Inspection on 05/07/07 for Church Road (7)

This inspection was carried out on 5th July 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 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

Church Road (7) 17/05/06

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 Unannounced Inspection 5th July 2007 08:45 Church Road (7) DS0000019322.V344812.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.V344812.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.V344812.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 583449 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) H4037@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.V344812.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 17th May 2006 Brief Description of the Service: 7 Church Road is a four bedroom family house 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 £3600. This information was provided by the service and is understood to be correct as at the date of this inspection. Church Road (7) DS0000019322.V344812.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 drawn up following a visit to Church Road during which it was possible to speak to the three people who live in the home together with members of the staff team present. A number of key records were checked and the environment was assessed. This inspection report also makes use of the information provided to the Commission for Social Care Inspection (CSCI) by Church Road in their Annual Quality Assurance Assessment, and any other information that has been received by the CSCI about Church Road since the last inspection in May 2006. What the service does well: What has improved since the last inspection? What they could do better: Plans are understood to be in hand to continue the process of refurbishment and redecoration of the home, which will benefit all those who live and work in the home. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 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.V344812.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 2 4 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good level of information provided for any person considering Church Road as their home. This information is in an appropriate format and includes all the details they will need to be able to make an informed decision about the home and whether they would be happy there. There is a very detailed assessment process in place to make sure that the needs of anybody considering Church Road as their home can be fully met. To make sure that the home is suitable for them and that they will be happy there, people thinking about moving into Church Road can visit the home to meet the people already living there. EVIDENCE: The home’s Statement of Purpose and Service User’s Guide, together with other information seen that is provided by Mencap, is produced in an accessible format for those people living in or considering moving into, Church Road. Care records seen provide evidence that comprehensive assessments are made of prospective residents’ needs and these are informed by the families and external health and social care professionals associated with people being considered to live in Church Road. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 9 Because a vacancy has recently arisen following many years with a settled service user group, this visit and subsequent conversations with the registered manager, provided an opportunity to discuss the issues involved in introducing a new person into a well-established home. These discussions were very positive and demonstrated a highly professional and informed approach on the part of the home’s management team. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 10 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): Standards 6 7 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care planning, operational routines and decisions made about the home are clearly focussed upon people who live in the home and fully involve them. There is a very thorough system of risk assessment in place that is essentially empowering and enabling rather than being restrictive or limiting. EVIDENCE: All people living in the home were seen to have comprehensive individual care plan documentation, which was well completed and up to date. People living in the home each have a key worker to help them and those responsible for them to remain up to date with their care. All people living in the home are supported within the Person Centred Planning Programme. Regular reviews take place to make sure that changing needs are identified and assessed. Documents seen showed that the review process involves not only the person concerned but also the health and social care professionals involved with them. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 11 A robust and comprehensive system of risk assessment was seen to be in place that demonstrated a clear emphasis on enabling reasonable and appropriate risks to be taken, rather than unreasonably restricting the lives of people living in the home. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 12 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): Standards 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. People living in the home are enabled to take part in a range of activities within the community in line with their expressed wishes and individual preferences. People living in the home are encouraged and enabled to make and maintain relationships with family and friends. People living in the home are able to exercise choice over their diet, in line with any specific likes and dislikes and taking appropriate account of any professional advice on their dietary and nutritional requirements. EVIDENCE: One service user was about to go on holiday with his girlfriend to Blackpool, another had visited Camber Sands and another had spent a few days in Norfolk. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 13 One person living in the home went off to day centre during the visit, another was going out with a member of staff to do some shopping and another was having a day off. One person has a rabbit called “Harry” and there was a selection of various artworks on display in the home that had been done by people living in the home. The person centred plans seen include ample evidence of the involvement of family and friends with people living in the home, where this is in line with their wishes. Dietary plans were seen within the individual care planning documentation for people living in the home. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 14 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): Standards 18 19 20 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in Church Road receive effective personal and healthcare support using a personal centred approach, they have care plans that are individual and clearly record their personal and healthcare needs and how they are to be met. Staff are very alert to changes in mood, behaviour and general well being and fully understand how they should respond and take action in order to meet an individual’s needs whilst at the same time ensuring the safety and well being of others living or working in the home. Church Road has an effective medication policy, procedure and guidance, which promotes and protects the health of people living in the home who require assistance with their medication. EVIDENCE: Medication records were checked and spot checks of medication held by the home was made. The good standard found provides for the safe and appropriate administration and storage of medication on behalf of people living in the home. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 15 A community nurse was visiting one person living in the home during this visit and care plans include full details of the involvement of a wide range of healthcare professionals with people living in the home. Care plans seen include excellent evidence in the “My Health” section, of the involvement of people living in the home with their own health care and decisions made about their health. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 16 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): Standards 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a robust complaints procedure in place that is presented in a suitable format to make sure that people living in the home can understand it and how to make use of it. Staff training and the policies and procedures that are in place should ensure that people living in the home are protected and safe and that their individual views are both sought and acted upon. EVIDENCE: The home has a comprehensive complaints procedure in place, and evidence was seen that it is understood and used by people living in the home. Records are kept of complaints made, detailing outcomes and actions taken. This information is available in a range of formats to make sure it is genuinely accessible to all people living in the home. Staff receive training in the recognition of abuse and the correct action to take if it is seen or suspected, in order to safeguard people living and working in the home. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 17 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): Standards 24 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Action has been taken to address previous areas of concern and the home now offers a good standard of accommodation for people living there. It is kept basically clean and safe and offers a homely environment. EVIDENCE: All the requirements made previously have now been addressed. The kitchen has been refurbished, a new bin has been provided, and there is a new shed for storage in the garden. Some bedrooms have already been decorated and others are due to be done during July. The redecoration of other communal areas is included in future schedules discussed with the registered manager. Action has been taken to address any health and safety concerns identified during the last inspection and no additional issues arose from this current visit. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 18 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): Standards 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, supported and experienced staff team. This means that service users needs are met and that they are provided with a high level of person centred care. EVIDENCE: Training and supervision records were seen and members of the staff team were able to discuss these during this visit. Excellent staff and service user interaction was observed, including when staff were defusing a potentially difficult temporary situation. The recruitment policy and practice of the home has previously been found to be comprehensive and robust and this was confirmed in conversation with a recently recruited member of staff. Church Road (7) DS0000019322.V344812.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): Standards 37 39 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered manager has the necessary qualifications and experience and is very competent to ensure that Church Road meets its stated aims and objectives. Staff are trained, supervised and supported in order that they can provide people living in the home with the care they need in the way that they want it provided. Regular and comprehensive quality assurance processes are in place to ensure that the home is operated in the best interests of the people living there and in line with its’ polices and procedures. The health and safety of people living and working in the home is given appropriate priority. Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 20 EVIDENCE: The people living in the home that were spoken to during this visit appeared very at ease in the home and there was a good and appropriate relationship between the staff team and those living in the home. People living in the home are involved in the running of the home, for example in cleaning their own rooms and some of the communal areas on a rota basis. This was observed during this visit. Records of meetings for people living in the home and staff working there were seen. Monthly quality audit returns were seen. These were particularly detailed and thorough and provide confidence that this is a genuine and robust process. The Annual Quality Assurance Self- Assessment return made by the home was fully borne out in practice by evidence obtained during this site visit. Church Road (7) DS0000019322.V344812.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 3 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 3 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 4 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 4 3 3 3 4 X 4 X X 3 X Church Road (7) DS0000019322.V344812.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. 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. Refer to Standard Good Practice Recommendations Church Road (7) DS0000019322.V344812.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Church Road (7) DS0000019322.V344812.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. 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!