Inspection on 08/02/06 for Mossmead (15)

This inspection was carried out on 8th February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 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) 07/12/05

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 8th February 2006 10:30 Mossmead (15) DS0000028274.V281971.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 Mossmead (15) DS0000028274.V281971.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. Mossmead (15) DS0000028274.V281971.R01.S.doc Version 5.1 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.V281971.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: 15 Moss Mead is one of a number of homes run by the Ordinary Life Project Association. 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.V281971.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a short notice inspection, arranged the previous afternoon. The inspection took place on the 8th February and lasted for 2 hours. The inspector met with three staff members and one service user. The other three service users were at their day care service and staff were in the process of handing over shifts. The following records were looked at; care plans, risk assessments and daily notes and complaint record. There was a partial tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: Reporting incidents by using regulation 37 notifications and ensuring that where necessary, incidents are referred to the Wiltshire Vulnerable Adult Unit. On occasions, there may be incidents that do not easily fit with usual or expected patterns. In such circumstances, it would be to the organisations’ advantage to discuss these incidents with the CSCI or the vulnerable adults unit, rather than conduct an internal investigation in the first instance. Mossmead (15) DS0000028274.V281971.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. Mossmead (15) DS0000028274.V281971.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 Mossmead (15) DS0000028274.V281971.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): 2 Standard not assessed on this occasion, as no new service users have been admitted. EVIDENCE: Mossmead (15) DS0000028274.V281971.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): Standards 6, 7 and 9 were assessed as met at the last inspection. EVIDENCE: Mossmead (15) DS0000028274.V281971.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): 12, 13, 15, 16 Service users have active lives, being involved in the local community, having regular contact with friends and family and in looking after their own home. EVIDENCE: Three of the four service users were out at day care at the time of the inspection. They have clear programmes describing the day care they take part in the community. One service user described in detail where she spends her time. She enjoys a voluntary post at a local care home for older people several days a week and has established relationships there. There are additional activities in the evening, such as Gateway club and other social events. The service user described how much she enjoys her social life. All of the service users have contact with their families. These arrangements are detailed in the care plan. Service users are involved in many aspects in the home. Their roles in housekeeping tasks are described and service users may need some support with meeting these needs. Staff described how sensitively they manage this, enabling service users to do these tasks successfully. Mossmead (15) DS0000028274.V281971.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, 19 The way service users receive personal support and physical and emotional health needs are well described. It is important to ensure that any relief or agency staff understand they must follow this guidance. Standard 20 was assessed at the last inspection with minor shortfalls. EVIDENCE: The way in which service users receive personal care is well detailed in the care plan. However, when cross referencing an entry in a complaint record, it was clear that an agency staff member employed in the home had not followed one aspect of the service user’s care plan. Further information about this can be found in standards 22 and 23. Records are kept of appointments service users have with health care professionals. The care plan goes into some detail about how service users are to be supported in this. Mossmead (15) DS0000028274.V281971.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, 23 Service users may not be able to fully discuss their views. Families may do this on their behalf. Not all of these views have been responded to according to the complaint record. Service users may be protected from abuse, neglect and self harm, however, they way the organisation responded to a recent incident had wider implications for the protection of service users. EVIDENCE: The complaint record was looked at. There were two complaints on file – one had clearly been acted upon and could be cross referenced to meetings held to try to resolve the complaint. It was unclear if the second entry relating to a different service user had been resolved in the same way. Further information about this situation was provided by staff and was available in the care plan file. This involved a situation where a member of agency staff has not followed some clear instructions in a care plan. The family member who saw the service user shortly after this incident was clearly not happy with what had happened. It transpired that the registered manager had reported this to the service co ordinator, who, along with the responsible individual had approached the agency the staff member had worked for and informed them of what had taken place. This incident warranted a Regulation 37 notification, as there was an allegation of misconduct. However, OLPA decided that this did not fit the criteria and did not report it to the CSCI, nor was it reported under the vulnerable adults procedure. This was subsequently reported to the Vulnerable Adult Unit and an investigation is underway. Mossmead (15) DS0000028274.V281971.R01.S.doc Version 5.1 Page 13 On discussing the incident with staff and on looking for clarification for staff about the Wiltshire Vulnerable Adult procedure, it as clear that staff knew of it, but were not fully aware of how it worked. Attempts were made to locate the OLPA adult protection policies and procedures. At the time, only the old policy and procedure file could be located. The following day, the manager contacted the inspector to explain that the file had been in the home the whole time and that she would ensure staff knew of the whereabouts of the file and would be re – inducting them. Mossmead (15) DS0000028274.V281971.R01.S.doc Version 5.1 Page 14 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): Standards 24 and 30 were assessed as met at the last inspection. EVIDENCE: Mossmead (15) DS0000028274.V281971.R01.S.doc Version 5.1 Page 15 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 This standard was not inspected on this occasion as no new staff have been admitted. Standards 32 and 35 were assessed at the last inspection. Standard 32 was almost met and standard 35 was met. EVIDENCE: Mossmead (15) DS0000028274.V281971.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 The quality assurance process needs to be led by the organisation rather than the manager. Standards 37 and 42 were assessed as met at the last inspection. EVIDENCE: The manager is devising her own programme for assessing quality assurance with the care home she manages. Questionnaires are being sent out and information on views are being gathered. Mossmead (15) DS0000028274.V281971.R01.S.doc Version 5.1 Page 17 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 2 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X X X 2 X X X X Mossmead (15) DS0000028274.V281971.R01.S.doc Version 5.1 Page 18 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 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 admission of new service users must be held in the home. This was not looked at during inspection of 8.2.06. Timescale for action 31/03/06 2. YA2 14 (a) (b) 31/01/06 3. YA20 13 (4)c18(1) a 4. YA23 12 (3) 5 b 37 e g 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. The manager informed the inspector that `a training course has been found and staff will attend this in due course. Where there has been an 31/03/06 incident that affects the well being of a service user, or an allegation of misconduct by the registered person, or any person DS0000028274.V281971.R01.S.doc Version 5.1 Page 19 Mossmead (15) 5. YA39 24 (1) (2) (3) who works at the care home, this must be reported using Regulation 37 Notification to the CSCI. There must be a quality assurance system in operation and a report must be sent to the CSCI on completion of the survey. 30/06/06 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. 2. Refer to Standard YA17 YA20 Good Practice Recommendations The choice service users make on ‘free choice’ days and takeaway days should be recorded. (Carried forward from last inspection) An outside professional should be part of the training in drug administration that takes place within the organisation. (Carried forward from last inspection) The responsible individual should give consideration to LDAF training within the foundation induction as part of the NVQ process. (Carried forward from last inspection) 3. YA35 Mossmead (15) DS0000028274.V281971.R01.S.doc Version 5.1 Page 20 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.V281971.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!