Inspection on 06/09/05 for Chace Dene

This inspection was carried out on 6th September 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 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

Chace Dene 05/03/07

Chace Dene 16/02/06

Chace Dene 08/02/05

Chace Dene 12/10/04

Chace Dene 22/01/04

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

CARE HOME ADULTS 18-65 Chacedene 4 Heath Road Southend Bradfield RG7 6HQ Lead Inspector Yvonne Souden Unannounced 6 September 2005 15:30 th 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. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chacedene Address 4 Heath Road Southend Bradfield Berkshire RG7 6HQ 0118 974 5062 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) Atlas Project Team Limited Mr Graham Kenyon Care Home 3 3 PC Category(ies) of Learning Disability LD registration, with number of places Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 8th February 2005 Brief Description of the Service: Atlas Project Team Ltd are the registered provider for Chacedene, and provide care and accommodation for 3 Young Adults aged 18-65, who have a learning disability with associated challenging behaviour. Chacedene is an extended detached three-bedroom bungalow owned by Housing Solutions; the maintenance of the home is undertaken by the landlord as reported to them by the Atlas Project Team. Chacedene is situated within a semi-rural residential road within the village of Southend Bradfield. Off-road parking is available at the front of the house and village shops are within walking distance. The home has a large garden with table and seating provided, and has a garage that accommodates a snooker table for the service users use. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection on a Tuesday afternoon conducted by one Inspector and a Regulation Manager. Discussions with staff and management, observation of the service provided and records viewed demonstrate that staff are knowledgeable about clients needs and are committed to ensuring a good quality of life. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 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 Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 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) 1 & 2 Chacedene has information available to ensure prospective service users can make an informed choice. The three service users have lived in the home for 13 years and their needs are assessed. EVIDENCE: The home has a Statement of Purpose that sets out the homes aims and objectives and philosophy of care, and has a Service Users Guide. Both documents were reviewed July 2005, and the home ensures symbol and picture formats of communication are available throughout the home, thus enabling the service users to make an informed choice about the service provided. The three service users within Chacedene have lived there since 1992 and there has been no new service users admitted in this time. The service users needs are reviewed annually or as changing needs dictate. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 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, 9 Service users changing needs and personal goals are reflected in their individual plan and are enabled to make decisions about their lives within a risk management framework. EVIDENCE: Staff were able to demonstrate that they are aware of the individual needs of the service users. One service user file was inspected and this reflected what staff had described. This file also identified details of reviews of care needs, risk assessments and guidelines on managing behaviour, and other relevant areas of the service users social life. Methods of signs and symbols used within the home demonstrate how individual service user are enabled to make choices, and of how their decisions are supported. A key worker system is in place and service users have two key workers allocated, staff spoken to at the time of inspection stated this worked well as it enabled at least one key worker of the service user to be present most of the time. It is recommended that staff and management review certain records such as ABC and intervention records, with a view to satisfying themselves whether signatures/initials and dates that entries were made would be appropriate. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 9 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, 14 & 16, 17 Service users take part in valued appropriate leisure activities with their peer group and within the local community, and are enabled to choose from a healthy diet. EVIDENCE: The inspectors observed that service users were able to come and go as they pleased, and make full use of the facilities within the home as one service user made coffee and another listened to the radio/CD via headphones. Interaction observed between service users and staff was positive as staff responded to MAKATON signs used, and training records identified staff had received MAKATON training. A service user who enjoys bike rides was accompanied by a staff member to purchase a bike on the day of inspection, and records show that the service user is also a member of the local ramblers group. Further records of activity plans demonstrate that service users are involved in activities outside of the home with their peer group, and within the community, and that the staff Rota accommodates activity plans in place. The Inspector observed a nutritionally balanced menu plan and the preparation of the daily meal. Staff showed the Inspector the procedure used that enables the service users to be involved in planning the weekly menu. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 10 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 & 20 Service users health and social care needs are met as they are supported within their preferred routine. EVIDENCE: Within a risk management framework service users are unable to administer their own medication, therefore staff administer service users medication as prescribed by their GP, and as dispensed by the pharmacist in a monitored dosage system. Medication in stock matched records kept, and training certificates of staff identify completion of drug assessment training. Discussions with staff confirmed in-house medication training takes place in line with the homes medication policy. The key worker system in place ensures consistency and continuity of care, and daily routines are promoted by the use of signs and symbols as service users are enabled to communicate their needs and preferences. Records show that health and social care professionals are informed and involved in meeting the health and social care needs of the service user. A holistic therapist employed by Atlas visited the home on the day of the inspection and was able to demonstrate a good rapport with staff and service users; therapeutic activities provided would include aromatherapy, reflexology and massage. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 11 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) Standards 22 and 23 were not assessed at this inspection. EVIDENCE: Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 12 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 & 30 Chacedene is homely and comfortable and provides a safe environment that needs some attention to enhance the homeliness of the service. EVIDENCE: In 2005 Atlas Project Team Ltd inherited new landlords who are responsible for the maintenance/repair and décor of Atlas homes within Berkshire. The inspectors were informed that management have built good working relationship with the new landlords and have submitted a Tick list of maintenance/repair and décor required to enable the home to meet the environmental standard. Management confirmed that they are awaiting receipt of a maintenance program with timescales from the landlords, and that on receipt they would forward a copy to CSCI to evident action taken to meet the environmental standard. Management informed inspectors that the new landlords respond promptly to requests of maintenance and repair that pose a health and safety risk. Observation at todays inspection showed that the home was homely with no unpleasant odours. The hall walls and doors leading to the various rooms and one service users room was starkly painted and gave a drab appearance, management have confirmed that they have identified these areas within their Tick list. The front garden was observed to be unkempt. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 13 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 & 35 Service users are supported by an effective staff team who are appropriately trained. EVIDENCE: The Inspector viewed service users individual weekly activity plan and staff Rota, and discussed the activity plan and Rota with a staff member. The staff member explained that the staff Rota allows a crossover of staff at various times of the day to enable service users to participate within their chosen plan of activity, and that this would amount to two or three staff on duty at any one time. One waking night staff is on duty from 10 p.m. until 8 a.m. The Rota identified three staff members were scheduled to be on shift at the time of the inspection, but one member of staff had called in sick, this was identified on the Rota with an expected absence of three days; measures had been taken by staff to cover the shortfall. The two staff on shift were relatively new in post, both were enthusiastic about training received to date and of support received from management. Records show that staff receive induction and mandatory/specialist training. One of the staff members spoke of attaining an National Vocational Qualification in care at level 2 and 3. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 14 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 Systems appear to be in place for the running of the care home in the absence of the registered manager, but CSCI have not been informed in writing. EVIDENCE: The inspectors were informed by staff on the day of the inspection that the manager of Chacedene and of another Atlas group home was on sabbatical leave for what may be a minimum period of three months. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chacedene Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x x x H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 16 N/A 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 37 Regulation 38 Requirement Management must inform CSCI in writing, the arrangements which have been made for the running of the care home during the managers absence. Timescale for action 28/09/05 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 6 Good Practice Recommendations Staff and management should review whether they feel it appropriate or necessary to include initials/signatures after certain entries in records, along with the date the entry was made, in order to ensure such entries are made promptly and not too long after incidents. A general tidy and clearance of the weeds should take place, particularly at the front of the house as this would enhance the homeliness of the service. On receipt and as agreed management should forward a copy of the landlords maintenance program that should detail timescales, to CSCI to evident what action is being taken to meet the environmental standard. 2. 24 3. 24 4. Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 17 Chacedene H52-H01 S11180 Chace Dene V236020 060905 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection 2nd Floor, 1015 Arlington Business Park Theale Berkshire RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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