Inspection on 18/04/07 for Chaffinches, St Anne`s Opportunity Centre,

This inspection was carried out on 18th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

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

Chaffinches, St Anne`s... 12/04/05

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 Anne`s Opportunity Centre, 108 Paynesdown Road Thatcham Berkshire RG19 3TE Lead Inspector Robert Dawes Unannounced Inspection 18th April 2007 01:30 Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.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 Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.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. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chaffinches, St Anne`s Opportunity Centre, Address 108 Paynesdown Road Thatcham Berkshire RG19 3TE 01635 874836 01635 40862 stannesopportunitycentre@btconnect.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) St Anne`s Opportunity Centre Limited Mrs Samantha Chengun Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2005 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 users are aged between 18 and 65. The home is one of four small homes with a similar purpose, run by St. Annes 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. The current scale of charge ranges from £884.56 to £997.13 per week. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit, which took place during the day on the 18th April 2007. The pre-inspection questionnaire and two service users’ questionnaires were returned to the inspector before the site visit. These, together with the site visit, were the main sources of information for the key inspection. During the site visit the inspector spoke with three service users; interviewed the manager and one member of staff; toured the premises; looked at records; case tracked; and observed the interaction between service users and staff. Twenty-two standards were assessed during the site visit of which eleven were exceeded, ten were met and one was nearly met. One requirement and one recommendation were made. 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. The summary of this inspection report can be made available in other formats on request. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Number 2. People who use the service experience good quality outcomes in this area. There is a clear criteria and procedure regarding the admission of new residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no recent admissions to this home therefore it is not possible to case track whether any new service users have only been admitted following a full assessment. However, the home does have policies and procedures to ensure that this process is completed prior to anyone moving into the home. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 6, 7 and 9. People who use the service experience excellent quality outcomes in this area. The manager believes service users should be able to take control of their lives. This is reflected in the individual plans, which are reviewed at regular intervals; how service users make decisions about their lives; and the level of support they receive to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the service users have detailed and comprehensive person centred care plans that reflect their preferences and what they want to achieve. They are reviewed regularly with the service user, relatives and key professionals and changed whenever the need arises. The weekly service user meeting records and individual files demonstrate how service users are involved in making decisions about their daily lives, i.e. choice of meals, activities, household tasks, colour of their rooms, holidays and clothes. Service users have the opportunity to have an advocate if required. In Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 9 reply to the question in the service user survey ‘do you make decisions about what you do each day?’ both service users replied ‘always’. Service users said ‘they can stay in their rooms or join others downstairs’. The manager believes it is the service users’ home and they should decide how it is run and what they do each day. Service users are encouraged and supported to be as independent as possible and take control of their lives. One service user does a weekly paper round on her own and another service user cycles to work and back on his own, does his own shopping and cooks his own meals. Two service users use public transport and two cycle on their own. All service users have risk assessments to cover potentially risky activities. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 12, 13, 15, 16 and 17. People who use the service experience excellent quality outcomes in this area. People who use the service are able to maintain paid employment and take part in a wide range of appropriate activities which reflect their diverse needs; they participate in the local community and are enabled to keep in touch with their families and friends; their rights are respected and responsibilities recognised in their daily lives; and are offered a healthy diet and enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said they are supported to maintain paid employment, i.e. one service user works four days a week at a local garden centre and another service user delivers a local paper once a week; attend courses at the local college, such as music, art therapy and computer skills; and engage in activities such as swimming, table tennis, bird watching and gardening. They Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 11 are encouraged to pursue their own interests and hobbies; go to the cinema, theatre and sporting events; and belong to local drama groups, churches and walking clubs. They all said ‘they have lots of things to do’. All vote at elections. Each service user has detailed individual plans in respect of work, education and leisure to ensure their diverse needs are addressed and a “strength and needs profile” which has been developed with each service user to identify areas of development. Service users are encouraged and enabled to keep in regular contact with relatives and friends in the community and from other homes. The home has a sexuality (intimate personal relationship) policy. Service users were observed to have unrestricted movement around the home, except other people’s bedrooms. Service users can choose to be alone. Records and observation showed staff consult service users as much as possible about the daily routines to encourage them to feel respected and responsible. The manager asked service users if the inspector could look at their rooms. A very positive and respectful interaction between staff and residents was observed. Service users assist with many of the housekeeping tasks. Service users have chosen not to have locks but have chains fitted to their doors, full risk assessment are in place to support this. In response to the question in the service user questionnaire, ‘can you do what you want to do during the day, evening and week ends?’ both replied ‘yes’. All the service users choose their own meals. One service user shops, prepares and cooks his own meals the other two with assistance. They sometimes eat their meals together and at other times on their own. Menus seen, showed service users have balanced and nutritious meals. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 18, 19 and 20. People who use the service experience excellent quality outcomes in this area. People who use the service receive personal support in the way they prefer and require; and their physical and emotional health needs are well met. Service users administer and control their own medication where appropriate and are protected by the home’s medication procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users are physically independent and require little assistance with personal care. Staff provide guidance and emotional support to enable service users be as independent as possible. In response to the questions in the service users’ questionnaire, ‘do the staff treat you well?’ and do the carers listen and act on what you say?’ both service users replied ‘yes’ to both questions. Service users said ‘they can go to bed and get up when they like’; ‘they like the home’; and ‘I have a lot of support with problems and they get sorted out’. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 13 The service users looked clean and presentable. Staff were observed to respond and care for the service users in a sensitive and professional manner. Care plans detail how any preferences in respect of the delivery of any care and support needs. A “healthcare profile” is in place on each individual file. Records showed service users’ physical and emotional health is monitored. Service users are provided with a considerable amount of emotional support and guidance to manage their every day lives. Behavioural guidelines and coping strategies were evident on the individual files, i.e. one resident had signed a contract to help her manage her obsessions and another had detailed coping strategies to be able to attend a local drama group. Service users are encouraged to voice their feelings and helped to manage their anxieties through activities in the house i.e. art therapy, and music and art at college. All the service users have regular sight and dental checks. Service users have support from specialists such as psychiatrists and dieticians. Two service users have prescribed medication. One service user selfadministers his own medication. He has a medicine cabinet in his room and completes his own administration chart. The manager audits his medication at regular intervals. Another service user administers her own non-prescribed medication. She has a cabinet in her room. No controlled drugs are on the premises. The medication administration records were in order. All the staff have received medication training. Appropriate medication policies and procedures are in place. A pharmacist visits the home once a year to inspect the storage, administration, recording and disposal of the medication. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 22 and 23. People who use the service experience good quality outcomes in this area. People who use the service feel their views are listened to and acted on; and are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints to the home or the Commission have been made since the last inspection. The home has clear complaints procedures in place. In response to the questions in the service users’ questionnaire, ‘do you know who to speak to if you are not happy?’ and ‘do you know how to make a complaint?’ both service users replied, ‘yes’. Service users said they would tell the manager if a member of staff did something they didn’t like. The manager said she encourages the service users to voice their views and concerns. No allegations of abuse have been made to the Commission since the last inspection. A vulnerable adults procedure, a racial harassment policy and a bullying policy are in place. The organisation operates a non-physical intervention policy. None of the service users have been physically challenging but on occasions can become very agitated and distressed. Some of the staff have received ‘breakaway technique training’ and the inspector recommended all staff receive this training. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 15 The home has appropriate policy and procedures for handling service users’ personal money. All the service users manage their own personal money with the assistance of staff. Records are kept and regularly audited. They have their own bank accounts and withdraw money themselves. Staff are prohibited from receiving money or gifts from residents and relatives. Protection of Vulnerable Adults training has been arranged for the six staff who have not received the appropriate training. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 16 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): Numbers 24 and 30. People who use the service experience adequate quality outcomes in this area. The home is comfortable and generally well maintained except for the kitchen, where units and work surfaces need replacing. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is comfortable, homely and well maintained except for the kitchen, where cupboard doors are broken and work surfaces are cracked. The manager said the organisation has requested the company who owns the house to replace the units. One of the bedrooms is under the recommended size. On the day of the inspection the home was clean and hygienic. Service users said the home is kept clean. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 17 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): Numbers 32, 34 and 35. People who use the service experience good quality outcomes in this area. An effective, competent and qualified staff team who receive adequate training support the people who use the service in a caring, respectful and equitable manner. The home operates a thorough recruitment procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff interviewed demonstrated a good understanding of the conditions and needs of the service users. 50 of care staff have a NVQ 2 or above in care. Staff were observed to be patient and relaxed with service users. Comments made to the inspector by service users were, ‘staff are very helpful and kind’ and ‘I like living in the home very much’. In response to the questions in the questionnaire, ‘do the staff treat you well?’ and ‘do the staff listen and act on what you say?’ both service users said ‘always’. Staff recruitment files seen showed the organisation complies with the recruitment procedures. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 18 All new staff undertake an induction training programme and receive training in the key areas of their work. Protection of Vulnerable Adults training has been arranged for the six staff who have not received the appropriate training. Refresher training of key areas of work takes place. As all three service users have very high levels of anxiety which can impact in the way they cope with their daily lives the inspector recommended that staff should receive specific training in this area to improve their understanding and response. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 19 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): Numbers 37, 39 and 42. People who use the service experience excellent quality outcomes in this area. People who use the service benefit from a well run home; their views underpin all self-monitoring, review and development by the home; and their health, safety and welfare are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is qualified, highly competent and experienced to run the home. The manager undertakes periodic training to maintain and update her knowledge and skills. Staff informed the inspector that the manager is supportive and clear in how she wants the service users cared for. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 20 The organisation ensures an effective quality assurance and monitoring system operates in the home through regular staff and service users’ meetings taking place; a representative of the organisation visiting the home every month to inspect the quality of care being delivered; the service users completing an annual satisfaction questionnaire; and the manager encouraging service users to be in charge of their lives and to voice their views about how they want the home to run and change. Records showed all health and safety checks and inspections are up to date and completed as required. Necessary health and safety policies and procedures are in place. All the service users’ files contained appropriate risk assessments and had been reviewed regularly. All the staff have received the necessary health and safety training including first aid. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 21 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 2 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 3 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 X 4 X X 3 X Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 22 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 YA24 Regulation 23 Requirement To replace the kitchen units and work surfaces to make the kitchen safe and hygienic. Timescale for action 31/07/07 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 YA35 Good Practice Recommendations All staff to receive training in ‘breakaway techniques’ and ‘understanding anxiety states in people who have learning disabilities’. Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate 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 Chaffinches, St Anne`s Opportunity Centre, DS0000011176.V331555.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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