Inspection on 06/02/06 for Hazel View

This inspection was carried out on 6th 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hazel View 10/12/08

Hazel View 29/12/06

Hazel View 08/08/05

Hazel View 31/01/05

Hazel View 07/06/04

Hazel View 01/03/04

Hazel View 06/11/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hazel View 21 Huckleberry Close Purley on Thames Reading Berkshire RG8 8EH Lead Inspector Stephen Webb Unannounced Inspection 6th February 2006 10:00 DS0000011171.V279785.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 DS0000011171.V279785.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. DS0000011171.V279785.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hazel View Address 21 Huckleberry Close Purley on Thames Reading Berkshire RG8 8EH 0118 9427608 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) rachelk@purleyparktrust.org Purley Park Trust Limited ***Post Vacant*** Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places DS0000011171.V279785.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2005 Brief Description of the Service: Hazel View is one of the three original outlying houses within the Purley Park Trust, and is now one of eight separate small units within the estate. The unit accommodates five adults of either gender, (currently five males), with a learning disability, in a pleasant unit providing each service user with their own bedroom. Communal accommodation consists of a shared lounge/kitchen/dining area, with comfortable furnishings, toilets and a bathroom. One service user has an en suite. Residents and staff work together on various aspects of the day-to-day running of the unit. DS0000011171.V279785.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out between 10.00am and 2.45pm on the 6th of February 2006. The inspection included the examination of key records and policies, a review of progress on previous requirements, discussion with a support worker, a tour of some areas of the premises and discussion with some of the service users. The inspector also had lunch with service users. This was a positive inspection. The manager post is currently vacant. The support worker on duty worked diligently to meet the needs of the service users whilst also supporting the inspection. All of the previous inspection requirements had been addressed. The unit has been fairly stable with no changes of service user, though one staff member had left since the last inspection and another had transferred out to another unit and was being replaced by someone from within the service. The unit manager post remains vacant and there is one other vacant post. Uncovered shifts are covered either from within the unit team or from other units within the service. One service user was in hospital with hip/pelvic problems and was awaiting a possible move to another hospital for surgery. He had been visited daily by staff and service users from this and other units. Some of the service users went out on activities during part of the inspection. The service users’ feedback about their care was positive and the relationships between them and the staff were positive and relaxed. In the longer term, there are proposals to replace the unit with a new one purpose-built to the new standards and including a lift. What the service does well: Service users obviously feel very much at home, both within the unit and around the campus. They have access to a good range of activities, both on and off-campus, many of which are organised by the in-house day-care team. Service users are encouraged to make day-to-day decisions and to take part in daily household tasks. Health-care needs are effectively met. They have access to an appropriate complaints procedure and can also raise any issues through other forums. DS0000011171.V279785.R01.S.doc Version 5.1 Page 6 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. DS0000011171.V279785.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 DS0000011171.V279785.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): EVIDENCE: None of these standards were inspected on this occasion. Standard 2 was inspected at the previous inspection and was met. DS0000011171.V279785.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): 6, 7 The needs of service users are reflected in their individual Care Plans, though most would not really be able to understand the content without explanation. Further evidence of goal-setting and how these are achieved would be beneficial. Service users are enabled to make day-to-day decisions about their lives, and receive support from the staff where necessary to do so. EVIDENCE: Each service user has a care plan comprising several documents, including a contact information sheet, Essential Lifestyle Plan, individual risk assessments and a record of consultation on whether the service user wishes to have a bedroom key. The Essential Lifestyle Plans contain details of individual interests, aspirations, care needs, likes and dislikes and of how individuals like to spend their time. However, there is limited evidence of goals set with/for service users, and how these are worked on between reviews. These could be identified in reviews and progress noted within daily record sheets if they were adapted. DS0000011171.V279785.R01.S.doc Version 5.1 Page 10 Each service user is allocated a keyworker who is involved in their reviews and planning meetings and takes the lead on individual work with them. The files examined contained copies of reviews at six monthly intervals. The service users attend their reviews and are asked their views where possible. Service users are supported where necessary to make decisions about their day-to-day lives, including participation in activities, the clothes they wear, the times they get up and go to bed and where they want to go on holiday. These are evidenced within care plans, activities plans and individual daily records. Two of the service users hold their own weekly personal allowance, and one has small amounts at a time to hold and spend. The unit holds these funds for the others, within individual wallets, secured in a locked cash tin. Any expenditure by staff on behalf of service users is recorded and receipted and records are kept of all of the service user’s money handled. Such expenditure would usually be in the presence of the service user and with their agreement. DS0000011171.V279785.R01.S.doc Version 5.1 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 the following standard(s): 16, 17 The rights of service users are respected and they are enabled to make day-today decisions and choices. Service users are offered a diet that is becoming more focused on healthy eating, whilst reflecting their preferences. EVIDENCE: As noted the daily routines are not restrictive and enable service users to make day-to-day choices about their lives and how they wish to spend their time. In dependence is encouraged, and support offered where desired. Each has been consulted on whether they want a key to their bedroom door, and there are consent forms on file confirming this. Service user’s mail is now delivered to the unit unopened and given to the addressee to open. Staff will assist or read the contents if requested. DS0000011171.V279785.R01.S.doc Version 5.1 Page 12 There is a relaxed relationship between staff and service users and continual interaction throughout the day. Individuals can opt to spend time alone in their room or out around the campus if they wish, and often visit friends in the other units. They can decide whether or not to take part in an activity. Two of the current group are also able to go off-site to the shops or church unaccompanied, based on risk assessment. The staff are familiar with the likes and dislikes of the service users around food and will provide an alternative if a particular meal is not liked. The menus are created in consultation with service users, though staff have to try to balance the menus in terms of healthy eating considerations. There is a move to try to provide more healthy options creatively, within the menus and see how popular they are. There was a good quantity of fresh vegetables in the fridge and fresh fruit was also available. Mealtimes are relaxed events and involve whoever is in the house at the time, and the weekday main meal is in the evening owing to individuals’ involvement in activities. Service users’ weight is taken and recorded regularly. DS0000011171.V279785.R01.S.doc Version 5.1 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 the following standard(s): 18 Personal support is provided to service users according to their needs and individual preferences. EVIDENCE: Staff support is provided according to need and based upon the known preferences of individual service users. The details are recorded within their Essential Lifestyle Plans. Any personal care support provided is carried out behind closed doors, as is treatment from healthcare professionals. This was seen to be the case when the chiropodist visited one service user during the inspection, and saw him in his bedroom. As already noted, service users choose when to get up and go to bed and make other choices with staff support if required. Each has a designated keyworker allocated, who takes the lead on any targets or goals, and on addressing any identified needs. Specialist external support is sought where necessary. Same gender care is not possible but is not an issue for the current group. The unit may be getting a male staff member soon. DS0000011171.V279785.R01.S.doc Version 5.1 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 the following standard(s): 22, 23 Though there is an appropriate complaints procedure in place it was not possible to examine its operation, as there were no recorded complaints. The feedback from service users indicated they had no complaints on the day of inspection, and were happy with the care provided by the staff. The unit effectively protects service users from abuse, and training on the protection of vulnerable adults was scheduled for February. Whistle blowing training should also be provided to staff. EVIDENCE: The unit has an appropriate complaints procedure but since the complaints log was empty, it was not possible to examine the procedure in operation. The service users spoken to during the inspection had no complaints. There is a version of the procedure in each service user’s file in symbol format and the procedure has been verbally explained to them. They also have access to the head of care and Chief Executive who both work on-site and make themselves freely available to service users; and to the Regulation 26 monitoring visitor, although these visits have not been taking place monthly as required. (Requirement made under Standard 39). The unit has an appropriate vulnerable adults protection procedure as well as a copy of the local multi-agency procedure. Any issues which arise are thoroughly investigated. DS0000011171.V279785.R01.S.doc Version 5.1 Page 15 Staff training on POVA (protection of vulnerable adults) is due in February, but staff should also receive training on the whistle-blowing procedure as part of their induction. Effective financial systems are in place to protect service users’ money. DS0000011171.V279785.R01.S.doc Version 5.1 Page 16 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): 24, 30 The service users live in a homely and comfortable and safe environment which is maintained in a clean and hygienic condition. EVIDENCE: The décor of the unit was satisfactory throughout, and it is furnished in a homely style, with numerous pictures and ornaments. The refurbished kitchen had been completed and is attractive and appropriate for the current needs of service users. It is clear that service users see the unit very much as their home. Bedrooms are individualised and reflect the personality and interests of their occupant. The unit is on an enclosed campus with others, and service users can move freely about the site, visiting friends in other units. A previous requirement to fit a self-closer to the laundry door had been addressed. The premises were in a clean and hygienic condition. DS0000011171.V279785.R01.S.doc Version 5.1 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 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 The level of protection offered to service users by the organisation’s recent recruitment practice was not assessed on this occasion, as there had been no recent recruits to the unit. Improvements have, however, previously been made, in response to requirements, and there are no known current issues. EVIDENCE: There have been no new external recruits to the unit since the previous inspection. The organisation have continually reviewed and improved their recruitment procedures in light of legislative changes and CSCI requirements. All staff receive an organisational and unit-based induction and foundation training programme, then commence on NVQ level 2. A range of specific training courses are also provided, both from in-house and external trainers, and the organisation has a range of supplementary training videos. Crisis intervention training (NCPI), has been booked for all staff and is due to commence in February. DS0000011171.V279785.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 The views of service users have been sought as part of a developing quality assurance system but the resulting report has yet to be produced. Regulation 26 monitoring visits are also not taking place with the required monthly frequency, reducing service user access to another party with whom they could share their views and any concerns. EVIDENCE: At the time of this inspection no quality assurance report was available, though it is understood that QA questionnaires have been made available to service users, families and medical practitioners, and are awaiting analysis. A summary report of the QA feedback should be produced and made available to interested parties. An annual cycle of QA surveys and reporting, should be established to inform the annual review and annual development planning for each unit, when combined with feedback from complaints, inspection reports and Regulation 26 reports. DS0000011171.V279785.R01.S.doc Version 5.1 Page 19 No annual development plan was available in the unit. An annual development plan for the unit should be produced for the year from April 2006, addressing the relevant areas. No copies of Regulation 26 monitoring visits were available for inspection in the unit an it was acknowledged that these visits had not been taking place monthly as required. Two new governors are reportedly due to be appointed in April and it is intended that they will carry out these visits. Copies of reports of all visits should be available in the unit for the manager and for inspection. DS0000011171.V279785.R01.S.doc Version 5.1 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X X X 2 X X X X DS0000011171.V279785.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO 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 YA39 Regulation 24(2) Requirement Timescale for action 06/05/06 2. YA39 3. YA39 4. YA39 The registered provider must produce a report of the findings of the service user survey, and make it available to interested parties 24(1), 24(2), The registered provider must 06/08/06 24(3) establish an annual quality assurance and review system in accordance with Standard 39, and make the resulting reports available to interested parties. 24(1)(b) The registered provider must 06/05/06 produce an annual development plan for the unit for the year from April 2006. 26(2)(3)(4)(5) The registered provider must 06/05/06 ensure that the unit is visited in accordance with Regulation 26 and reports are produced. DS0000011171.V279785.R01.S.doc Version 5.1 Page 22 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 YA6 YA23 Good Practice Recommendations The registered provider should consider ways to identify individual goals for service users and how best to record progress towards these. The registered provider should provide staff with training on the whistle-blowing policy/procedure. DS0000011171.V279785.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. Extracts may not be used or reproduced without the express permission of CSCI DS0000011171.V279785.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!