Inspection on 10/01/06 for Manor Road (30)

This inspection was carried out on 10th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Manor Road (30) 25/07/06

Manor Road (30) 19/09/05

Manor Road (30) 27/01/05

Manor Road (30) 14/10/04

Manor Road (30) 15/03/04

Manor Road (30) 06/09/02

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Manor Road (30) 30 Manor Road Potters Bar Hertfordshire EN6 1DG Lead Inspector Mr Robert Kittle Unannounced Inspection 10th January 2006 09:30 Manor Road (30) DS0000019455.V276600.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 Manor Road (30) DS0000019455.V276600.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. Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Manor Road (30) Address 30 Manor Road Potters Bar Hertfordshire EN6 1DG 01707 663 908 01707 663 908 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) H4037@mencap.org.uk Royal Mencap Society Mr Francis G Derrick Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 6 people with learning disability (above 40 years of age). 19th September 2005 Date of last inspection Brief Description of the Service: 30 Manor Road is a two-storey detached house, with six bedrooms. It is located in a quiet cul-de-sac in Potters Bar. The home is within walking distance of the town centre, train station and public transport routes. The home offers support to service users with learning difficulties and mild physical disabilities. Manor Road is a Mencap home. Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this inspection during the morning. Two service users, three staff members and the registered manager participated in the process. This inspection concentrated mainly on the areas not fully covered in the inspection that took place on 19 September 2005 and reference should be made to the resulting inspection report for standards not assessed on this occasion. No requirements were made on this occasion. What the service does well: What has improved since the last inspection? What they could do better: The hall, stairs and landing need decorative attention to bring them up to the standards of the rest of the property. There continues to be a need for additional storage and the introduction of a walk-in shower would be both ageappropriate and would reduce the very real risks associated with elders and the current step-over shower arrangements. Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 6 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. Manor Road (30) DS0000019455.V276600.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 Manor Road (30) DS0000019455.V276600.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): These standards were not assessed on this occasion. EVIDENCE: See inspection report dated 19 September 2005 for the most recent assessment of these standards. Manor Road (30) DS0000019455.V276600.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 and 8 Service users confirmed that they are fully involved in all aspects of their care and this will be enhanced by the introduction of person-centred care planning. EVIDENCE: The staff team have developed close links with the local Learning Disability Team who are currently undertaking follow-up work on two recent dementia assessments. The staff team have reviewed und up-dated all the paperwork including risk assessments, and are working collaboratively on the introduction of person-centred planning. One person-centred care plan has already been finalised and is operational and work constructing the other five has begun. A staff workshop had been scheduled to take place on the afternoon of the inspection day to enable staff to progress their care planning work and there was evidence to support that service users have been pivotal in the creation of the new plans. Service user meetings have taken place since the last inspection and these have been task focussed rather that routine as this has held more relevance for the service users. Manor Road (30) DS0000019455.V276600.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): 11, 13, 15 and 17 Service users enjoy and thrive in an age-appropriate setting where staff encourage the maintenance of skills and develop new interests. EVIDENCE: The service users at this home are advanced in years and, although they do make good use of community facilities, routinely have age and peer groupappropriate activities offered to them. Four of the service users were attending a day centre on this occasion and the two that were at home both went out at different times (one independently and the other shopping with a staff member). The service users at home were able to confirm family and social connections were maintained. Service users participate in food preparation with staff assistance when needed and all are able to make their own breakfast and packed lunch (when attending the day centre). The service users at home were clear that they enjoyed the food provided. Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 11 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, 20 and 21 Ensuring the delivery of appropriate personal and healthcare support is one of the areas where the staff are particularly good. EVIDENCE: Observing the relaxed interaction between service users and staff as well as through conversations with the two differing ability service users that were at home supported the premise that service users are supported in a manner that they prefer and need. Although staff would be glad to support any service user who was assessed as able to manage their own medication, none of the current group is able and none have expressed an interest an interest in managing their own medication. The staff and service users have had the experience of two of their number who have died. However, how individuals would wish to be supported through serious illness and what should be done in the event of their death has not been recorded. The manager plans to contact families wherever practical and address the issues over the next six-month period so that an informed record can be made for each service user. As was recorded in the last inspection report, there are good relationships with the health and social care professionals. Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 12 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 Service users may be confident that their views are respected. EVIDENCE: The two service users that were involved in this inspection were able to demonstrate in their own individual ways that their opinions were sought, listened to and acted upon. Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 13 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, 28, 29 & 30 Overall, the home is well suited to the care of the service users. It is comfortably maintained and kept to a good standard of cleanliness. EVIDENCE: The most recently admitted service user was proud of his room and is still in the process of personalising it. The other service user in the home is well established and her room (which she funded to have decorated) reflects her interests and personality. Overall, the home was well decorated and the standard of cleanliness was good. However, the hall, stairs and landing are in need of decoration and create a poor first impression of the home. Storage space is also at a premium and the space under the stairs was being used as a temporary storage area. It was also noted that shower units have been added to baths. However, to give a real choice, (and considering service users’ advancing years a safe alternative), the provision of a walk-in shower should be considered. Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 14 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): 31, 32, 33, 34, 35 and 36 The service has a well-established and highly trained staff team who demonstrate that the needs and life goals of the service users are paramount. EVIDENCE: The staff team are experienced carers who appear to have taken advantage of training opportunities offered. They exceed the national minimum standard recommended level of qualifications at NVQ 2 and several members of staff are engaged in (or have obtained) the qualification at level 3. The team work well together and have themed workshops where they work cohesively to achieve a task (and are currently concentrating on person-centred care plans). Staff on duty stated that the minimum six formal one-to-one supervision sessions are exceeded each year. There are robust recruitment procedures and the manager has all documentation required by legislation available for inspection. It was recommended that a separate register of CRB disclosures containing the unique number, individual’s name, date of birth and postcode be kept. This would enable the original documents to be destroyed after an inspection and provide an opportunity for the inspecting officer to sign under the last entry as a demonstration that the documents had been made available. All documentation seen was satisfactory. Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 15 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): 42 The requirement relating to this standard that was made in the inspection report dated 19th September 2005 had been fully met. EVIDENCE: The home appeared to be well managed and the health and safety of both service users and staff was protected. Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 16 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 X ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 2 30 X STAFFING Standard No Score 31 3 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 2 X X X X X 3 X Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 17 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. Standard Regulation Requirement Timescale for action 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. 3. 4. 5. Refer to Standard YA21 YA24 YA28 YA29 YA34 Good Practice Recommendations It is recommended that families be approached to establish how the home should deal with the death of each service user (and a record to be made). The hall, stairs and landing should be brought up to the decorative standards of the rest of the house. Consideration should be given to the creation of additional storage space. It is strongly recommended that a walk-in shower be provided to negate the potential danger of the current bath/shower combined arrangements It was recommended that a CRB disclosure register be created to enable the disclosures currently held to be destroyed. Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Manor Road (30) DS0000019455.V276600.R01.S.doc Version 5.1 Page 19 - 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. 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