through NVQ 4 training. She has applied for registration and is awaiting the outcome of the process. It was clear from evidence obtained throughout the inspection process that she has made a positive impact on the home and has the service users needs and interests at the forefront of thinking. DS0000011180.V328751.R01.S.doc Version 5.2 Page 22 Although the home does not have formal service user meetings their views are actively sought through a variety of forums. The formal care plan review process is used to identify the wishes and needs of service users and these are in turn reviewed internally on a regular basis. A key worker system operates in the home where individual staff take overall responsibility to ensure that each service user has their needs met and their views and preferences taken account of. There are also staff meetings approximately every two weeks where all aspects of each service users needs is discussed. The health and safety systems operating in the home are robust. Evidence was obtained from information provided in a questionnaire by the home, from a range of records seen during the course of the visit and from discussion with the manager. The home is subject to an external health and safety audit on an annual basis. The last report contained three recommendations, which the manager confirmed had been addressed. There is a fire risk assessment for the home and arrange of regular checks are undertaken on fire safety equipment and regular fire drills are arranged. During the tour of the premises the inspector noticed that some fire doors did not have intumecent strips that reduce the risks of smoke inhalation. The home will therefore be required to consult with the Fire Authority for appropriate guidance. The inspector was informed that the fitting of hold open devices was awaited for the two lounge doors and it was further confirmed that these are kept closed at night. Records were seen for water temperature checks and fridge and freezer temperature checks. A food safety inspection was undertaken by the Environmental Health dept in August 2006 where two recommendations were made. The manager confirmed that these were addressed without delay. All records seen were kept up to date. DS0000011180.V328751.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 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 4 3 X 4 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 4 3 3 X 3 X 3 X X 3 X DS0000011180.V328751.R01.S.doc Version 5.2 Page 24 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. 1 Standard YA42 Regulation 23 (4) Timescale for action To consult with the Fire Authority 31/03/07 to ensure that the fire precautions are adequate in the home. Requirement 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 DS0000011180.V328751.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 DS0000011180.V328751.R01.S.doc Version 5.2 Page 26 - 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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