Inspection on 01/09/05 for Community Care Solutions (Brambling Way)

This inspection was carried out on 1st September 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

Community Care Solutions... 16/08/06

Community Care Solutions... 20/12/05

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Chapel Cottage Home (Oadby) 53 Brambling Way Oadby Leicester LE2 5PB Lead Inspector Trisha Gibbs Unannounced Inspection Thursday, 01 September 2005 at 10.00 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. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chapel Cottage Home (Oadby) Address 53 Brambling Way Oadby Leicester LE2 5PB 0116 2719644 0116 2719644 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) Community Care Solutions Limited Ms Kathryn Wainwright Care Home (CRH) 9 Category(ies) of Mental Disorder (MD) - 9 registration, with number Learning Disability (LD) - 9 of places Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No additional conditions of registration apply. Date of last inspection 22nd November 2004 Brief Description of the Service: Chapel Cottage consists of two residential facilities, one situated in Husbands Bosworth, near Market Harborough, and the other in Oadby. Both homes have recently been subject to a change of Registered Provider, and Community care Solutions are now the new Registered Owners. Chapel Cottage Oadby is a modern detached house, situated on an estate close to the centre of the village, and provides care and support for up to nine adults who have learning disabilities, or mental health disorders. There are two single bedrooms and one double bedroom at ground floor level, and three single bedrooms and one double on the first floor. There are bathroom and toilet facilities on both floors. Communal facilities consist of an open-plan style kitchen, lounge and conservatory extension, which is used as a dining area. There is a lawned garden to the rear of the property with seating. Service users are encouraged to live an independent lifestyle, while receiving the necessary care and support from the staff team. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took over three hours and was the first of two statutory unannounced Inspections this year. The focus of Inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users. The primary method used during this Inspection was that of case tracking, which involved selecting two service users currently living at the home, and tracking the care they are receiving, through looking at their records. In addition, the Inspector held discussions with staff and service users at the home. Other related documents were also looked at. The Inspector spoke to the senior care worker who also facilitated the Inspection. The Inspector toured and inspected the premises. Two service users were present throughout the Inspection and talked to the Inspector, two others arrived home later and were spoken to. This was a satisfactory Inspection. What the service does well: What has improved since the last inspection? What they could do better: Ensure current Care Plans provide stand-alone information about service users’ changing needs. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 Page 6 Identify where more detailed risk assessment is necessary, and ensure these are in place. Ensure that worn carpets are replaced, and that rooms requiring redecoration, are redecorated. The Inspector has been informed that this will be achieved in the near future by the new Registered Provider and has therefore not made this a requirement at this Inspection. The home is currently without an Acting Manager to cover the current Registered Manager’s maternity leave. There is only a small team of support and senior workers to provide care for the seven service users. The new Registered Provider has confirmed to the Commission that he is currently seeking to recruit new staff. The Staffing and Management Standards and Regulations will be inspected at the next Inspection later this year. 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. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 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 Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 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) x It was not possible to assess Standard 2 in the absence of any recent admissions to the home. EVIDENCE: Although there have been no recent admissions to the home, there was some evidence within files, that current residents have their needs re assessed through care planning review systems. A copy of the updated Statement of Purpose for the home has been requested and will be looked at by the Inspector before the next unannounced Inspection, later this year. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 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 Service users are enabled to make choices, take acceptable risks, and to have their needs met, but care plans could better account for these. EVIDENCE: The two files looked at contained appropriate historical information, and acceptable care planning information and records, covering different aspects of that service user’s daily life. The two care plans were generally brief but appropriately reviewed, signed, and dated. There were aspects of the care plans that the Inspector advised should be more detailed, e.g. one care plan noted under the heading ‘Dietary Needs’ that the service user required a‘ Diabetic diet’. The care plan did not go on to give examples of this diet or to provide a typical diet sheet. While staff working at the home knew exactly what the service user could, or could not eat, a new member of staff would not know, from simply looking at the current care plan. There were other examples where care plans did not include details of a need that was perhaps documented elsewhere, but which should have been included within the one key planning document. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 Page 10 It was evident that generally the service users enjoy a good level of independence, some utilising public transport and going shopping alone. Others are provided with transport to attend for day services. Risk Assessments on files looked at, were summarised on a one-sheet, tick box style, format. While this format may be sufficient to account for a general assessment of ‘low risk’ service users, assessment of medium and higher risk service users should contain more details about identified risk and of the measures put into place by the home to counter this. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 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) 12,13,15,16,17 Overall, service users are enabled to enjoy a healthy lifestyle and to access a range of leisure and day activities. EVIDENCE: Staff confirmed that service users are encouraged to pursue interests outside of the home. One service user undertakes a small work placement, and another is in part-time paid employment. Some attend for community day services in neighbourhood centres. One service user is reluctant to engage in activities outside of the home, but does collect a daily paper and accompany staff to go shopping. This service user told the Inspector, ‘I am happy here, I go to the paper shop every day’. It was evident that the service users enjoyed being ‘at home’. During the Inspection five service users were at the home or returning to the home. They watched television, helped to prepare lunch, and easily occupied themselves. Games, books, music systems and jigsaws were available in the lounge. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 Page 12 Service users are encouraged to maintain family links. This was evident from files tracked. On the day of the Inspection, one service user was looking at her book of family birthdays and anniversaries for the coming month, and planning to buy cards. Daily menus are well detailed and provide very good choices for service users. Service users are consulted one day in advance about the next day’s meal, and have their main meal in the evening. There is always a cooked option for breakfast in addition to cereals and toast. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 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 Good attention is given to the personal and health care needs of the service users. EVIDENCE: Although care plans contained brief details about general and specific healthcare needs, there was good supporting evidence on file, of staff facilitating service users to attend for both routine health care appointments, and additionally specialist consultant appointments. One service user tracked receives significant and regular input from the Multi Agency Mental Health Team, and annual reviews provided good information about his needs. Medication administrative systems were looked at and found to be satisfactory. The senior staff member on duty explained that the new Registered Providers are currently negotiating a contract for Pharmacy services with Boots the Chemist. She explained that she would be shadowing medication systems at other homes owned by the new Providers. Although there is a now small medication cabinet in the office, as required at the last Inspection, the staff member said that a more suitable new medication cabinet is to be purchased. She confirmed that all staff have now received full Medication training. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 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) x N/A EVIDENCE: The above Standards were not inspected on the occasion of this Inspection and will be inspected during the second Inspection of the home later this year. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 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) 24,30 Chapel Cottages, Brambling Way provides a homely, and comfortable environment for the service users living there, however several areas of the house are in need of new carpets and fresh decoration. EVIDENCE: The open plan kitchen, conservatory and lounge area were clean and pleasant. The open plan design provides good opportunities for informal contact between staff and service users, and a family style setting. Carpets in some bedrooms, and in hallways leading to bedrooms, were worn, loose and in need of replacement. Some appeared not very clean, because of old stains. The member of staff facilitating the Inspection said that the new Registered Provider was replacing these. One shared service user’s bedroom has within it, a door that exits directly on to a public footpath. This door did not lock. The Inspector issued an immediate requirement for a lock to be fitted by the end of the day. The Inspector received confirmation that the door had been secured later that day. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 Page 16 A risk assessment should now be undertaken with regard to this door, given that service users could leave the premises without staff knowing this. Staff noted that one service user who has Mental Health difficulties, would not be happy about his worn, old carpet being refitted. The Inspector advised that staff should work with his Mental Health Care Management worker who could advise how best to proceed with, and work through, this process. Although bathrooms and toilets were clean and fresh, the washbasin, and flannels in the shared service users’ bedroom were not. Service users do much of their own cleaning and tidying up, but staff should ensure that personal washing facilities are clean and hygienic. There is a nice garden to the rear of the house, and a good lawn area. One service user has enhanced the garden by planting up several big flowerpots, with plants and shrubs. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 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) x N/A EVIDENCE: The above Standards were not inspected on the occasion of this Inspection and will be inspected during the second Inspection of the home later this year. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 Page 18 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) x N/A EVIDENCE: The above Standards were not inspected on the occasion of this Inspection and will be inspected during the second Inspection of the home later this year. Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chapel Cottage Home (Oadby) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 Page 20 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 26 Regulation 13,4,(a) Requirement The Registered Provider is required to secure a door, in a shared service users bedroom, that exits directly on to a public footpath, and is not currently lockable. Timescale for action This was addressed on the day of the Inspection. 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. 2. Refer to Standard 6 and 9 24 Good Practice Recommendations Care Plans should be sufficiently detailed to accuraetly reflect the full needs of the service user. A risk assessment should be drawn up with regard to the risk of the exit door, that opens on to a public footpath from a shared bedroom, being used to leave the house by service users, without the knowledge of staff. Staff should work with Mental Health professionals to facilitate a service user to cope with refurbishment of his bedroom. Personal washing facilities in service users bedrooms should be maintained to a clean and hygienic standard at all times. 3. 4. 24 24 Chapel Cottage Home (Oadby) C51 C01 S64677 Chapel Cottage (Oadby) V247366 010905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park, Enderby Leicester LE19 1SX 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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