Inspection on 23/11/05 for Nelson House

This inspection was carried out on 23rd November 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 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

Nelson House 19/09/07

Nelson House 05/12/06

Nelson House 12/07/05

Nelson House 24/02/05

Nelson House 04/11/04

Nelson House 08/03/04

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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

CARE HOME ADULTS 18-65 Nelson House Brimscombe Hill Stroud Glos GL5 2QP Lead Inspector Mr Paul Chapman Unannounced Inspection 23rd November 2005 12:30 Nelson House DS0000016507.V274296.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 Nelson House DS0000016507.V274296.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. Nelson House DS0000016507.V274296.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Nelson House Address Brimscombe Hill Stroud Glos GL5 2QP 01453 887721 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) Nelson House Recovery Trust Mr Sean O`Brien Corbett Care Home 16 Category(ies) of Past or present alcohol dependence (16), Past or registration, with number present drug dependence (16) of places Nelson House DS0000016507.V274296.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12/07/05 Brief Description of the Service: Nelson House is an adapted Grade II listed building and is registered to accommodate up to 16 adults who are recovering from drug and/or alcohol addiction. Accommodation is provided over three floors with a range of communal rooms. All bedrooms are doubles as it is considered part of the rehabilitative process that residents must share to avoid isolation. The counselling programme is delivered at a nearby adapted old school building and the Trust also runs a training and education centre close by. Nelson House is part of the Nelson House Recovery Trust which comprises the residential care home and also a number of supported housing projects in Stroud and Gloucester. Residents from these houses may also attend the counselling facilities and the training and education centre. Nelson House DS0000016507.V274296.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed over a period of 5 hours on a day in November 2005. The focus of the inspection was to assess the progress of the home towards meeting the 2 requirements of the previous report and to inspect the core standards not covered at the previous inspection. It is recommended for a more comprehensive overview of the service that this report should be read in conjunction with the report dated 12/07/05. As part of this inspection a tour of the premises was completed and the inspector spent time with a member of the counselling team to discuss the assessment, admission and treatment programme. In addition to this the medication administration was assessed along with the recruitment procedure for staff. The inspector would like to thank the staff and residents for their time and cooperation during the inspection. What the service does well: What has improved since the last inspection? Recruitment records now meet the criteria of the regulations. Regulation 26 visits that are required by the CSCI are now being completed each month. The medication administration procedure is comprehensive and meets the criteria of the regulations. Nelson House DS0000016507.V274296.R01.S.doc Version 5.1 Page 6 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. Nelson House DS0000016507.V274296.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 Nelson House DS0000016507.V274296.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 Potential residents are comprehensively assessed ensuring that the home is able to meet their needs before they are admitted. The use of contracts respects the individual’s rights by clearly identifying the expectations and role of each party. EVIDENCE: Counselling staff confirmed that all new residents are issued with the Client handbook. Senior counselling staff are responsible for completing the assessments of potential residents before they are admitted. Evidence of these assessments being completed was available. When a resident is admitted to the home they are asked to sign 3 contracts: 1. Confidentiality 2. Voluntary testing 3. Expectation The inspector saw examples of these documents being signed by the residents. Nelson House DS0000016507.V274296.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 Care plans are developed with the residents’ and regular reviews with their involvement ensure that they are still appropriate and are being achieved. EVIDENCE: The inspector met with a member of the counselling team who explained the assessment, admission and treatment procedures. Records seen clearly indicated that these procedures were being adhered to. Examination of a resident’s file showed that the assessments, care plans, goals and reviews had been completed involving the resident. Records gave evidence that progress was being made towards meeting some goals, whilst others had been achieved. Residents’ record significant events each day and these documents can be used in conjunction with the other elements of their care plans/goals. Risk assessments will be examined in depth at the next inspection. Nelson House DS0000016507.V274296.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): None of these standards were inspected on this occasion. EVIDENCE: Nelson House DS0000016507.V274296.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): 20 Effective management of the medication administration minimises potential risks to the residents. EVIDENCE: The inspector met with one of the staff members responsible for the management of the residents’ medication. The member of staff explained the medication procedure and the inspector examined a sample of the medication records which were seen to be order and meet the criteria of these regulations. Nelson House DS0000016507.V274296.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): Neither of these standards were inspected on this occasion. EVIDENCE: Since the previous inspection the CSCI have received a complaint from a person previously a resident at the home. The inspector has completed an investigation into these allegations since this inspection and copies of the findings are available from the CSCI. Nelson House DS0000016507.V274296.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, 30 The residents’ benefit from a good quality environment that is comfortable, clean and homely. EVIDENCE: The inspector completed a tour of the building with staff. All of the rooms were seen and found to be clean and hygienic. All of the rooms were comfortably furnished to meet the needs of the residents. Bedrooms seen were personalised with residents’ possessions. All of the toilets and bathrooms were decorated to a good standard. Nelson House DS0000016507.V274296.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): 34, 35 Risks to the residents are minimised by thorough recruitment procedures. Staff training minimises potential risks to the residents and ensures that the service provided is of a satisfactory standard. EVIDENCE: The staff spoken with during the inspection were clear about their roles and were able to demonstrate their competence by explaining their approach to meeting the residents needs and a good knowledge of the home’s procedures. At the next inspection the aim will be to examine the staff training records more closely to confirm staff are appropriately qualified. A requirement of the previous inspection was that the home must ensure that 2 written references and a CRB check is received before a new member of staff takes up their duties. In exceptional circumstances, the member of staff may need to commence their duties before the CRB is returned, in which case the home must obtain a POVAfirst check, complete a risk assessment for the person and ensure that they do not work unsupervised, or have access to medication or money, until the full CRB is received. This process was reviewed as part of this inspection and evidence was seen in the recruitment records that the home are adhereing to the regulations. Nelson House DS0000016507.V274296.R01.S.doc Version 5.1 Page 15 A recommendation of the previous inspection report was for a database of staff training to be compiled. The inspector met with the Compliance manager who stated that this had not been implemented as yet but it is planned for the new year. The Compliance manager stated that staff had completed fire safety training and that before the end of this year all of the staff would complete manual handling training. Food hygiene training has been organised for the staff team in January ’06. Nelson House DS0000016507.V274296.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, 42 Regulation 26 visits being completed by a Trustee allows external monitoring of procedures and quality of the service and promotes quality assurance. Risks to the residents’ health and safety are minimised through a comprehensive health and safety policy, staff training and monitoring of the environment. EVIDENCE: At present the home does not have a registered manager in post and the CSCI are working with the chief executive of the Nelson Trust to find a satisfactory solution for both parties. A requirement of the previous inspection report was that the home must ensure that monthly, unannounced visits are carried out by representatives of the Nelson House Recovery Trust and a copy of the written report forwarded to the CSCI. (Previous timescale of 31/03/05 not met). The inspector has received two completed regulation 26 visit forms for September and October and another was due to be completed. Since this inspection was completed the Nelson House DS0000016507.V274296.R01.S.doc Version 5.1 Page 17 inspector has been contacted by the trustee who will be responsible for these visits in the future and the format of future visits was discussed and agreed. The inspector spoke to the Compliance manager (who is also the health and safety officer) about how they maintain a safe environment for the residents. The home has a comprehensive health and safety policy/procedure that staff are aware of and follow. The health and safety officer stated that to ensure that staff are aware of the procedures she explains them to staff as part of their induction. As stated previously fire safety, manual handling and food hygiene training is being addressed. Whilst completing the tour of the premises the inspector was able to see records that confirmed that all the fire equipment was checked appropriately and alarm tests and drills were completed as required by the regulations. Nelson House DS0000016507.V274296.R01.S.doc Version 5.1 Page 18 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 3 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 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X 3 X X 3 X Nelson House DS0000016507.V274296.R01.S.doc Version 5.1 Page 19 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. 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. Refer to Standard YA35 Good Practice Recommendations Compile a database of staff training to show what training has been undertaken, when, and to include dates for refresher training. Nelson House DS0000016507.V274296.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Nelson House DS0000016507.V274296.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. 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