Inspection on 08/07/05 for Church Road (7)

This inspection was carried out on 8th July 2005.

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 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) 05/07/07

Church Road (7) 17/05/06

Church Road (7) 31/01/06

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 Church Road Bengeo Hertford SG14 3DP Lead Inspector Julia Bradshaw Unannounced 08.07.05 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Church Road Address 7 Church Road Bengeo Hertford Hertfordshire SG14 3DP 01992 501266 01992 501266 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mencap Ms Teresa Acraman Care Home 4 Category(ies) of LD LD Learning Disability - 4 registration, with number of places LD (E) LD(E) Learning Disability - over 65 - 4 Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22.02.05 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 I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced Inspection of the Inspection year and took place over one day. The majority of the time was spent talking to service users, staff and the manager of the home. Some time was also spent looking through service user plans, complaints, staff training and staff personnel files. A tour of the environment was also carried out. Discussions were held with the manager regarding the new Inspection format and the changes made in relation to the style and implementation of the Inspection process. This was a very positive inspection with only two requirements made in relation to staff training and risk assessments. What the service does well: What has improved since the last inspection? There is very little that the manager and staff need to do in order to improve the current service provided. There is an annual renewal and replacement programme in place and the home could always benefit from some redecoration and the front wall needs to expand to allow the minibus to manoeuvre more easily. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 6 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 I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 &4. Prospective service users individual aspirations and needs are assessed and reviewed, enabling the service user and the home to continuously update the individuals care package provided. Information provided to the service user about the home and its terms is suitable to meet their needs and therefore enables the service user to make an informed choice about where to live. EVIDENCE: A comprehensive Statement of Purpose is held within the home and all current and prospective service users are provided with a copy. The Statement contains information for the service user to make an informed choice about where to live. Full assessments of each service users needs and aspiration are made before the service user moves into the home. The assessments carried out within the home are continuously occurring supporting and monitoring individual progress and needs identified. Experienced and competent people complete the assessments. The home also receives and seeks external specialist support to meet the individual service users needs. Whole Life Reviews occur within the home to support the service users in achieving and reviewing individual needs, goals and aspirations. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 &10 Individual needs and choices within the home are being promoted to encourage and empower user self-determination. EVIDENCE: All service users have an individual care plan and an allocated key worker to support them in the home. Individual daily guidelines/diary notes for service users were observed within the home. 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 manager and staff should be congratulated on the high standard of these documents and the three service users plans inspected were a fine example of how the Person Centred Planning process should be implemented with clear evidence to support the service user having full involvement in this process. The ethos within the home promotes that the care plans of each individual are owned by the individual, those service users spoken to during the inspection were aware of their individual care plans Within the home each service user is encouraged to take part in daily living tasks, for example being supported with meal preparation, washing up, laying the table and shopping. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 10 The staff and the service users have devised a rota, following discussions with the service users and is effective and people appear to enjoy being part of the running of the home. The home is nicely decorated and the service users have made the choices for decoration collectively. All information within the home is handled with care and respect. All personal notes and files detailing information on the service user are locked away. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,13,16&17 Personal development opportunities are encouraged for all service users ensuring interactions within the local community and that individual rights and responsibilities are recognised and supported. EVIDENCE: All service users living at Church Road are encouraged to be involved in activities according to their individual needs and aspirations. Service users appear to have a wide range of activities offered activities within the local community, these include pub trips, local museum trip, boating trips, and also people attend day care facilities at Geddings. Although some service users still attend the day centres, there is recognition that the current service user group is becoming older and frailer, therefore the staff are endeavouring to provide more appropriate daytime recreational and social activities for people rather than work related programmes. However, the home also encourages the service users to take part in the daily domestic routines within the home, which include cooking, washing their laundry and cleaning their own rooms. Each user has a day off to carry out these domestic tasks and to enjoy some social and recreational activities with staff support. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 12 The home has an “open door” policy regarding visits from family and friends. The staff appear both approachable and welcoming with the service users and visitors. Everyone is able to receive visitors either in the privacy of their own room or the lounge area is made available. The existing service user group, with the exception of the newer service user, have been living together for some time and appear to enjoy each others company and welcome all visitors to the home. The home organises regular events such as parties and day trips to the seaside, in conjunction with other Mencap homes within the area. The home will be providing holidays in the summer; two service users will be going to a holiday cottage in Norfolk, and two service users will be going to a holiday camp in Bognor Regis. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19&20. All personal and health care support is well maintained within the home ensuring individual needs, choices and preferences are met at all times. EVIDENCE: All care provided is individual and tailored to each person needs with service users choices and preferences being promoted. Assessments and reviews are continuously completed ensuring that the approach adopted by the home is person centred and holistic to each service users needs. Service users needs and are supported with all aspects of their physical and emotional health and receive adequate and appropriate input from specialists such as community nurses, consultants, GP, dentists, opticians and dieticians. Information and advice is provided to all services users regarding general health issues. The home has a robust policy and procedure in place to support the safe administration, storage and receipt of medicines. All staff receives training prior to being deemed competent to administer medication. The home uses the Boots pharmacy service and has a good working relationship with them. Contracts are present between the pharmacy and the home and pharmacy inspections are carried out frequently (the last visit was carried out on the 16/6/05). The home uses a Dosette box system for safe administration. A running record is kept of paracetemol for each service user and the G.P. has written individual service up for this PRN medication. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22&23. The complaints procedure within the home is sufficient and adequate in order for the service users to feel that their individual views are listened to. Robust policies and procedures are in place to ensure service users are protected and safe. However, training must be provided to all staff so that continued protection is assured. 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 should be congratulated in providing this information on audiotape for all service users who find the written word difficult to interpret. All service users have been informed about the complaints procedure. This is also on display within the home. The complaints procedure includes the correct contact details of the CSCI. Robust procedures are in place to ensure that service users are protected from abuse and harm. However the manager must ensure that Adult protection training is provided as part of the annual training programme in order to ensure service users are protected and that staff have the appropriate training in order to carry out their role effectively and efficiently. Staff employed within the home are all subject to enhanced Criminal Records Bureau (CRB). Staff personnel files were inspected and contained all the relevant and necessary information. Staff files are secured in a locked cabinet within the manager’s office. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,27&30, The home and its surroundings offer a pleasant, comfortable and safe environment to its service users. The home is extremely clean and well maintained. All bedrooms are personalised offering a homely, lived in feel. EVIDENCE: Service users are encouraged to bring personal items such as furniture and pictures into their room when they move in. Service users spoken to were happy with their rooms and commented on how staff assist them in choosing and purchasing new items for their rooms and are wholly involved in deciding on their own colour schemes and soft furnishings. The home is exceptionally clean and attention to detail is given. The cleaning of the home is carried out by the care staff and with service users assisting where possible. The manager monitors this closely to ensure that standards of cleanliness remain high. Hygiene and infection controls are high and gloves and are always readily available. The kitchen and laundry rooms are domestic in style and appear to manage their current workload effectively. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 16 The home provides sufficient lighting, heating and ventilation. A maintenance and renewal and redecoration plan is required. Each service user has a single bedroom. The communal areas of the home are decorated and furnished to a high standard and there is a range of home entertainment equipment for service user to access. The manager has purchased a new cordless phone since the last inspection took place, which provides service users adequate privacy in order to make personal phone calls. Water temperatures are recorded regularly and temperatures for the day of the inspection were being delivered within safe limits. The manager must carry out individual risk assessments on each service user regarding the portable fans that are used in bedrooms during the hot weather. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35&36 The home is suitably staffed with well-trained and experienced individuals ensuring that at all times service users changing needs can be met. The staff team are enthusiastic and appear to take great pride in the service. EVIDENCE: Staff spoken with during the inspection appeared very clear of their individual roles and responsibilities. Evidence was seen and staff were observed to be supporting the main aims and values of the home. The home has clearly defined job descriptions and person specifications in place. All staff have received a series of mandatory training course in order for them to meet the needs of the service users. Training includes PCP training, medication training, Disciplinary/sickness training, recruitment training, and health and safety. As previously stated all staff must receive Adult Protection training. Recruitment practices were inspected and all the necessary documentation was in place. Two staff files were inspected in detail and both contained two references, a job application, job description, CRB declaration and medical information. Supervision and appraisal occurs within the home and staff felt that this was a valuable process. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 18 The manager is also in the process of doing her NVQ level 4 and one person is currently doing her NVQ level 3 and four staff are currently doing NVQ level 2. The home should be congratulated on their commitment to NVQ`training. The manager is also an NVQ assessor. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,41&42. The management within the home is secure and effective ensuring that changing needs of service users are met and that the home is running meeting its aims and objectives. Quality assurance systems are in place. Service user meetings are held and documented. Health and safety standards within the home are being maintained. Risk assessments must be created where a risk is identified. EVIDENCE: Service users spoken to during the inspection appeared to be extremely happy with the home and appeared to be relaxed in their environment. The relationship between the service users and the staff is well balanced with interactions observed being appropriate and supportive. The ethos and management approach of the home creates an open, positive and inclusive atmosphere, staff and service users spoken to commented that they feel extremely supported and they feel the home is well managed. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 20 A clear commitment is made to equal opportunities within the home, with staff and service users expressing positive views with regards to this. The service users appeared to benefit from this well structured and well run home. All staff and managers within the home are adequately and suitably trained in order to meet the complex changing needs of the service users, with the exception of adult protection. Quality assurance systems are in place and the manager carries out her own weekly and monthly audits within the home. There was adequate evidence to support that service users have regular meetings and the minutes reflected the involvement of the service user within the home. All records are secure within the home and were up to date and held in accordance with the Data Protection act 1998 ensuring that service users rights and best interests are safe guarded by the homes polices and procedures. Records regarding staff were inspected and the two staff files checked contained all the necessary information for the protection of vulnerable people. Individual and generic risk assessments were in place within home, with all external required safety checks occurring. However the manager must carry out individual risk assessments on the portable fans, which have been placed in service users bedrooms whilst the weather is very hot. All fire records were up to date and all health and safety records were in place and being maintained appropriately. Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 x x 3 Standard No 11 12 13 14 15 16 17 3 x 3 x x 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Church Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 2 2 x I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 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 9 24 42 35 23 41 Regulation 13(4)(c) Requirement The manager must carry out a risk assessment on all protable fans within the home in order to protect the service users. The manager must ensure that all staff have the necessary training to carry out their role effectively,including adult protection to ensure that all service users are protected from situations of abuse Timescale for action 8/7/05 2. 13(6) 18(1)(c) (i) 30/9/05 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 N/A Good Practice Recommendations Church Road I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 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 I52_s19322 Church Road v235318 080705 stage 4.doc Version 1.40 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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