Inspection on 31/01/06 for Church Road (7)

This inspection was carried out on 31st January 2006.

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 found no outstanding requirements from the previous inspection report, but made 2 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) 17/05/06

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 Unannounced Inspection 31st January 2006 08:45 Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 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.V277808.R01.S.doc Version 5.1 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.V277808.R01.S.doc Version 5.1 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.V277808.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th July 2005 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 appropriately converted to provide accommodation for four adults. 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 Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place early in the morning and provided an opportunity to observe the routine in the home as residents prepared for the day’s activities and to speak with some of the residents. Two residents were taken to the day centre and later on in the morning the remaining residents went for a trip with staff in the home’s new MPV transport. It was possible to speak to the staff on duty about the home, the residents and various issues and concerns that they are facing following changes in day care provision and as the residents become older. The current age range is between 64 and 90 yrs. Some basic records such as medication and resident’s finances were also spot-checked. During this inspection progress with the very few requirements made following the previous inspection of the 8th July 2005 was monitored. Where key standards have already been assessed during that inspection, they were not necessarily assessed again on this occasion. For details you should therefore refer to the report of the inspection of the 8th July 2005. What the service does well: What has improved since the last inspection? What they could do better: There were only some very minor adjustments recommended to practice, principally relating to medication storage and improvements to specific recording of some medication, overall however, as previously noted this is a well run and managed service which provides well for its residents. Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 Page 6 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.V277808.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 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 the following standard(s): The key standard(s) were assessed during the inspection of the 8th July 2005; please refer to the report of that inspection for full details. EVIDENCE: Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 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 the following standard(s): 8 Service users are encouraged and assisted to retain control over their lives within a risk assessment framework that balances their rights as individuals with the duty to ensure they are not exposed to inappropriate or unacceptable levels of risk. (The key standard(s) were assessed during the inspection of the 8th July 2005, please refer to the report of that inspection for full details.) EVIDENCE: The Person Centred Planning process in place includes clear evidence to support service user involvement in the process. It has previously been noted that the manager and staff promote and encourage the involvement of service users in decisions made about their home and their care. Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 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, 14 & 15 The manager and staff have a very good awareness of the changing needs of the home’s residents and ensure that they have a wide range of social, leisure and community activities available to them, in line with their expressed preferences. EVIDENCE: Talking with staff and reading the person centred planning documentation for residents, provided ample evidence that a proactive approach is being taken to respond to the changing needs of residents and to changes in the way that both day care and college based activities are accessed and organised. It was clearly recognised by staff spoken to that there is a need to continue to explore and develop appropriate alternative leisure, social and community activities as well as developing home based activities in line with the individual preferences of the residents. Each of these may have implications for staffing in the home. Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 Page 11 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): 20 The home’s policies and procedures in respect of medication should provide satisfactory safeguards for its residents. Two requirements are made in respect of storage and recording practice of medication, however overall the standard of practice remains good. EVIDENCE: The home has satisfactory policies and procedure in place to support the safe administration, storage and receipt of medicines. All staff receives training before being allowed to administer medication. The home uses the Boots pharmacy service and has a good working relationship with them, including a regular system of checks and audits. Where medication is prescribed with variable dosages, the exact dose administered must be recorded on each occasion, this is not always the case at present. To ensure that all medication is stored at the correct temperature, temperatures of medication storage must in future be monitored and recorded on a regular basis. This is to ensure that medication administered is effective and not been compromised by inappropriate storage. Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 Page 12 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): The key standard(s) were assessed during the inspection of the 8th July 2005, please refer to the report of that inspection for full details. EVIDENCE: Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 Page 13 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): The key standard(s) were assessed during the inspection of the 8th July 2005, please refer to the report of that inspection for full details. EVIDENCE: Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 Page 14 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): 33 The changing needs of service users and relatively recent changes in the way that they relate to one another puts additional pressure on staff, particularly at week-ends or other occasions where staff numbers can sometimes be reduced. EVIDENCE: Daily record notes and individual care plan documentation provide a very good record of recent changes in the relationship between some of the service users. A person centred approach to activities and care is more difficult to sustain if staff numbers only permit group activities outside the home, or service users are restricted to home based activities, during those times when staffing is reduced because of illness, holidays or training. Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 Page 15 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): 41 There is a system of accounting in place, in respect of monies held and administered by the home on behalf of residents, which should protect their interests satisfactorily. Where service users sign records of transactions, this should be done at the earliest opportunity after the transaction. EVIDENCE: A random record was inspected and the balance held agreed. Some recent transactions, undertaken on behalf of one service user, had not been signed by him. Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 Page 16 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 2 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X 2 X X Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 Page 17 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 YA20 Regulation 13(2) Requirement Where medication is prescribed in variable dosages, the exact amount administered must be recorded on each occasion. The storage temperature for medication held in the home must be monitored and recorded to ensure it remains within recommended levels. Timescale for action 31/01/06 2 YA20 13(2) 31/01/06 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 YA33 Good Practice Recommendations The manager should continue to keep staffing levels under review to ensure that they are adequate at all times, including week-ends, to meet the changing needs of service users and to enable the provision of activities on a person centred basis. Service users should sign financial records relating to transactions carried out on their behalf as soon as reasonably possible after the transaction. 2 YA41 Church Road (7) DS0000019322.V277808.R01.S.doc Version 5.1 Page 18 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. 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