Inspection on 12/10/05 for Hermitage Lane (4)

This inspection was carried out on 12th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hermitage Lane (4) 13/06/07

Hermitage Lane (4) 19/07/06

Hermitage Lane (4) 28/04/05

Hermitage Lane (4) 14/10/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Hermitage Lane (4) Hermitage Lane Upper Stratton Swindon Wiltshire SN2 6QS Lead Inspector Pauline Lintern Unannounced Inspection 12th October 2005 10:00 Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 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 Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 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. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hermitage Lane (4) Address Hermitage Lane Upper Stratton Swindon Wiltshire SN2 6QS 01793 727790 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) Milbury Care Services Limited Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28/04/05 Brief Description of the Service: 4 Hermitage Lane is one of number of homes owned and managed by Millbury Care Services. The property is a large detached house located down a quiet lane and within easy reach of local amenities, public transport and Swindon Centre. The home provides accommodation for six service users with learning disabilities with the philosophy of care underpinned by John O’Brien’s five accomplishments. The emphasis of care is to promote independence and support service users enjoyment in experiencing the wider community. The accommodation provides single bedroom en suite facilities for all service users that exceed the National Minimum Standards for communal and living space. Staffing arrangements ensures there is a minimum of three staff on duty at all times Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this unannounced inspection the inspector met six service users and seven staff. Shortfalls from the last inspection were examined and most had been met. Care plans; risk assessments, recruitment files and health and safety records were inspected. Although all of the service users were met only one was able to comment on the service that is being provided. What the service does well: What has improved since the last inspection? A new carpet is now on order for the hallway. Portable appliance testing is completed. The complaints procedure is now in individuals’ Person Centred Plans and is supported by pictures. All care plans and risk assessments have been reviewed and updated. Service users make choices and decisions using pictures and body language if they are unable to verbally communicate. There is evidence that the staff team are developing ways of aiding communication for service users. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 6 There is provision for the home to provide meals for service users, which are taken outside of the home. Protocols for “as required medication” are incorporated into the care plans. Although no service user receives advocacy support, there is information on display. 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. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 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 Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 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): 5 Each service user has a person centred plan that has a copy of their contract in it. There have been no new admissions to the home since the last inspection. EVIDENCE: Each service user has a Person Centred Plan. This contains a copy of their contract and the terms and conditions. The contract contains pictures to enable service users to understand the contents. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 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, 8 and 9 Service users are encouraged to make decisions about their lives where possible. Risk assessments and care plans have been reviewed and updated. Care plans now contain detailed plans of the needs of the service users. EVIDENCE: The manager has reviewed and updated all service users care plans. Risk assessments are in place to enable service users to participate in activities whilst minimising risks where possible. Documentations demonstrate that the plan is drawn up with involvement from families, psychiatrists, operational manager and the care manager. There is evidence that one service user was able to participate in the review of his care needs. People who have communication difficulties are empowered to make decisions about their lives by the use of pictures and offering choices. The home runs a key worker system. The manager has developed a comprehensive Person Centred Plan for each service user. They contain a vast amount of information on the needs of the individual. The PCP contains monthly summary sheets to be completed by staff to ensure that the changing needs of individuals are met. Every effort Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 10 has been made to support the written word with photographs or pictures to help the service user understand the contents. One service user said in his PCP that he was happy to do tasks about the house but it stated “ask if I would like to help-do not presume” During the inspection one staff member was seen to be encouraging a service user to make decisions with regards to his choice of clothes for the day. Staff said that they knew the service users likes and dislikes and could identify when somebody was not happy or did not wish to do something which had been offered. If one service user did not wish to go for a walk staff said she would simply refuse to go. The manager and staff show that they are actively looking for ways to help develop service users communication skills. No service users accesses advocacy services however information on this subject is located on the wall in the hallway and if required, staff would assist service users in obtaining contact with an advocacy service. The home has received input from the organisations behavioural specialist for one service user. Guidelines are in place to help with the management of behaviours. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 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): 11, 13, 14, 15, 16 and 17 When possible the home encourages service users to attend leisure activities within the local community. The homes vehicle can often restrict the frequency of this. Staff are looking at opportunities for service users to develop practical life skills. Families and friends of service users are welcomed into the home. The home provides nutritional, varied meals EVIDENCE: One service user had certificates of past learning on his bedroom wall. The manager said that they had made contact with the local college to look at opportunities for him when the new term starts. The college contacted the home during the inspection to arrange a meeting with the service user. Each service user has an individual activity plan for the week. There are pictures of the activity on each particular day. One service user is able to pick from picture cards which activity she wishes to do. Staff reported that individuals might indicate that they wish to do another activity and not the one specified for that day, this is encouraged and supported where possible. Discussion with one service user confirmed that he attended activities he enjoyed such as railway museums, looking at trains and going to McDonalds. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 12 The home is located fairly near to a pub that has a regular disco evening. Staff accompanies service users to this and confirm that they appear to enjoy the music. Other activities that the service users participate in are swimming, the gym, shopping, video sessions, hand massage, foot spa, walking and horse riding. It was reported that sometimes activities could not take place due to home having one small vehicle. The car is not fit for purpose and causes restriction to accessing the local community and further a field. The manager reported that the home pays £200 for each service user for the provision of an annual holiday. One service user said that he had enjoyed a holiday in Weymouth and two weeks that he had spent in Salisbury visiting a relation. Staff confirmed that one service user would love to go to Spain on a holiday to visit a brother who lives there. Family contact is encouraged by the home. One service user stated that he goes home to see his mum every other weekend, which he really looks forward to. He is hoping to go home for Christmas with staff support. During the inspection the inspector observed lunchtime and saw that all service users and staff sat together to enjoy their meal. One service user told the inspector that he enjoyed the food and looked forward to mealtimes. The manager ensures that the meals are nutritional, well balanced and varied. Observation of the menus confirmed this. On occasions the home will order a Chinese take away for a change. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 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): 19, 20,21 Protocols are now in the care plans for the giving of “as needed” medications. Service users are protected by the homes’ policies and procedures for dealing with medication. Arrangements are in place in the event of death of a service user EVIDENCE: The care plans provide evidence of regular contact with healthcare professionals. These include opticians, physiotherapists, podiatrist, occupational therapists, dentists, psychiatrists and GP. Each service user has their healthcare needs assessed and clearly detailed within their plan. It was reported that all service users need support with their personal care. One service user has indicated that he prefers to have a male help him and this is recorded. During the inspection one service user asked a staff member to assist him with a bath later in the day. Mobility assessments are recorded and outline specific individual requirements. One service user may require invasive treatment for their medical condition. All staff has received training in this procedure. All medications are securely locked away and records inspected were clear, concise and accurate. The manager completes a weekly medication stock check. All medication returns and disposals are recorded. Service users all have a medication profile in their plan. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 14 One service user receives support from the organisations’ behavioural specialist to help manage his emotions. Guidelines in place confirm this. Each service user has a section in their plan where any funeral wishes or arrangements are documented discreetly. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 15 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 and 23 The home protects service users from abuse and neglect where possible. The home aims to empower service users to raise concerns if they wish. EVIDENCE: Due to communication difficulties for the majority of service users staff members often have to rely on body language, facial expression and knowledge of an individual to enable them to recognise if someone is unhappy or distressed. The home has a complaints procedure that is also in a pictorial format. A copy of the complaints policy is on display in the hallway and within service users personal files. The inspector spoke to one service user who said that he “was happy” living at the home. A few of the family comment cards stated that they were unsure of the homes complaints procedure. Although a copy is in the hallway, it is recommended that the manager send each interested party a copy. There have been no complaints since the last inspection. A “whistle blowing policy” is in place and staff reported that they knew the procedure for reporting suspected abuse. All staff said that they have seen a copy of Wiltshire and Swindon “no secrets” guidance for staff. The home has now addressed an issue that was raised at the last inspection. Service users no longer pay for meals taken away from the home. The manager confirmed that this is now taken from the homes budget. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 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, 25, 26, 27 and 30 The home provides a safe and secure environment. Each service user has a bedroom that promotes their choice and independence. EVIDENCE: The inspector completed a tour of the home including all service users bedrooms. The home was clean and tidy and had a nice feeling of space. During the inspection service users were observed taking advantage of this. At the last inspection the inspector noted the stained carpet in the hallway. During this inspection the manager received a call to confirm that the new carpet had been ordered. All of the bedrooms are a good size and in good decorative order. All furnishing are matching and reflect the service users individual taste. One service user that he liked his room and that he had picked the colour of it. There is provision in the rooms for service users to be able to relax in armchairs and listen to their music if this is their specific wish. People that wish to watch televisions in their rooms are able to. All radiators have safety covers over them. Each bedroom has an en-suite facility and a Jacuzzi. During the inspection all bathroom facilities were examined and were found to be clean and hygienic. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 17 The home benefits from having a conservatory at the rear of the property that is also used as a dining room. Staff reported that one service user loves to sit in the conservatory during the day. There is a small lounge where service users can watch videos if they wish and another lounge at the front of the house where another television is situated. Staff uses a gate in the kitchen to ensure that the service users are safe when hot pans are in use. There are risk assessments in place with regard to the kitchen are and food preparation. The home has a separate laundry room with drying facilities. Soiled linen is kept well away from the kitchen area. The manager confirmed that the staff team have not yet received Infection Control training. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 18 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, 35 and 36 The home has a thorough recruitment procedure that ensures the safety of service users where possible. All staff receives structured training and refresher courses. Staff are generally supervised and supported well. EVIDENCE: Examination of staff personal files provided evidence that the service users are protected where possible by the home’s recruitment policy and practices. All staff has received satisfactory check of the Protection of Vulnerable adult’s registers and have two written references. All staff have an induction period when commencing employment at the home. The inspector met with seven staff during the inspection. They confirmed that they have received regular training in CPI, Health and Safety, Risk assessments, Fire awareness, Manual handling, safe handling of medicines, Person centred planning, basic food hygiene, disciplinary and grievances and 4 day first aid. Certificates on the personal files evidenced this. Five staff are doing their NVQ level 3 and all staff are registered on the Learning Disability Award Framework (LDAF) prior to undertaking their NVQ award. Staff who spoke to the inspector said that they felt well supported by the manager and the organisation. Records showed that supervisions were not always happening as frequently as they should. The manager confirmed that she is waiting for her senior support worker to complete her supervision training that will then help alleviate the situation, as she can delegate some of the staff supervisions to her. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 19 There is evidence that staff team meetings take place every two months. One staff member reported that he felt there “was a good house team” in place with staff supporting each other. There has been a reduction in the use of agency staff. The home does use bank staff when needed; however these staff are consistent which benefits the service users, as they know them well. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 20 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): 37, 39, 40, 41 and 42 The home is well run by a qualified, experienced and competent manager. Service users are empowered where possible to participate in the development of the home. Policies and Procedures are in place to promote service users rights. There are robust recording systems in place. EVIDENCE: The manager has been in post for eight months and has taken steps to register with the Commission. The manager has almost completed her Registered Managers Award (RMA). She reported that it has been difficult for her to complete, as she has not been able to access an assessor. The manager encourages service users to attend house meetings where they could air any views if possible. Due to communication difficulties some service users are unable to vocalise their views, staff will use pictures and photos to support them if appropriate. All staff have completed mandatory training in manual handling and fire safety, however the manager has been unable to identify training on infection control. This needs to be addressed. The last recorded fire practice was held on 5/8/05 and there is evidence that a Fire safety audit was completed on Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 21 11/10/0. There is evidence that all Health and Safety checks such as water temperatures, Fridge freezer temperatures and the probing of foods are recorded on a regular basis. The home had a Gas safety check on 26/8/05. The homes accident books were examined during the inspection. There is an emergency plan in place which identifies what to do in the case of an emergency e.g. where the stopcock is located and how to turn it off. Risk assessments are in place to protect the service users where possible whilst promoting their independence. There is a locked COSHH cupboard to store any hazardous materials and there is Data to accompany this. The Manager plans to develop methods of monitoring Quality Assurance, which will involve families, friends and stakeholders. Service Users person centred plans include a pictorial quality assurance questionnaire for service to users to complete with staff support if appropriate. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 22 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 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 x x 3 LIFESTYLES Standard No Score 11 3 12 x 13 2 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x x 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hermitage Lane (4) Score x 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 x 3 3 3 2 x DS0000061405.V255234.R01.S.doc Version 5.0 Page 23 Yes 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 2 3 4 Standard 37 42 37 36 Regulation 9(2)(i) 13(3) 18 (1)(i) CSA sect 12 18(2) Requirement The registered manager must complete their NVQ qualification. The registered person must ensure staff receive infection control training The manager must make an application to the CSCI for registration as manager. The registered person should ensure staff receive formal supervision a minimum of six times a year The registered manager must ensure that service users have access to a vehicle that is fit for purpose to enable access to the community activities Timescale for action 01/03/05 12/12/05 12/10/05 12/12/05 5 13 16(2)(m) 12/01/06 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 Refer to Standard 39 Good Practice Recommendations The registered manager should develop a method for monitoring quality assurance. DS0000061405.V255234.R01.S.doc Version 5.0 Page 24 Hermitage Lane (4) 2 3 35 22 The registered manager should develop a training matrix for recording staff training completed and to identify when refresher training is due. The registered manager should ensure that all families receive guidance on how to make a complaint. Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Hermitage Lane (4) DS0000061405.V255234.R01.S.doc Version 5.0 Page 26 - 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. 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