CARE HOME ADULTS 18-65
Manor Road (30) 30 Manor Road Potters Bar Hertfordshire EN6 1DG Lead Inspector
Louise Bushell Unannounced Inspection 19th September 2005 10:00 Manor Road (30) DS0000019455.V259081.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 Manor Road (30) DS0000019455.V259081.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. Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 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) Royal Mencap (Housing & Support Services) 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.V259081.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. This home is registered for 6 people with learning disability (above 40 years of age and above 65 years of age). 20th April 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.V259081.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection of the year, taking place early morning to mid afternoon. It was an extremely positive inspection, reflecting the comments made by both service users and staff at the home. Time was spent with two members of staff and a number of service users who were present throughout the inspection. This inspection focused specific areas; service users needs and environment. A number of the key standards were inspected. What the service does well:
There are many areas in which the service is performing well. On the day of inspection, it was observed that the home presents as a warm, cosy, homely environment, where the needs of the service users are paramount to the smooth running of the home. Each service users bedroom is individualised to reflect their personalities and characters in turn. The garden area presents as a well-maintained area that encourages the service users to access in the warm months, with appropriate seating available. All service users have been provided with a Statement of Purpose and Service Users Guide, both of these documents are extremely well presented and service user focused. The documents are pictorial and meet the diverse communication needs of the service user group. These documents are regularly reviewed. Following the inspection of numerous records regarding the specialist services provided to the service users, it is clear that the staff have a sound working relationship with other professionals. Staff interactions were extremely positive and tailored to meet individual needs. A new member of staff was completing part of her induction programme during the inspection. Mencap provide a detailed and well-structured induction and foundation sessions for all new members of staff. This includes mandatory training sessions, which ensures the core skills of the staff team are supported. COSHH data sheets are well organised and reviewed regularly, thus ensuring that the health and safety standards are maintained in the best interest of the staff and service users. Risk assessments are detailed and cover numerous risk areas, which are personal to the service users and specific to the home. A sound system is in place for recording the fridge and freezer temperatures, the fridge was organised to ensure that food hygiene good practice principles had been adhered too. Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 6 Due to the service user group aging, the staff are currently completing referrals to determine the possibility of early onset dementia for a number of service users. What has improved since the last inspection? What they could do better:
A number of service users have limited links with persons out side of the home. It is recommended that referrals are made to an independent advocacy service to support in decisions in service users life’s, thus supporting in the gathering of information to support in the implementation of person centred planning. In the ground floor toilet, there is a need for a blind to be up at the window, to protect and dignify the service users. A hand towel dispenser is required also in the toilet to ensure appropriate measures are in place for the management of infection control and sound hygiene practices being encouraged. A system must be implemented to record core food temperatures; these must be recorded as part of food hygiene practices. A service user has recently moved into Manor Road; he is in the process of making and being supported to make choices regarding the general decoration of the room. The large sofa bed must be removed from the room. Many service users have active guidelines in place to support in the sound management and the meeting of specific individual need. There is a need for these guidelines to be signed and dated to ensure that all guidelines are in place are working documents that are reviewed periodically. Where free standing fans are located, there must be a risk assessment implemented to ensure the effective management of risk. Continence aids
Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 7 were observed on the chairs in the main lounge area. These must be removed to promote and dignify service users. Service user meetings take place to ensure the needs, choices and preferences with service users occur. It is recommended that these are undertaken more frequently to increase consultation. 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.V259081.R01.S.doc Version 5.0 Page 8 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.V259081.R01.S.doc Version 5.0 Page 9 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): 1, 2, 3, 4 & 5 The service users guide and statement of purpose are comprehensive and informative documents for service users to determine and make positives choices within the their lives about where to live. EVIDENCE: A comprehensive Statement of Purpose is held within the home and all current and prospective service users are provided with a copy. The Statement contains information for the service user to make an informed choice about where to live. The documents are good working examples are tailored to meet individual needs. The content of the Terms and Conditions of Tenancy is comprehensive, The home is currently working on systems within the home to present a greater person centred approach. Plans are currently being drawn with the involvement of the service users. A service user has recently moved into the home. Following discussions with him, it is determined that the service user felt very supported throughout the process. The admissions procedure to the home includes trial visits for the service users to make an informed choice about where to live. There is a detailed referrals and admission procedure to the home. Detailed assessments remain on all service users files and include a medical and a social history. Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 10 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, 9 & 10 Individual needs and choices are reflected in the service user care plan ensuring changing need and goals are reviewed, meet and developed. EVIDENCE: Individual needs and choices are reflected in the service user care plan ensuring changing need and goals are reviewed, meet and developed. Person centred planning systems are currently being implemented, ensuing that service users choices, preferences and needs are being met. All service users have an individual care plan and an allocated key worker to support them in the home. Individual daily notes and guidelines for the service users where observed within the home. All service users are supported within the Care Management Framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed. The ethos in the home promotes that the care plans of each individual are owned by the individual. Currently the management, staff and service users are adapting all care planning systems to ensure and develop a person centred approach to all work. The system appears to be effective as working document and focuses on service users individual goals and aspirations. Once fully operational this will be effective.
Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 11 Each service user has numerous plans and working guidelines in place that further support the home in effective management and support in the best interests of the service user. There is a need to ensure that these guidelines are signed and dated to ensure that the records pertaining to the service users are accurate and up to date. The home holds service user meeting. However, it is recommended that as part of a consultation process in meeting service users needs, wishes and preferences that these should occur more frequently. It is recommended that advocacy services are contacted to ensure that the rights and choices of the service users are supported and represented at all times. All information is handled with care and respect. All personal notes and files detailing information on the service user are locked away. Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 12 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, 14 & 16 Personal development opportunities are encouraged for all service users ensuring interactions within the local community and that individual rights and responsibilities are recognised and supported. There are also a range of opportunities for engagement in activities in the home. EVIDENCE: The home encourages inclusion into the local community thus enabling integration into community life. Service users attend a day centre which is suitable to their individual needs and aspirations. Discussions with the service users supported by staff determined that they have a variety of day activities to be involved in. Enquiries are being made by the providers about further day care provisions. The home has access to transport and allocated drivers. Staff support and encourage all service users to maintain and develop social, emotional, communication and independent living skills. The involvement and encouragement of the service users in a variety of tasks was observed throughout the inspection.
Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 13 The home is centrally located, a short distance form shops and the local community amenities. The home values and seeks to reflect racial and cultural diversity of service users through celebration of, and awareness of different cultures, religions and festivities. During the inspection staff and service users were observed to interact equally with one another. Service users are supported appropriately to take part in activities in the home. Individual needs, choices and preferences are always considered. A record of activities is maintained in the daily recording system. Service users access the local community services frequently and visit the local area, enjoying going out for lunch and shopping. Activities that are provided are age appropriate and meet the current needs of an ageing service user group. Recently activity items have been purchased to encourage one to one and group engagement. Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 14 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 health needs are met, ensuring that their safety, wellbeing and health is promoted at all times. All personal and health care support is well maintained in the home ensuring individual needs, choices and preferences are met at all times. EVIDENCE: All care provided is individual and tailored to each person, with service users needs, choices and preferences being promoted. Service users needs are supported with all aspects of their physical and emotional health and receive adequate and appropriate input from specialists such as community nurses, consultants, GP, dentists, opticians and dieticians. Information and advice is provided to all services users regarding general health issues. Service users confirmed that the care provided is tailored to their individual needs and choices and preferences are always supported. Manor Road (30) DS0000019455.V259081.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): 23 Robust policies, procedures and training are in place to ensure service users are protected and safe. EVIDENCE: Robust procedures are in place to ensure that service users are protected from abuse and harm. Staff receive suitable and adequate Protection of Vulnerable Adults (POVA) training, which is currently occurring within the home. Staff are all subject to enhanced Criminal Records Bureau (CRB). Staff personnel files were unable to be inspected due to the manager not working during the inspection. Training records reflected that protection of vulnerable adults training has occurred. Manor Road (30) DS0000019455.V259081.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, 28, 29 & 30 The environment is comfortably maintained, thus promoting a homely, comfortable safe space for service users to live. All resources and equipment is provided within the home, ensuring specialist and individual needs are promoted and changing needs met at all times. Shared space both compliments and supplements service users individual space ensuring that individual space is tailored to personal style and taste. Minor works are required to ensure that privacy is maintained. EVIDENCE: All bedrooms are well maintained and decorated. All service users are supported and empowered to decorate their individual rooms to their taste and reflecting their own personalities. Toilet and bathing facilities ensuring that choices and preferences can be met, and specialist equipment is available as per individual service user need. The home was clean and hygienic throughout. In the ground floor toilet, there is a need for a covering to be up at the window, to protect and dignify the service users. A hand towel dispenser is required also in the toilet to ensure appropriate measures are in place for the management of infection control and sound hygiene practices being encouraged. Equipment is provided to ensure
Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 17 that the individual needs of the service users are currently being met. Where free standing fans are located, there must be a risk assessment implemented to ensure the effective management of risk. Manor Road (30) DS0000019455.V259081.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): Not inspected on this occasion. EVIDENCE: Standards not inspected on this occasion. Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 19 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, 38, 40, 41 The management within the home is secure and effective ensuring that changing needs of service users are met and that the home is running meeting its aims and objectives. Systems for effective health and safety management are in place. EVIDENCE: The relationship between the service users and the staff is well balanced with interactions observed as being appropriate and supportive. The ethos and management approach of the home creates an open, positive and inclusive atmosphere. Staff and service users spoken to commented that they feel extremely supported and they feel the home is well managed. A clear commitment is made to equal opportunities, with staff and service users expressing positive views with regards to this. The service users appeared to benefit from this well structured and well run home. Service users spoken to during the inspection appeared to be happy with the home and appeared to be relaxed in their environment. Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 20 The staff team and the manager are adequately trained and experienced to ensure that service users needs are being met. Periodic training occurs within the home to ensure staff development is maintained. The home has a vast range of policies and procedural guidelines in place. Staff are requested to read and sign risk assessments and polices. There are a multitude of risk assessments in place. All records required by regulation were available and maintained. All records are secure within the home and were up to date and held in accordance with the Data Protection Act 1998 ensuring that service users rights and best interests are safe guarded by the homes polices and procedures. Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 21 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 3 3 3 3 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 2 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 3 2 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Manor Road (30) Score X 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 2 X DS0000019455.V259081.R01.S.doc Version 5.0 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (2) (b) Requirement Timescale for action 30/11/05 2 3 YA8 YA42YA24 24 (3) 13 (4) Guidelines and plans implemented must be signed and dated to ensure accurate recording occurs. Service user meetings to occur 15/12/05 more frequently. A freestanding fan risk 15/11/05 assessment must be implemented. Following the inspection, this has since been implemented. A blind and hand towel dispenser must be erected in the ground floor toilet area. 15/12/05 4 YA28 13 (4) (c) 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 YA7 Good Practice Recommendations It is recommended that the service users meetings occur more frequently. Manor Road (30) DS0000019455.V259081.R01.S.doc Version 5.0 Page 23 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
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