CARE HOME ADULTS 18-65
Faith Global Links Ventures Ltd 158 Galeywood Road Great Baddow Chelmsford Essex CM2 8YT Lead Inspector
Pauline Marshall Unannounced Inspection 21st January 2008 09:45 Faith Global Links Ventures Ltd DS0000070440.V353451.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 Faith Global Links Ventures Ltd DS0000070440.V353451.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. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Faith Global Links Ventures Ltd Address 158 Galeywood Road Great Baddow Chelmsford Essex CM2 8YT 01245 478797 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) fglvhousing@hotmail.co.uk Faith Global Links Ventures Ltd Mrs Olufumike Olubunmi Adediji Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following categories of service: Care Home – PC whose primary care needs on admission to the home are within the following categories: Learning Disability - code LD Mental Disorder, excluding learning disability or dementia - code MD To service users of the following gender: Both This is the homes first inspection Date of last inspection Brief Description of the Service: The home is positioned in a quiet residential street on the outskirts of Chelmsford in the village of Great Baddow and is easily accessible by public transport. The property is an end of terraced house with three double bedrooms, one bathroom, lounge, laundry room, kitchen and dining room and a small conservatory. There is a small garden and a garage to the rear of the property with a parking facility; there is on street parking opposite and at the rear of the house. The home has been registered for three people who have learning or mental disabilities and it is expected that each person living in the home will have their own keys to the front door and their individual bedroom. There is one shared bathroom and there are no washing facilities in the individual bedrooms. The homes Statement of Purpose and Service User Guide provides up to date information and is given to prospective residents before they move in. The charges will range between £700 and £1000 per week depending on the assessed needs of the individual; toiletries, newspapers, magazines, confectionery and taxis are not included in the above fees. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was originally planned to take place on 8th January 2008 as an unannounced inspection, however there was no reply on arrival at the home on this date. We contacted the manager and arranged to carry out an announced inspection on 21st January 2008. The process included discussions with the manager, a tour of the building, an examination of policies and procedures and inspection of three staff files. Although the manager has carried out the recruitment process, staff has not yet started work. We are unable to score the outcomes for prospective residents but have made judgments on each of the outcome groups. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 7 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. People can expect to receive good up to date information and a thorough assessment prior to their admission. EVIDENCE: The Statement of Purpose and Service User Guide contained information on the service that the home intends to provide and included summaries of the complaints procedure and the quality monitoring system. The Service User Guide contained information on the homes local amenities that includes a nearby express supermarket, Chelmsford town centre, the library, pubs, restaurants and take-away foods. The guide also includes details of public transport services and the manager said that bus services are good around the home and into Chelmsford. The manager has prepared a pre-admission assessment document which is entitled FGLV Supported Accommodation Referral Form. Although there are currently no residents in the home the manager has recently undertaken an assessment for a prospective resident and the assessment documentation includes a personal history (written by the resident), a psychiatric, medical and physical history. The assessment looks at all areas of need including
Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 8 budgeting and the use of money, road sense and personal safety. The manager said that behavioural and safety issues are identified at the assessment stage and that risk management plans will be put in place. The assessment documentation has provision to record the residents’ personal hopes and aspirations and is signed and dated. The manager has devised a contract of terms and conditions that will be provided to residents Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. People can expect to have a plan of care that reflects their personal needs and wishes and to be able to make everyday decisions about their lives. People can expect to be supported to take risks as part of an independent lifestyle. EVIDENCE: There are currently no residents living at the home. The manager has devised care plan and risk assessment documentation; all of the documentation examined was person centred. The manager said that when the home is operational there will be a daily planning meeting after breakfast where residents choose their meals and activities and discuss any issues that have arisen that have not already been dealt with. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 10 There is a range of shops, pubs, restaurants and take-away foods and a library within twenty minutes walk of the home. Chelmsford town centre is also within walking distance. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. People can expect to have an appropriate and fulfilling lifestyle both in and outside the home. EVIDENCE: Although the home is not yet operational, the manager has detailed in her Service User Guide the services that are available in and around the local area. The manager said that leisure activities and occupation and education are a very important part of residents’ therapy and that all residents will be encouraged to participate in activities within the local community. The assessment documentation examined identifies residents’ capabilities in cooking skills and they will be encouraged to maintain and develop any skills they already have. The manager said that mealtimes will be flexible and that residents will decide what they want to eat and when they want to eat it.
Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. People can expect to receive appropriate healthcare support. EVIDENCE: There was no documentation to examine, however policies and procedures for medication were appropriate and the manager is a qualified nurse. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. People can expect their complaints to be listened to and acted upon and to be protected from neglect and abuse. EVIDENCE: The complaints policy has recently been updated by the manager and includes clear timescales and the contact details of the local CSCI office. There were several copies of the complaints procedure available that contained old information. The manager has a complaints log sheet where all complaints will be logged for ease of reference; the log sheet will be kept in the complaints folder and will include a summary of each complaint made. Although the home is not yet operational, the manager has recruited three members of staff that are due to have adult safeguarding (POVA) training on 6th February 2008. The homes adult safeguarding procedure has not been reviewed since 1st February 2006 and does not include the requirement to report suspected abuse to the Local Authority. The manager said that she is undergoing training on 6th February 2008 with her staff and that she will amend the procedure to include the need to refer any suspected abuse to the Local Authority. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. Shortfalls on bathing and laundry facilities may not provide residents with the best outcomes. People can expect to live in a clean and homely environment. EVIDENCE: The home has three large bedrooms that do not have any en-suite facilities; there is one general bathroom nearby that has a toilet, a bidet and a bath with an electric shower over it and people living in the home will share this for bathing. All of the rooms had warm air heating and basic furniture and a television set. The manager said that residents would be able to bring their own possessions and small items of furniture that will fit into their rooms. The property is in a reasonable state of repair and the manager said that bedrooms will not be decorated until residents move in so that they can choose how they wish it to be decorated. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 15 There is a small conservatory with a football games table in it; the manager said that this will be the activities room and further items will be purchased that suit the needs of individual residents. There is a lockable cupboard in the laundry room for storing cleaning equipment which contains shelving for the storage of cleaning materials and there is a COSHH notice on the outside of the cupboard. The home has one domestic washing machine that is sited in the laundry room; there is no tumble dryer. The manager said that it is her intention to purchase a tumble dryer but that it may need to be sited in the garage as there is not enough space in the laundry room. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. People can expect to be supported by a well-trained and supervised staff team that have been appropriately recruited. EVIDENCE: The manager has started the recruitment process; three staff has been interviewed and is prepared to start work when the first resident moves in. Two of the staff files examined contained application forms, two written references, criminal records bureau checks and evidence of training including NVQ certificates. One of the criminal records bureau checks was negative and there was no written assessment of the risk, however the manager said that she had discussed this with the employee and considered that they did not present a potential risk to residents. The third file examined was awaiting further information on the employees training. There was no evidence of staff fitness on any of the files examined. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 17 Staff is booked to attend adult safeguarding (POVA) training on 6th February 2008 and there was evidence on the three staff files examined that staff have first aid, health and safety and food hygiene training. The manager said that she plans to provide supervision to all staff a minimum of six times each year and that she will be working alongside staff at the home on a daily basis so will frequently provide additional support. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. People can expect to live in a well run home that is operated in their best interests. EVIDENCE: All of the homes policies and procedures were prepared and dated 1st February 2006 and the manager said that as there had been changes to some of these policies she would be reviewing them to ensure they were accurate. The policies and procedures demonstrated a good understanding of the needs of the prospective residents and staff. The manager has been a registered nurse for the past eight years and has experience of working with residents who have learning and mental disabilities. The manager has been employed in a management position prior to being registered and is a qualified nurse. Although the manager has not yet undertaken the Registered Managers Award
Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 19 she said that she will be making enquiries with her NVQ provider to establish the qualification that she requires to meet the National Minimum Standards. There is a quality assurance system in place and the manager returned her annual quality assurance assessment (AQAA) by the due date. The manager said that surveys will regularly be given to residents and sent to their relatives and friends in addition to the regular resident meetings and daily planning meetings that will take place. A discussion took place around the importance of obtaining the views of others including GP’s social workers, nurses and care managers and the manager said it could be difficult to obtain a response but that she would include them in the process. The home had a fire notice displayed in the dining area and there were appropriate signage on the back door; the key is kept on a chain in easy reach in case of fire. There were good health and safety policies and procedures and all safety certificates were in date. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 20 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 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X X X X Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 21 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 YA23 Regulation 13 (6) Requirement Timescale for action 01/03/08 2. YA34 19 (1) (a) (b) (i) Schedule 2 The abuse policy must have the correct details of where and how to report any suspected abuse to ensure that prospective residents are fully protected. The correct employment checks 01/03/08 must be carried out for all staff and includes two written references and evidence of their fitness. An assessment of risk must be carried out for any negative criminal records bureau checks. 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 YA22 Good Practice Recommendations All copies of the complaints procedure should contain the same information and timescales. Faith Global Links Ventures Ltd DS0000070440.V353451.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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
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