Inspection on 06/10/05 for Pathways

This inspection was carried out on 6th October 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pathways 04/12/07

Pathways 10/01/07

Pathways 09/02/06

Pathways 22/02/05

Pathways 24/09/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Pathways 56a Baden Powell Drive Colchester Essex C03 4SR Lead Inspector Steve Boyd Final Unannounced Inspection 09:30 6th October Pathways DS0000017904.V252842.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 Pathways DS0000017904.V252842.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. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pathways Address 56a Baden Powell Drive Colchester Essex C03 4SR 01206 761680 01206 862750 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) Mr Pelandapatirage Gemunu Susantha Dias Mr Jean Ghislain Domingue Mr Jean Ghislain Domingue Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home accommodates 12 people with learning disabilities who may also have physical disabilities 22nd February 2005 Date of last inspection Brief Description of the Service: Pathways is a care home providing personal care and accommodation for 12 individuals with learning disabilities and physical disabilities. It is owned by Mr Dias and Mr Domingue. manager. Mr Domingue is the registered Pathways consists of two purpose built, detached bungalows set back from a quiet road in the Shrub End area of Colchester. The home is within easy reach of local shops and a short journey from Colchester town centre, either by public transport or car. The home has it’s own transport. Well maintained and purpose built, all accommodation is in single rooms, two of which have en suite facilities and there is easy access to all areas of the home and grounds. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day, in October 2005. The inspector spoke with four service users, several staff and the manager during the course of inspection. The inspector also contacted the relative of one service user by telephone to ascertain their views on the service offered at Pathways. A tour of the premises was undertaken and various records and policies were viewed throughout the inspection. Twenty-two of the forty-three National Minimum Standards were assessed at this inspection and twenty-one were found to be met. What the service does well: What has improved since the last inspection? Both bungalows have benefited from much redecoration since the last inspection, meaning that the home maintains an excellent environment for service users. New lounge furniture has been purchased for both lounges. The home has developed a quality assurance system and completed the first cycle of monitoring and reviewing service users’ and interested parties’ views on the home. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 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. Pathways DS0000017904.V252842.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 Pathways DS0000017904.V252842.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 Prospective service users could be confident their individual aspirations and needs would be assessed. The home has not had any new admissions for some period of time. However, a policy on admissions was seen to be in place that outlined the home’s assessment process and who would be involved in that. EVIDENCE: Evidence was seen on existing service users’ files that they had been subject to assessments prior to their admission to the home. Pathways DS0000017904.V252842.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 were found to have individual plans of care, which reflected assessed and changing needs. Service users are encouraged to make decisions about their lives with appropriate assistance as necessary. Risk is understood as a part of service users’ lives. EVIDENCE: Individual plans were seen to be available for a number of service users sampled during the inspection. The plans identified needs of service users, as well as aspirations. Actions on how to implement goals were recorded within the plans and reviews were seen to take place at periodic intervals. Service users and their representatives were involved in the care planning process, where able, and an ethos of encouraging independence as much as possible was clear in the care planning. Risk assessments were seen to be available for service users with strategies in place as to how to minimise the risk to individual service users. For example, one service user had a risk assessment that included strategies on how to manage road safety. Pathways DS0000017904.V252842.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): 12, 13, 15, 16 & 17 Service users were found to be able to take part in appropriate activities, given their age and cultural background. The local community was utilised in different ways by service users. Service users had appropriate personal and family relationships. The rights and responsibilities of service users were seen to be recognised. Service users enjoyed their meals and mealtimes. EVIDENCE: Activities for service users included those that took place in the home and outside of the home. Within the home service users enjoyed music, television, DVDs, computers etc. Outside of the home service users attended a local Gateway club, go swimming, visit pubs and local shopping centres. Service users also attend a local day centre and educational centres to pursue interests such as craftwork. Service users utilise various facilities in the local community for example libraries, shops and pubs. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 11 Service users spoken with during the inspection all had contact with their families to varying degrees. Some had also made friends from the clubs and day centres they attend. The service users spoke positively about the relations they had with their family and friends. The inspector observed service users being afforded privacy and dignity during the inspection and being asked for their views on a range of matters. Service users’ comments were very positive about the food on offer at the home. Individual food intake is recorded for each service user and menus seen during the inspection reflected a good choice of foodstuffs on offer. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 20 Service users received support in the way they required and preferred. The home’s medicines policies and procedures were appropriate for the needs of service users. EVIDENCE: Service users able to comment spoke well about their relationships with staff and indicated that where they needed assistance, for example with personal care, that this was given in an appropriate and dignified manner. The home operates a monitored dosage system of medicine administration. This was checked in one of the bungalows and generally found to be working well. The inspector did advise that one bottle of Tegretol be sent back to the pharmacy to avoid over stocking on this particular medication. None of the service users at Pathways have been assessed as being able to administer their own medication. Staff who administer medication have had training in administration techniques, uses and side effects. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 13 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 who were able to comment felt their views were listened to and acted upon. The home is aware of the need to protect services from abuse, neglect and self-harm. EVIDENCE: The home had not recorded any complaints from service users or others since the previous inspection. The inspector was not aware of any complaints having been made direct to the Commission for Social Care Inspection. No service user spoken to during the inspection raised any concerns or complaints about the home or their treatment. No one in the home has been subject to Protection of Vulnerable Adult Procedures or investigation since the previous inspection. Policies and procedures on the Protection of Vulnerable Adults were seen to be in place. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 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): 24, 25, 27 & 30 Service users live in a homely, comfortable and safe environment. Their bedrooms were seen to reflect their needs and lifestyles. Suitable toilets and bathrooms were available for service users. The home was found to be clean and hygienic during the inspection. EVIDENCE: As indicated in the summary section, plenty of redecoration had taken place in both bungalows since the last inspection. This further enhanced the already good environment. No safety hazards were noted during the course of inspection in either of the bungalows. Service users’ bedrooms were seen to be individually decorated and furnished to meet their tastes and needs. Evidence was seen of photographs, paintings, ornaments, music systems, televisions etc. Toilets and bathrooms within both bungalows offered privacy by means of locks. The space within bathrooms and en-suite facilities was adequate to meet the needs of service users, as was the equipment with the bathrooms. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 15 The home was found to be clean and odour free during the course of inspection. Service users were able to help with keeping their rooms clean and tidy. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 16 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 & 34 Service users appeared to be supported by competent and qualified staff, though better record keeping was necessary in this respect. The home’s recruitment policy and practices serve to help support and protect service users. EVIDENCE: The inspector was not able to see an individual record of each staff’s training and qualifications. Evidence was seen on various staff files of them having attended relevant courses, including National Vocational Qualification training. Staff spoken with during the inspection presented a competent and knowledgeable about service users. Evidence was seen on staff files of application forms having been filled in, references taken up, Criminal Record Bureau checks undertaken and an induction period being followed. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 17 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, 39 & 40 Service users benefit from a well managed home. assurance system includes the views of service users. The home’s quality The home’s policies and procedures are robust and accessible to staff and interested parties. EVIDENCE: Mr Domingue has been the manager of Pathways for many years, since the home opened and has relevant professional qualifications. The home’s quality assurance system was seen during the inspection. Views of service users and significant others had been sought on a range of issues and responses had been audited and presented in numerical and graphical form. Only minor areas had been identified as requiring action and these had been addressed. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 18 The home had a comprehensive set of policies and procedures, alphabetically indexed for ease of use and available to staff for reference. Polices and procedures sampled during the inspection put service users’ best interests as their prime focus. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 19 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 3 X X X Standard No 22 23 Score 3 3 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 3 3 X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pathways Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 X X X DS0000017904.V252842.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA32 Regulation 17(2) Requirement The registered person must keep sufficient records of staff training to allow an appropriate judgement to be made on the overall competence and qualification of staff within the home. Timescale for action 30/11/05 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 YA20 YA24 Good Practice Recommendations It is recommended that medication surplus to the needs of service users is returned to the pharmacy. It is recommended that an additional garden shed be purchased for the home. Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Pathways DS0000017904.V252842.R01.S.doc Version 5.0 Page 22 - 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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