Inspection on 09/02/06 for Pathways

This inspection was carried out on 9th February 2006.

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 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 4 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 06/10/05

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 Tim Thornton-Jones Unannounced Inspection 9th February 2006 09:30 Pathways DS0000017904.V282892.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 Pathways DS0000017904.V282892.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. Pathways DS0000017904.V282892.R01.S.doc Version 5.1 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.V282892.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home accommodates 12 people with learning disabilities who may also have physical disabilities 6th October 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 its own transport. Well maintained and purpose built, all accommodation is in single rooms, two of which have en suite facilities, there is easy access to all areas of the home and grounds. Pathways DS0000017904.V282892.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection focussed upon the need to ensure that all core National Minimum Standards had been inspected within the period of April 2005 to March 2006. All of these standards have been inspected during this period, in addition to others selected in relation to the service objectives and the service user group accommodated. Over the year, 33 National Minimum Standards (NMS) have been assessed. The first inspection highlighted one shortfall and two recommendations. This inspection concluded that this standard remained unmet, with three further standards rated at below compliance with NMS. This indicates an increased short fall, although overall the service was rated as good with a high proportion of NMS being achieved. The dwelling in which the inspection was focussed was clean, well decorated, furnished and equipped. The Manager and Deputy Manager demonstrated sound understanding of the requirements and of good professional practice. Service users spoken with were very cheerful, enthusiastic and upbeat. The interaction between carers and service users was observed as supportive and positive. Overall the service delivers a positive and supportive environment. What the service does well: What has improved since the last inspection? • The service has maintained a good standard of care outcomes for service users, although the inspection did not identify any particular developments. Pathways DS0000017904.V282892.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. Pathways DS0000017904.V282892.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 Pathways DS0000017904.V282892.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): 4 • Service users benefit from the home’s admission procedures. EVIDENCE: The service has infrequent admissions to the home and therefore assessment of practice was limited. Resulting from records available and discussion with the Manager it was established that the home has an admissions procedure that includes a three month trial period and incorporates terms and conditions of stay. Pathways DS0000017904.V282892.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): • None of the National Minimum Standards within this group were assessed on this occasion. EVIDENCE: Standards 6, 7 and 9 were assessed at the previous inspection and were found to comply with National Minimum Standards. Pathways DS0000017904.V282892.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): 14 • Service users benefit from planned leisure opportunities. EVIDENCE: Resulting from discussion with some of the service users at the home, the Manager and various records seen, service users regularly access social and leisure opportunities within the Colchester area. These typically include swimming and tenpin bowling at the leisure centre, and specific social clubs. Service users also attend further education and occupational based activities, including self help courses and other training based activities. Pathways DS0000017904.V282892.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): 19 • Service users benefit from appropriate personal and healthcare support. EVIDENCE: Service users spoken with were confident and relaxed and spoke well of the support they receive. The observed interactions between those who live and work at the home were supportive and friendly. Service users are encouraged to access healthcare services through outpatient appointments in accordance with the overall philosophy of the home. Service users are encouraged to be as involved as possible in matters associated with their health and welfare. Periodic healthcare checks are arranged with all main primary healthcare professionals as appropriate. Pathways DS0000017904.V282892.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 and their representatives have access to a complaints procedure. Arrangements are in place to report matters of adult protection. EVIDENCE: The home has a complaints procedure that meets with National Minimum Standards. The service has not investigated any complaints during the period since the previous inspection. Shortly before this inspection CSCI received an anonymous complaint in relation to the care of a service user. This matter was discussed with the Manager who was asked to proceed with the matter as a formal complaint and provide findings to CSCI in due course. The home was able to show that a policy and procedure was in place to help protect vulnerable people from abuse. Both of these standards were examined at the previous inspection and were found to meet with National Minimum Standards. The arrangements have not altered and continue to meet with requirements. Pathways DS0000017904.V282892.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): 26, 28 & 29 • Service users benefit from individualised bedrooms and comfortable shared spaces that have been adapted, where appropriate, to meet their daily living needs. EVIDENCE: Not all rooms were visited on this occasion, however, from the rooms seen, all were individual in nature reflecting the personality of the individual occupant. One was ‘themed’ to reflect the specific interests of the service user, who expressed satisfaction with the room and how it looked. Shared rooms were comfortable and were adapted as appropriate. The Inspector spoke with one service user who uses a wheel chair and demonstrated that they were able to, for example, reach light switches. The home has some adaptations and equipment for the specific use of those who have mobility difficulties. These include lifting equipment, levelled surfaces, grab handles and similar features. The home achieves a good balance between an environment for those with and without physical disabilities. Pathways DS0000017904.V282892.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): 32, 33, 35 & 36 • The standards inspected within this section showed that service users do not fully benefit from a well managed service. EVIDENCE: The home was not able to show that a training and development plan was in place for the service as a whole or for each individual staff member. Some training had taken place, although it was noted it was not always co-ordinated or linked to the specific need of the service. Whilst the training undertaken was relevant, there was no rationale for priorities. The Manager was advised to ensure that all staff had an assessment of their existing knowledge, skills and experience to determine the possible ongoing development and training needs required. This should be linked to the service requirements and service users’ needs. The supervisory approach was examined and a sample of staff files were seen. This showed that whilst all staff were receiving support through organised supervision, in addition to unstructured support, the frequency of recorded sessions did not meet the requirements set out in National Minimum Standards. The Manager should ensure that all parties sign all supervision records. Pathways DS0000017904.V282892.R01.S.doc Version 5.1 Page 15 It is recommended that the Manager undertake an additional service user/staff ratio assessment to determine the staff requirement for service support tasks such as cooking, cleaning and laundry. The ratio calculation is conducted using a method recommended by the Department of Health, however, this only calculates the number of hours required to provide personal care. At the time of inspection the assessment concluded that 244.93 hours were required with 364 hours deployed. Pathways DS0000017904.V282892.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): 41 & 42 • • Some record keeping is in need of improvement. Service users benefit from satisfactory arrangements regarding health and safety. EVIDENCE: A sample of records were examined and were mainly satisfactory. The requirement for the Registered Person to complete a monthly conduct report, under Regulation 26 of the Care Homes Regulations, was not available for inspection. Staff related records were not all in place. Based upon the tour of the building, whilst not all parts of the home were visited, there were no obvious health and safety issues noted. The home was maintaining adequate records in this regard. Pathways DS0000017904.V282892.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 3 5 X X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 3 27 X 28 3 29 3 30 X STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 X X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X X X X X 2 3 X Pathways DS0000017904.V282892.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? YES 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) Timescale for action The Registered Person must 30/06/06 ensure that staff have all of the competencies required to meet the needs of service users accommodated. The Registered Person must 31/03/06 ensure that a suitable staff development and training programme is in place. This is a repeat requirement. The Registered Person must 30/04/06 ensure that staff are adequately supervised. The Registered Person must 31/03/06 ensure that all records required by Regulation are appropriately maintained. Requirement 2. YA35 18(1c) 3. 4. YA36 YA41 18(2) 17(2) 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 YA33 Good Practice Recommendations The Registered Person is recommended to undertake an assessment of the required hours for staff to undertake DS0000017904.V282892.R01.S.doc Version 5.1 Page 19 Pathways non-care related tasks. Pathways DS0000017904.V282892.R01.S.doc Version 5.1 Page 20 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. 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