Inspection on 13/10/05 for REACH Lower Cippenham Lane

This inspection was carried out on 13th October 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

REACH Lower Cippenham Lane 18/10/06

REACH Lower Cippenham Lane 10/05/05

REACH Lower Cippenham Lane 05/10/04

REACH Lower Cippenham Lane 25/05/04

REACH Lower Cippenham Lane 27/01/04

REACH Lower Cippenham Lane 12/08/03

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

CARE HOME ADULTS 18-65 178 Lower Cippenham Lane Cippenham Slough Berkshire SL1 5EA Lead Inspector Kerry Kingston Unannounced Inspection 13th October 2005 10:00 178 Lower Cippenham Lane DS0000011286.V251761.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 178 Lower Cippenham Lane DS0000011286.V251761.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. 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 178 Lower Cippenham Lane Address Cippenham Slough Berkshire SL1 5EA 01628 666132 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) R.E.A.C.H. Limited Care Home 12 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (3), Mental disorder, excluding of places learning disability or dementia (1) 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users not to be admitted over the age of 65 years. Date of last inspection 10th May 2005 Brief Description of the Service: 178 Lower Cippenham Lane offers twenty-four hour residential care to twelve, male and female service users who have a diverse range of learning and associated disabilities. The house is a large two-storied detached building with accommodation on both floors. The home is situated in a residential area of Slough, the town is accessible via the public transport system and the home has its’ own vehicle. There are local shops and amenities within walking distance, and the home is an integral part of the community. The building is owned and the care is provided by REACH Ltd. Although the home is relatively large, staff ensure that its’ domestic ambience is retained. 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine short notice inspection, carried out between 13.00 and 16.00 on 13th October 2005. The inspector looked at care plans several records and spent some time with residents. The new manager was present throughout the inspection and several residents spoke with the inspector, ten were present for various intervals during the inspection. The manager and residents had completed a consultation exercise, discussing the last inspection report. Their comments were given to the inspector, in written form but there was no further interest in discussing it. What the service does well: What has improved since the last inspection? 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. 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 Page 6 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 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 Page 7 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 The new service users needs were assessed and his views taken into account. EVIDENCE: The home had conducted a review of the new service users care plan on the 6th May 05 and this included evidence that he was, currently, suitably placed. There was also evidence that his future plans and aspirations are discussed, regularly with him and his family members (as appropriate.) 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 Page 8 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 and 9 The service uses have regularly reviewed individual care plans and are assisted to make as many decisions about their lives as is practicable. Service users have appropriate individual risk assessments, which enable them to be as independent as possible. EVIDENCE: Four service users care plans were seen and all showed that a review had taken place during 2005. The home reviews the care plans six monthly and they are up-dated as necessary. Service users attend their reviews and key workers work with them, to ensure they have as much understanding of the process as is possible. Service users confirmed that they were involved in the review process. The home holds monthly residents meetings and notes of the meetings evidenced that they are used for information exchange and gauging service users views. The home have sill not been able to access an advocacy service. All service users have adequate risk assessments but there was a discussion with the manager about ensuring that there was enough detail in all assessments, and all needed to be kept up-to-date. 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 Page 9 178 Lower Cippenham Lane DS0000011286.V251761.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 and 17 Service users have varied activities programmes, according to their ability and preferences. The service users use the community as part of their daily lifestyle and the home is an integral part of the community. Service users are assisted to maintain personal and family relationships and are helped to be as independent as possible. The home provides varied and wholesome food to service users. EVIDENCE: The service users have diverse and varied needs and these are reflected in their individual activity programmes. Individual choices and preferences are also an important factor when developing the programmes. There was discussion around in-house activities not always being accurately recorded which tended to evidence that a percentage of service users watched the T.V. for much of their time. Three service users confirmed that they enjoyed their activities and they have ‘plenty to do’. There was evidence of several trips and outings taking place during the summer period. Six of the twelve service users attend church on a Sunday and all access the community at different times during the week. 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 Page 11 Families are encouraged to stay in contact with service users and are as involved in their care, as is appropriate. Staff interaction with service users, on the day of inspection, was better than at the last visit but the inspector observed some staff not engaging service users in the usual daily activities. The new manager was observed interacting very effectively and sensitively and although she has been in post for a limited time her relationship with the service users appeared to be very positive. The menus seen were varied and nutritious and service users confirmed that they enjoyed their food. 178 Lower Cippenham Lane DS0000011286.V251761.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): none EVIDENCE: 178 Lower Cippenham Lane DS0000011286.V251761.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): 23 Service users are protected from abuse. EVIDENCE: Standard 23 was partially assessed in relation to the way the home deals with service users monies, as this was an issue at the last inspection. The inspector found financial records accurate and appropriate guidelines are in place to ensure service users money is handled safely. The manager now takes responsibility for all monies on the premises and has specific guidelines for the staff to follow. The manager advised that the practice of service users paying staff’s ‘out of pocket ‘expenses had now ceased and a policy document had been issued, with effect from 13th October 05. 178 Lower Cippenham Lane DS0000011286.V251761.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): None EVIDENCE: 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 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): 32,34,35 and 36 The saff team are competent and qualified, they are offered good training opportunities, and are able to meet the needs of the service users. The organisation has robust recruitment policies. Staff are not, appropriately supervised. EVIDENCE: All staff have an individual training and development plan developed from a training needs assessment. Four of the eleven staff have an N.V.Q. qualification and there are four new staff who are currently in the induction stage of employment. The home follows a robust recruitment process and ensures all have the necessary checks prior to commencing employment. Staff are afforded good training opportunities to ensure that they are able to meet the needs of the service users. The new manager has a development programme to ensure that staff are supervised regularly in the future but currently there is no regular pattern of supervision. Some staff have had only two supervisions in a twelve month period. This was reflected in the interactions between staff and service users. This had improved considerably since the last inspection but some staff still appeared to be struggling to ‘engage’ service users appropriately. The manager, however, was acting as an excellent ‘role model’. 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 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 Te home has a newly appointed manager who has not applied for registration with the C.S.C.I. The inspector was unable to assess the quality assurance system. EVIDENCE: The home has been without a registered manager for several years, a manger has been recently appointed but the application for registration has not yet been received by the C.S.C.I. The new manger was unable to produce the quality assurance system for the home. The inspector has seen annual development plan and quality assurance paperwork on past inspections but up-to-date paperwork was not available. The last regulation 26 visit was recorded in June 05 and the C.S.C.I. Have not received copies since June. 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X 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 X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 178 Lower Cippenham Lane Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X X X DS0000011286.V251761.R01.S.doc Version 5.0 Page 18 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 YA36 Regulation 18.2 Requirement To ensure that staff are adequately supervised. (3rd repeat of requirement 01.06.05) To apply for registration of the newly appointed manager. For a quality assurance system to be available and to ensure regulation 26 visits are completed monthly. Timescale for action 01/12/05 2 3 YA37 YA39 8 24 26 01/12/05 01/12/05 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 Refer to Standard YA9 Good Practice Recommendations To ensure risk assessments are appropriately detailed and up-to-date. 178 Lower Cippenham Lane DS0000011286.V251761.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 178 Lower Cippenham Lane DS0000011286.V251761.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. 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