Inspection on 23/02/06 for Foxdown

This inspection was carried out on 23rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Foxdown 19/02/08

Foxdown 23/02/07

Foxdown 08/09/05

Foxdown 08/03/05

Foxdown 04/11/04

Foxdown 02/03/04

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

CARE HOME ADULTS 18-65 Foxdown Paley Street Nr Maidenhead Berkshire SL6 3JT Lead Inspector Amanda Longman Unannounced Inspection 23rd February 2006 10:00 Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Foxdown Address Paley Street Nr Maidenhead Berkshire SL6 3JT 0208 5699131 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) Owl Housing Limited Mr John Willem Smith Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: Foxdown is a 6-bed bungalow situated in a quiet location in Paley Street near Maidenhead. The home caters for the needs of people with learning and associated physical disabilities some of whom may display challenging behaviours. The aims and objectives of the home are to provide 24-hour care and support, promoting equality and independence in accordance with the individual’s needs and aspirations Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Foxdown is owned by Owl Housing. It has been home to the same group of six service users since its opening in 1999. This was an unannounced inspection. It was a positive inspection. The home has a happy, homely atmosphere and benefits from good facilities. Service users’ rooms are large, comfortable and individually furnished and decorated. Service users benefit from well structured care plans with clear goals and regular reviews, and are supported by caring staff. The manager is supportive of his staff and an excellent advocate for the rights of the service users. He is striving hard to bring policies and procedures up to date and to arrange training where it is necessary. The number of requirements made should not be taken as an indication of poor service, as these corresponded to minor shortfalls on particular aspects of the standards to which they refer. To gain a fuller picture of the home this report should be read with the other inspection report completed in the current inspection year, which was undertaken on 8 September 2005. To complete the inspection, the inspector spent several hours at the home. Two staff were spoken with. The bulk of time was spent reviewing the functioning of the home with the manager. This included reviewing the policies and procedures, encompassing all those relating to recruitment, quality assurance and health and safety. Interactions between staff and service users were observed. What the service does well: What has improved since the last inspection? Since the last inspection the manager has reviewed much of the functioning of the home. Family contacts for service users have improved and the social activities of service users are being improved through the manager’s committemnt to increase the number of opportunities. This can be seen for example in the introduction of the calendar with a focus on new activities, and in the re-newed social contacts of service users. The home has also focused on Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 6 the respect for service users by, for example, its agreed introduction of a mobile phone etiquette for staff. 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. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards in this section were inspected on this occasion EVIDENCE: Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards from this section were inspected on this occasion. EVIDENCE: Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 and 16 Service users are able to take part in appropriate activities and are part of the local community. Service users have appropriate relationships; their rights are respected and their responsibilities recognised in their daily lives. EVIDENCE: The inspector discussed the above standards with the registered manager, reviewed individual plans and diaries for service user activities and saw photographs of activities. The manager has worked with other Owl Housing employees to develop a calendar for this year, which has a focus for activities every month, including trying new activities. These include for example, a focus on walking or the environment. This has led to activities being organised across Owl homes on a monthly basis and has enable service users to meet up again with friends with whom they used to share accommodation. Service users are part of the local community and are supported to go out, for example to the pub or shops and to church if they wish to go. Since taking up his post last year the registered manager has sought to improve contact with service users’ families and evidence was seen of letters sent to families encouraging involvement. This has led to some families becoming more involved with their relatives living at Foxdown both on a social basis and for reviews. The manager wishes to pursue this further. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 11 Service users’ rights are respected in terms of privacy and dignity. One service user has a key and locks his room when he chooses, other service users do not wish to hold keys. Staff were observed treating service users with respect, for example knocking on doors and a staff mobile phone etiquette is in place to ensure respect for service users. Service users are encouraged to take responsibility and help with household chores. For example one service user draws the curtains; others are involved with sweeping up and two of the service users help with the weekly shop. The manager informed the inspector that in the summer the service users are encouraged to assist with the gardening. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Service users’ physical and emotional health needs are met. EVIDENCE: Service user files showed that a checklist of health needs is undertaken at reviews, regular eye, dentist and chiropody appointments are made and that GP appointments are made as necessary. Service users are supported to attend such appointments. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are protected from abuse, neglect and self-harm but improvements to the training and reference to the Inter-Agency Guidelines in Owl’s policy and procedures are required. EVIDENCE: The policy relating to the protection of vulnerable adults was largely appropriate but needs to include a reference to the inter-agency procedures led by the social service department. All staff have received training in POVA procedures as part of their induction, with the exception of one of the night staff who works alone. The manager addressed this shortfall during the inspection by contacting his head office to arrange for him to attend a training course. It is also recommended that all staff receive regular updates on a more in-depth basis. All service user files contain detailed guidance of how to cope with different aspects of behaviour, including physically aggressive behaviour. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The home is clean and hygienic. A urine odour from one bedroom needs to be addressed and the infection control policy needs reviewing. EVIDENCE: A tour of the home showed it to be clean, generally to a high standard. However an odour in one bedroom was found to emanate from pads stored in an appropriate bin in the service user’s ensuite bathroom. This problem of storage was discussed with the home’s manager who agreed to look in to alternative storage methods, such as an appropriate outside bin. The laundry facilities were reviewed and found to be appropriate. However two mops were seen stored in their buckets, soaking in bleach or some form of disinfectant. This was discussed with the home’s manager and it was recommended that these mops be thoroughly washed and dried everyday. The home’s infection control policy was seen to be appropriate, although it stated it was due for review in 2005 and therefore should be reviewed. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Fowdown’s recruitment procedures need improvements. Most staff are appropriately trained, with the exception of one night worker. EVIDENCE: Foxdown is owned by Owl Housing and they have a recruitment policy in place to ensure checks regarding potential new staff are undertaken. However, the policy does not include guidance on CRBs nor does it require candidates to supply a full employment history. Moreover, documents relating to recruited workers were not available for inspection at the home as they are held at Owl’s head office. The manager was recommended to view the recent guidance on CSCI’s website relating to CRBs and recruitment records, which provides guidance about drawing up a proforma to record evidence that full recruitment checks have been undertaken, in cases were records are held at head office. The manager is part of an Owl Housing working group on recruitment and gave assurance that these issues will be addressed. Evidence of both induction and foundation training showed generally a wellqualified and competent workforce. Training is provided and updated in Manual Handling, First Aid, Food Hygiene, Fire Safety and Infection Control. Most staff training was up to date, with the exception of one member of staff. Other training needs are identified from the point of view of the needs of service users for which each member of staff is key worker. Since the inspection visit the Manager has confirmed that arrangements have been put in place to meet the training needs of the member of staff whose training was out of date. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 16 Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, and 42 Service users views under-pin self-monitoring and development by the home. Although their rights and best interests are safeguarded by the nature of the policies and procedures in place, many policies are past their review date. The health, safety and welfare of service users are promoted and protected EVIDENCE: Various means of quality assurance were seen to be undertaken by the manager. Reports are prepared quarterly for head office, some of which provide statistical information such as staff sickness and training days However they also includes a review of the individual goals for each service user and input to this is provided by all professionals and family who have contact with the service user. However an annual quality assurance report which collates this information, relates to the aims and objectives of the statement of purpose and produces a development plan for the next year, is not currently undertaken. With the exception of specific comments in this report relating to necessary improvement, the organisation has in place an appropriate set of policies and procedures. However 34 of the 82 policies continued in the policy manuals had Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 18 not been reviewed since 2003 or before. To ensure practise is appropriate and up to date all policies need to be regularly reviewed and signed by the registered manager. This was discussed with the registered manager who immediately began the process of checking with head office whether the home had all the latest policies. The policies, records and training relating to health and safety were reviewed. The manual handling policy was reviewed in October 2005 and all staff, with the exception of the night care worker, have received practical training within the last two years the inspection. The night care worker was scheduled to receive his training the day after the inspection. Arrangements have been made for other training to be delivered by June 2006. The fire safety and food hygiene policies were reviewed in 2005 and a minority of staff needed an update in this training A review of the first aid policy is due in July 2006 and all but one member of staff have received an update in their training since 2003. The COSHH policy was last reviewed in 2004 and is due to be reviewed in July 2006. The COSHH cupboard was observed to be locked. All fire testing and policies were seen to be up to date. Appropriate emergency plans are in place for all service users in the event of fire, based, appropriately, on their individual risk assessments and their reaction to fire drills. The staff rota showed that very shift has a designated fire officer. Appropriate electrical and testing is in place. The manager is attempting to identify where the responsibility lies for the boiler, as the building is not itself owned by Owl Housing. Water temperatures are monitored weekly and showed a consistently high temperature in one outlet, which needs to be investigated. The home has an appropriate risk assessment policy and appropriate risk assessments are in place for all activities for service users as well as for such things as tools and kitchen equipment. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 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 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 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 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 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X X X 2 2 X 3 X Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 20 No Are there any outstanding requirements from the last inspection? Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 21 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 16/06/06 2 YA30 16(2)(k) 3 YA34 19 4 YA35 18(1)© To ensure the safety of service users, the responsible individual needs to review the POVA procedures to ensure they appropriately refer to the agreed inter-agency guidelines to handle the suspected abuse of vulnerable adults; and the registered manager needs to ensure the night care member of staff receives appropriate training. To ensure the comfort of service 16/06/06 users, the registered manager needs to find an alternative means of storing nighttime pads used for one service user. To ensure the protection of 16/06/06 service users the responsible individual needs to introduce a proforma to record evidence that all necessary recruitment checks have been undertaken and needs to modify the recruitment procedures to include CRB guidance and the requirement for prospective employees to provide a full employment history To ensure the safety of service 30/06/06 users the registered manager must ensure that the night care worker receives appropriate training as detailed in this report. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 22 5 YA42 13(4)(a) To ensure the safety of service users, the registered manager must make arrangements to appropriately reduce the water temperatures from the tap, which is consistently delivering water at too high a temperature. 16/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA30 YA39 Good Practice Recommendations It is recommended that the registered manager review the infection control policy, with specific reference to the daily washing and drying of cleaning mops. It is recommended that the registered manager use the quality assurance information to produce an annual quality assurance report which refers to the aims and objectives of the home, and from which an annual development plan can then be formulated. Foxdown DS0000047598.V284435.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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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