Inspection on 17/05/06 for Church Road (7)

This inspection was carried out on 17th May 2006.

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

Other inspections for this house

Church Road (7) 05/07/07

Church Road (7) 31/01/06

Church Road (7) 08/07/05

Church Road (7) 22/02/05

Church Road (7) 11/11/04

Church Road (7) 25/03/04

Church Road (7) 03/10/02

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Church Road (7) 7 Church Road Bengeo Hertford Hertfordshire SG14 3DP Lead Inspector Jeffrey Orange Key Unannounced Inspection 17th May 2006 08:45 Church Road (7) DS0000019322.V295697.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 Church Road (7) DS0000019322.V295697.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. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Road (7) Address 7 Church Road Bengeo Hertford Hertfordshire SG14 3DP 01992 501266 01992 501266 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) www.mencap.org.uk Royal Mencap Society Ms Teresa Acraman Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 31st January 2006 Brief Description of the Service: 7 Church Road is a four bedroom family house, which is situated in a residential area of Bengeo. The house has been converted to provide accommodation for four adults with learning disabilities. The ground floor consists of a bedroom with an en-suite shower, a lounge, kitchen/dining area, WC and a small office. The first floor consists of three single bedrooms, a staff sleeping-in room and bathroom. The rear garden is small but provides enough space to accommodate some garden furniture and a small patio area. The local shops are within walking distance. The county town of Hertford is approximately one mile away and all forms of transport can be easily accessed, the home also has the use of its own transport. The home provides information for prospective service users in an appropriate format for them and copies of the latest report on the home by the Commission for Social Care Inspection (CSCI) are also available. The net monthly cost of a place in the home is £3339.92. This information was provided by the service and is understood to be correct as at the date of this inspection. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been compiled following a visit to the home, during which it was possible to speak to service users, staff and the home’s manager. Some records were checked and the environment was assessed. This report also takes account of any information received about the home since the last inspection in January 2006. The inspector would like to thank service users for welcoming him into their home and for their patience. 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. Church Road (7) DS0000019322.V295697.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 Church Road (7) DS0000019322.V295697.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 245 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home currently has a settled service user group. Any prospective service users’ individual aspirations and needs would be assessed and they would be given opportunities to visit the home and meet the other service users prior to any decision being made as to the suitability of the home for them. Information provided to the service user about the home and its terms is in an appropriate format and should enable them to make an informed choice about whether it is where they would like to live. . EVIDENCE: The home’s Statement of Purpose and other documentation contain the necessary information, in an appropriate format, to enable any prospective service user to make an informed choice about where to live. Care records seen confirm that full assessments of any prospective service users’ needs and aspiration are made, by qualified staff, before they move into the home. This assessment process is also informed by external health and social care professionals, associated with prospective service users. Church Road (7) DS0000019322.V295697.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning, operational routines and any decisions about the home are all focussed upon the individual service users and fully involve them, within a risk assessment process that is essentially empowering and enabling rather than restrictive or limiting. EVIDENCE: All service users have an individual care plan and an allocated key worker to support them in the home. The standard of care plan documentation seen was good. All service users are supported within the Person Centred Planning programme and regular reviews occur to ensure changing needs are continuously assessed and reviewed. The review process was seen to involve a range of professionals as well as the service users themselves. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 9 A robust system of risk assessment was seen to be in place, with a definite emphasis on enabling reasonable and appropriate risks to be taken, rather than unreasonably restricting the lives of service users. Church Road (7) DS0000019322.V295697.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user takes part in a range of activities within the community in line with their expressed wishes and individual requirements. Service users are encouraged and enabled to make and maintain relationships with family and friends. Service users are able to exercise choice in their diet, in line with any specific likes and dislikes, and incorporating any professional advice on their dietary requirements. EVIDENCE: Service users were keen to discuss a forthcoming trip to Blackpool, including going up the tower “to the very top”. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 11 One service user has a pet rabbit called Harry and enjoys outdoor activities including coppicing skills, accessed through the local college. Some service users were going to college and day centres on the day of the inspection whilst others were having a trip into town. Person centred plans provide ample evidence of the involvement of family and friends in the care process, in line with the wishes of service users. Dietary plans, informed by expert advice, form part of individual care plans. Church Road (7) DS0000019322.V295697.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users individual health and social care needs are individually assessed and met, in ways which meet their preferences wherever possible, and with the participation of a range of community health and social care professionals. The home has a robust system for the administration of medication where that is done on behalf of service users. EVIDENCE: Medication records and practice were examined and were found to provided for the safe and appropriate administration and storage of medication on behalf of service users. Care plans include good evidence of the involvement of service users in their health care, together with input from a range of community health and social care professionals. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure is robust and in a suitable format to enable service users to feel that their individual views are listened to. Suitable policies and procedures are in place to ensure service users are protected and safe. EVIDENCE: The home has a comprehensive complaints procedure in place, which details that all complaints are responded to within 28 days. A record is maintained within the home of complaints made, detailing actions and outcomes as necessary. The home has provided this information on audiotape for any service users who find the written word difficult to interpret. All service users have been informed about the complaints procedure, which is also on display within the home. Staff receive training in the recognition of adult abuse and the correct action to take if it is suspected. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 24 27 29 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although comfortable and homely there are some areas of the home that now require action to bring them up to an acceptable standard. It is recognised that some rooms have been refurbished and decorated, however the scope and pace of this process needs to be accelerated. EVIDENCE: The home’s hoist, whilst not currently used, has not been regularly serviced and cannot be used unless it is serviced. There was no towel in the upstairs bathroom during this inspection. The downstairs toilet is not decorated or presented in a suitable or acceptable condition for a domestic setting. There was a dustbin being used as a waste receptacle in the eating area. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 15 The condition of the kitchen units and décor is poor, with handles missing and paper coming off the walls. One service users carpet is badly marked and requires replacement. The standard of cleanliness overall was quite good although hygiene could be compromised for those using the downstairs toilet because of a risk of cross infection from the material used to provide padding to a handrail. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is adequately staffed with a well-trained and experienced staff team, which means that service users needs are met and that they are provided with a good level of person centred care. EVIDENCE: Training and supervision were discussed with those members of staff on duty and with the manager. Training and supervision records were seen and staff and service user interaction was observed. All of these gave positive evidence of a well-supported, skilled and committed staff team. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is well run by the manager and her staff team. The staff team is committed to the full involvement of service users in the review, monitoring and future development of the service. With the exception of the hoist and the downstairs toilet, the health, safety and welfare of service users are promoted and protected. EVIDENCE: Service users spoken to during the inspection were happy with the home and appeared to be relaxed and comfortable. The relationship between the service users and the staff was seen to be very positive, appropriate and supportive. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 18 Service users are involved in the running of the home and participate in decision taken about the home and their care. Records seen supported this judgement. Whilst it is understood that the hoist is not currently in use, it should be either disposed of or serviced so that it could be safely used if required. The downstairs toilet provides some danger of cross-infection with the use of inappropriate material as protective padding. Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 19 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 3 5 3 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 2 28 X 29 2 30 2 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 3 X 3 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 3 3 3 x 3 X 3 X X 3 X Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 20 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 Timescale for action 30/06/06 2 YA27 YA30 23 & 13 3 YA29 23 An audit of the home’s physical environment must be carried out to establish those areas that require attention in order to maintain a satisfactory standard of décor and repair. This must include a timetable for completion of any work identified and a copy must be sent to the CSCI. The downstairs toilet must be 01/06/06 provided with a handrail that does not represent a risk of cross infection to those using it. The hoist must be serviced and 17/05/06 maintained thereafter before it can be used. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations In line with the person centred approach of the home, service users should be encouraged to contribute to the DS0000019322.V295697.R01.S.doc Version 5.2 Page 21 Church Road (7) above audit (see requirement 1). The audit should wherever possible be from the viewpoint of someone who is permanently resident in the home and their preferences, choices and priorities should, wherever possible, be considered in drawing up a list of action. (Subject to the over-riding need to maintain a safe environment) Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Church Road (7) DS0000019322.V295697.R01.S.doc Version 5.2 Page 23 - 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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