Inspection on 07/12/05 for Mossmead (15)

This inspection was carried out on 7th December 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mossmead (15) 07/08/06

Mossmead (15) 08/02/06

Mossmead (15) 02/02/05

Mossmead (15) 01/10/04

Mossmead (15) 23/03/04

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 Mossmead (15) 15 Mossmead Chippenham Wiltshire SN14 0TN Lead Inspector Mrs Jacqui Burvill Unannounced Inspection 13.30 7 December 2005 th Mossmead (15) DS0000028274.V257076.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 Mossmead (15) DS0000028274.V257076.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. Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mossmead (15) Address 15 Mossmead Chippenham Wiltshire SN14 0TN 01249 461587 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) Ordinary Life Project Association Mrs Linda Hunter Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2005 Brief Description of the Service: 15 Moss Mead is one of a number of homes run by the Ordinary Life Project. This home accommodates four service users who have a learning disability aged between 18 and 65 years. The home is staffed at all times by at least one member of staff when the service users are at home. This includes nights, when at least one member of staff sleeps in. Service users have their own bedrooms, which are well decorated and furnished. One of the bedrooms has an ensuite shower room, with a toilet and hand washbasin. There is a downstairs toilet and hand washbasin. On the first floor there is a communal bathroom and a separate shower room. There is a large lounge and dining room with a separate kitchen and utility room on the ground floor. Access to the first floor is by stairs only. There is an enclosed rear garden, laid to lawn and patio, with a summerhouse. Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was arranged at short notice as two visits had been made when no one was at home. The inspection lasted for 3 hours and 15 minutes. Two service users and one member of staff were at home during the inspection. Part way through the inspection, the staff member collected the other two service users from day care whilst the inspector waited outside. All of the service users were met with and although service users are not able to comment directly on their care, they discussed the lives they lead and what they enjoy doing. The inspector observed the interactions between the staff member and the service users. The following areas were looked at; admission and assessment documents, care plans, daily notes, medication and medication records, accident records, the staff rota and staff training records. What the service does well: What has improved since the last inspection? What they could do better: It is important that when staff are expected to administer any invasive procedure, that their competency to do so is assessed by a healthcare professional. Menu records need to be more accurate, especially when recording service users’ ‘free choices.’ Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 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. Mossmead (15) DS0000028274.V257076.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 Mossmead (15) DS0000028274.V257076.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): 2 A lack of formal evidence suggests that the admission policy and procedure is not followed. This may mean service users are not assessed prior to admission. EVIDENCE: There has been one new service user admitted since the last inspection. There is an admission policy and procedure, which states that there should be an initial visit and then further visits to meet the service users and staff at the home. This could include sharing a meal together and staying overnight. The policy and procedure also state that there is to be a record kept in the home of each stage of the plan. There was no formal evidence that this took place. Staff confirmed that there had been visits, but no overnight stay and this did not seem to be appropriate to the service user at the time. There was evidence of previous history and information from the previous placement, but no evaluation of the process as described. The manager, who spoke to the inspector following the inspection, stated that a record had been made and may be held in another office. There was a record of a review of the placement following a three month trial period. Comments made about the purchasing authority were complimentary about the effect the move had on the service user. Comments were also made that there were improvements to health and well being through a consistent approach by the staff team. Mossmead (15) DS0000028274.V257076.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, 9 Service users benefit from well constructed care plans, guidelines and risk assessments. EVIDENCE: The care plan for one service user was seen. This showed a comprehensive range of needs and how the staff team at the home would meet them. Guidelines were well written and clear and easy to follow. There are some particular restrictions and these were well described. The entire care plan was in date. The care plan was linked to risk assessments and all of these were relevant in date. Daily records are made at least twice a day and describe the activities and tasks the service user had taken part in, as well as contact with family and friends. On occasion, the staff had recorded where service users had made alternative choices. This is good practice. Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 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): 17 Service users benefit from a healthy diet available in the home. EVIDENCE: During the inspection, the staff member was preparing the evening meal. This was because service users were going to a social club that night. The evening meal consisted of cauliflower cheese, grilled bacon and potato wedges. All of this food was freshly prepared. The staff at the home see nutrition and healthy freshly prepared food as an important part of the service they offer. The menu record could be improved as staff are not recording the meals at lunchtime on every occasion. Most days, service users take a packed lunch to their day care. There are occasions when service users have a free choice, or a takeaway and these options have not been recorded regularly. The health of one service user has dramatically improved as a result of the healthy diet on offer in the home. Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 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): 20 Service users receive appropriate medication. One aspect of healthcare support may pose a risk to a service user from a lack of staff training. EVIDENCE: None of the service users self medicate in the home. All of the medication and accompanying records were in order. Staff are responsible for taking blood tests weekly and have not received training in how to do this. Staff spoken with said they felt they were competent, as they had received training in the past. Staff do need to have training from a person qualified to assess staff. This may be a healthcare professional. Health and safety procedures were in place to deal with this. Staff have received training within the organisation on ‘drug administration’. Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 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): These standards were not looked at on this occasion. EVIDENCE: Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 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, 30 Service users live in clean, comfortable, safe and attractive surroundings. EVIDENCE: 15 Moss Mead provides good quality accommodation, which is well furnished and decorated. Service users are involved in making choices over the décor of their room and the communal areas. Staff commented that when the choice may be inappropriate then they are supported to choose an alternative colour. Service users also choose furniture for their room and pictures to make the room more homely. Two bedrooms were seen with the service users on this occasion. Both commented on how they liked having certain things in their rooms, such as TV and computer. Two service users spent the majority of time in their own rooms, with staff popping in and out to see if they were in need of anything. During the inspection, staff stayed with service users in their rooms for up to 20 minutes at a time, singing with them and engaging them in conversation. Service users were observed to move around the home comfortably, using the kitchen to clear away their packed lunches and to have a drink as they arrived home. The home was clean and tidy on the day of inspection. There is a separate utility room next to the kitchen. Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 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): 32, 35 Service users are supported staff who have some knowledge of their needs. EVIDENCE: One newly appointed staff member has completed NVQ level 2 but has not received the certificate yet. Other staff have been put forward to enrol onto NVQ training, as this is a requirement within the organisation. Staff have received in house training in fire safety, abuse awareness, epilepsy, moving and handling and medication since the last inspection. Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 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): 37, 42 The home is well run and in the service users’ best interests. The health, safety and welfare of service users is promoted and protected. EVIDENCE: The manager has been in post for several years and in the last year has been registered to run two three bedded homes within the organisation. The manager clearly states on the rota which home she is working in on any particular day. Staff spoken with said that they had no difficulty with this as the manager balanced both roles very well. The manager has recently completed the Registered Managers Award. There are safety data sheets in place for any cleaning products used in the home. Most of the radiators are covered and those that are not are risk assessed. Water temperatures are regulated and recorded. All fire safety records were in order. Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mossmead (15) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000028274.V257076.R01.S.doc Version 5.0 Page 17 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. Standard YA1 Regulation 5 (1) (c) Requirement Timescale for action 31/03/06 2. 3. YA2 YA20 14 (a) (b) 13 (4)(c) 18(1) (a) The responsible individual must ensure that all service users have a contract in place from the placing authority. (One new service user has a contract in place.) There are unresolved issues with the organisation and the placing authority, which have been an issue for over 2 years now. This was to be actioned by 31st May 2005 Records of assessment for the 31/01/06 admission of new service users must be held in the home. Where staff are expected to test 27/02/06 for sugar levels using an invasive procedure, staff must be trained and assessed by a person competent to do so. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 Page 18 1. 2. 3. YA17 YA20 YA35 The choice service users make on ‘free choice’ days and takeaway days should be recorded. An outside professional should be part of the training in drug administration that takes place within the organisation. The responsible individual should give consideration to LDAF training within the foundation induction as part of the NVQ process. Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 Page 19 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 Mossmead (15) DS0000028274.V257076.R01.S.doc Version 5.0 Page 20 - 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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