Inspection on 12/04/05 for Chaffinches, St Anne`s Opportunity Centre,

This inspection was carried out on 12th 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 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

Chaffinches, St Anne`s... 18/04/07

Chaffinches, St Anne`s... 12/09/05

Chaffinches, St Anne`s... 02/02/05

Chaffinches, St Anne`s... 11/11/04

Chaffinches, St Anne`s... 17/03/04

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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 CHAFFINCHES St Annes Opportunity Centre 108 Paynesdown Road Thatcham Berks, RG19 3TE Lead Inspector Tracy McGuire-Brown Unannounced 12 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. CHAFFINCHES Version 1.10 Page 3 SERVICE INFORMATION Name of service Chaffinches, St Annes Opportunity Centre Address 108 Paynesdown Road, Thatcham, Berks RG19 3TE 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) 01635 874836 St Annes Opportunit Centre Limited Mrs Samantha Chengun Care Home 3 Category(ies) of Learning Disability registration, with number of places CHAFFINCHES Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: No Date of last inspection 2/02/05 Brief Description of the Service: Chaffinches is a small residential home, established in 1993, offering support to three service users with complex emotional needs and moderate learning difficulties. The Service are aged between 18 and 65. The home is one of four small homes with a similar purpose, run by St. Anne’s Opportunity Centre Limited, a West Berkshire based care provider. It is a semi-detached house situated in a cul-de-sac, which leads to entrances to the local primary school, on the borders of Thatcham and Newbury.The purpose of the company is to facilitate the development of the individual to attain independent living skills and management of behaviour that can be challenging. CHAFFINCHES 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 a 4-hour period. The Inspector spent some time being shown around the home by residents. The Inspector spoke to all of the residents who live at the home. Time was also spent talking to the agency staff member on duty and the Manager. A selection of records were looked at including residents files. What the service does well: What has improved since the last inspection? What they could do better: CHAFFINCHES Version 1.10 Page 6 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. CHAFFINCHES Version 1.10 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 Standards Statutory Requirements Identified During the Inspection CHAFFINCHES Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The home gains detailed assessment information and had a clear satisfactory admissions process. EVIDENCE: There have been no recent admission to the home. Individual Service User records were examined, historical assessment information was available. This assessment material was tracked and is regularly reviewed and updated. Examples of Care Management and other social and healthcare assessments were also on file. One Service User spoken to informed the Inspector of the process involved if they wanted to move on from the home, this included assessment and introductory visits. CHAFFINCHES Version 1.10 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,and 10 Service Users have detailed individual care plans and are involved as possible in decision making. Care plans are reviewed Service Users are continually consulted and make decisions about their lives and life within the home. Service Users have risk assessments in place to support care plans. Service Users information is handled appropriately and in confidence. Service Users have a sound understanding of confidentiality. EVIDENCE: Comprehensive care plans are place for each individual Service Users. Care plans are reviewed and are signed by Service Users. Service User meeting records and individual files demonstrate how Service Users are involved in making decisions about their lives and life within the home. Service Users have the opportunity to have an advocate if required. One Service User in the home benefits from the input of an advocate. Service Users have guidelines in place and examples of “contracts” were seen to assist Service Users to make decisions. CHAFFINCHES Version 1.10 Page 10 Risk assessments are in place to ensure Service Users safety, these are reviewed on a regular basis and Service Users are consulted. Riske assessments are developed alongside and support the care plans in place. The home has a detailed policy in place in respect of record keeping, confidentiality and data protection. A copy of this is also available in each individual Service User file. Staff and Service Users demonstrated sound knowledge of issues of confidentiality when speaking to the Inspector. CHAFFINCHES Version 1.10 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15,16 and 17. Service Users in the home take part in a range of appropriate daily activities including work and educational opportunities. Service Users utilise the local community and have varied and extensive leisure activities. Service Users are supported to maintain appropriate relationships. Service Users in the home are aware of their rights and are supported to exercise these in all aspects of their daily lives. Service Users have varied and well balanced meal and make independent choices. EVIDENCE: Daily diaries and individual activity sheets in detail that the Service Users undertake a variety of day opportunities including; attendance at college courses and various local employment options. In addition Service User informed the Inspector they visit the local community shops, pubs and restaurants, use the library and local G.P. and dentist facilities. This was evident in Service User files and in the “report books.” Service Users make use of public transport if appropriate and access local shops on a regular basis. CHAFFINCHES Version 1.10 Page 12 Service User meeting are held on a regular basis and minutes are recorded, these demonstrate how Service Users are involved in deciding and discussing various issues including the day to day running of the house, group and individual holidays and outings. The Inspector saw rotas, which are in place for a variety of “house jobs” and cooking. Daily records and Service User file indicate that Service Users are supported to develop and maintain relationships with family and friends. Service Users were seen spending time together and alone in their room if chosen, privacy is respected. Service Users have chosen not to have locks but have chains fitted to their doors, full risk assessment are in place to support this. The Inspector spoke to staff and Service Users about concern in respect of chains and the home has agreed to review this and detail this in writing. Menus are developed both individually and as a group A Service User explained to the Inspector that they choose to eat together as a group generally at weekends, other days they eat individually. Menus seen are varied and well balanced and include meals out and takeaway options. Service Users were seen to prepare and enjoy lunch. Service User can make drinks and snacks if they choose. The Inspector was made welcome and offered drinks by the Service Users. CHAFFINCHES Version 1.10 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,and 20 The physical and emotional well being of the Service Users is of prime consideration and importance and these needs are well met. Medication is dealt with in a satisfactory manner. EVIDENCE: In addition to extensive care and assessment detail there is also a “healthcare profile” in place on each individual file. Care plans detail how any preferences in respect of the delivery of any care and support needs. Historical social, emotional and physical assessments are on file also. Regular healthcare appointments and any required assessments are detailed on Service Users individual files. The Manager informed the Inspector that there had been some changes made to the recording of medication administration since the previous inspection. Records seen were satisfactory. The home is due to arrange a visit with the C.S.C.I pharmacy Inspector this month to review and discuss general medication issues and seek advice if required. Some Service Users in the home self-medicate and their medication is stored securely and appropriately in their rooms. Staff have received medication training from the local college. CHAFFINCHES 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) 22and 23 The home has satisfactory complaints procedures and protects Service Users from abuse. EVIDENCE: The home has a satisfactory complaints process in place and a log for recording complaints. No complaints have been recorded recently. The Service Users in the home spoke to the Inspector and had sound knowledge of whom they could complain to if they were not happy. The home has a detailed policy in respect of the protection of Vulnerable Adults and policies are detailed taken Service Users rights and issues of confidentiality into careful consideration. CHAFFINCHES 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) 24,25,26,27,28,29, and 30 The home is safe and comfortable with a homely feel. Service Users have single bedrooms and there are suitable bathroom facilities. Internally the home is well maintained and is clean and tidy throughout. EVIDENCE: The home is well presented internally; the home is decorated and furnished to a good standard. The external entrance porch is in need of some redecoration. Service Users have single bedrooms, which are decorated and personalised to reflect the personality of the individual Service User. One Service Users spoken to informed the Inspector “I really like my room, I am very happy living here” The home had a nicely decorated bathroom with bath/shower and toilet and there is an additional separate toilet downstairs. The home has suitable communal space internally which is well maintained. There is a suitable garden to the rear of the property. There is large separate laundry/utility room. The home was clean and tidy throughout and one Service User was cleaning with relevant support on the day of inspection. CHAFFINCHES 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) EVIDENCE: CHAFFINCHES Version 1.10 Page 17 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 is well managed; there are detailed policies and procedures in place, which are stored securely. Health and Safety is promoted. There is an informal Quality Assurance system in the home. EVIDENCE: The Manager is currently on maternity leave, C.S.C.I have been kept informed of arrangements and a Manager from another home is covering this leave. The Manager, who was on duty on the day of inspection, has relevant qualifications skills and experience. The Manger demonstrated sound knowledge of individual Service Users and issues in the home. The Inspector was informed the home currently seeks views of Service Users, friends and families through Service Users reviews, Service User meetings and regular contact with families. Views of Service Users are recorded in meeting minutes and daily reports and issues raised are linked into the Annual CHAFFINCHES Version 1.10 Page 18 Development plan for the home. The Annual Development plan is currently being updated. Management Audit visits are undertaken and recorded. The home has detailed policies, which are reviewed and updated. Records are well maintained up to date and stored in a secure manner in the sleeping in room. Health and Safety checks are completed on a regular basis and records are kept. Records seen included, fire drill and servicing, water, fridge and freezer temperature recording, electrical, gas, first aid and hazard book. Records seen were up to date. Water temperature records demonstrate that temperatures are still above the recommended 43 degrees Celsius. Risk assessments are in place and assessments of the capabilities and needs of Service Users are in place. The home needs to continue to review and monitor this issue. 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 2 3 CHAFFINCHES Score x 3 x Standard No 22 23 Score x x Version 1.10 Page 19 4 5 x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 4 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 3 3 3 x CHAFFINCHES Version 1.10 Page 20 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 16 42 Good Practice Recommendations The home reviews and informs the C.C.S.I. in writing the arrangements for chains on Sewrvice bedroom doors The home continues to review, monitor and record the records in respect of water temperatures including assessments capabilities and risk assessments. CHAFFINCHES Version 1.10 Page 21 Commission for Social Care Inspection 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 CHAFFINCHES Version 1.10 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!