Inspection on 14/02/06 for Santa Maria

This inspection was carried out on 14th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Santa Maria 30/09/08

Santa Maria 20/03/07

Santa Maria 23/06/05

Santa Maria 01/02/05

Santa Maria 10/08/04

Santa Maria 26/02/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Santa Maria 268 London Road Wokingham Berkshire RG40 1RD Lead Inspector Stewart Mynott Unannounced Inspection 14th February 2006 10:20 Santa Maria DS0000011363.V271447.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 Santa Maria DS0000011363.V271447.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. Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Santa Maria Address 268 London Road Wokingham Berkshire RG40 1RD 0118 9791546 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) Atlas Project Team Limited Mr Grahame Lawrence Dillon Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: Atlas Project Team Ltd are the provider for Santa Maria, which is a care home providing personal care and accommodation for 3 adults aged 18-65 who have a learning disability with associated behavioural problems. The home is situated on the outskirts of Wokingham on a main road and has unmarked vehicles used for the short drive to all the recreational and shopping amenities within Reading and Wokingham. Santa Maria is a three bedroomed detached bungalow with communal space for the service users and a large back garden that service users have access to; the front garden has room to park 4 vehicles. Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection during the weekday lasting for 2½ hours in duration. The purpose of this visit was to examine the lifestyle and daily routines for service users, the staffing and management arrangements at the home. Time was spent both the staff on duty and two of the service users at home during this inspection. The third service user was briefly met on their return from a community-based activity. Time was spent with the registered manager (area manager) and a regional manager reviewing staffing and management standards. 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. Santa Maria DS0000011363.V271447.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 Santa Maria DS0000011363.V271447.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 home has a clear admission and assessment process to ensure prospective service users needs would be fully met. EVIDENCE: The service users at the home are an established and settled group having been resident in the home since 1992. There is a comprehensive “referral and admission procedure” available in the home and further information is provided in the statement of purpose in the event of any vacancy arising in the future. Santa Maria DS0000011363.V271447.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): Standards 6 to 10 were not assessed during this inspection. EVIDENCE: Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 Page 9 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, 14, 15, 16 and 17 Service users are offered a good range of appropriate activities and leisure pursuits to suit their individual preferences. There is an inclusive daily routine supported by a dedicated staff team. Service users benefit from a healthy diet with a varied menu that they are involved in choosing and preparing. EVIDENCE: The staff member confirmed that service users have a good range of activities and leisure pursuits arranged to meet their current needs and preferences. On the day of the inspection one service user was out “rambling” with an organised group supported by a staff member in Woodley. Two other service users had activities planned within the home and an aromatherapy session was arranged during the afternoon. Notice boards in the dining room displayed current events and for one service user their personal communication board was in use during the inspection as demonstrated by the staff member on duty with the service user. The activity planner for the week was viewed and was seen to be fully inclusive of activities of daily living around the home and organised activities. Amenities Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 Page 10 in the local community are well used and include the use of leisure centres, and specialist resources to include music sessions, swimming, bowling and for one service user the use of the spa at a local country club. Visits to shops and town centre facilities are scheduled during one to one time. One service user has employment and completes a paper round on a weekly basis with staff assistance. A daily plan for service users is accessed on the homes computer and includes all day-to-day plans, which staff could also access. This system was very organised and maximized the opportunities and choice given to service users. The daily routines were observed during the inspection and time some was spent around the home. Staff treated service users with a friendly, relaxed and inclusive manner. Both service users had access to all areas of the home and the staff member supported service users in their choices such as making drinks in the kitchen. Service users are encouraged to take ownership where possible and become involved in normal household routines such as tidying personal space, making their beds and laundry with staff support. This further evidences the inclusive ethos within the home. Each service user opportunities and engagement in daily life, occupational and recreational activities are further carefully monitored by the staff team and recorded on the “keeping tracks” document. One service user’s “keeping tracks” document was examined which revealed the opportunities and engagement in a variety of daily activities. This information is further collated so ongoing progress can be assessed to support reviews and future planning for individual activities for service users. Staff were able to describe the support given to service users to maintain relationships with their family members. There are also arrangements for visits to and from a nearby home so service users can maintain their friendships with other individuals. During the morning one service user assisted in the preparation of the lunch with the staff member. They had prepared fish with vegetables as described in the menu. The opportunity for this involvement was recorded on their activity schedule. The activity planner demonstrated that all service users have the opportunity to become involved in meal preparation on a regular basis. The staff member informed the inspector that service users are encouraged to choose the menu for the week each Saturday from a large array of menu/recipe cards with photos of each meal. The menu seen for this week was varied and regarded as appropriate and typical of a “family” style approach. Minutes from a recent staff meeting also confirmed that fresh produce is purchased as opposed to ready-made meals. Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 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): Standards 18 to 21 were not assessed during this insection. EVIDENCE: Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 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): Standards 22 and 23 were not assessed during this inspection. EVIDENCE: Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 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): Standards 24 to 30 were not assessed during this inspection. EVIDENCE: Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 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, 34 and 35 The home has a comprehensive recruitment and selection procedure, which is protective of service users. Staff at the home receive a good varied program of appropriate training, development and support to meet service users needs. EVIDENCE: There are currently seven full time and one part time staff employed at the home (excluding the registered manager). The inspector was informed that four staff have achieved at least NVQ level 2. The regional manager stated that most staff (dependant on experience) are encouraged to commence NVQ level 3 which is more suited to their roles. The staff member on duty demonstrated a good understanding of service users needs and preferences and was able to demonstrate the skill and experience in communication and understanding of both service users at home. The staff member has just completed his NVQ level 3. The regional manager described the recruitment process at the home. The process of staff recruitment is coordinated by the registered manager, regional manager and head office to identify vacancies and successfully recruit new staff as needed. All staff are invited to interview at the regional office inclusive of the homes senior staff, and then invited to meet the service users in respect of the service as part of the interviewing and selection process. A personal file for a recently employed staff member was viewed and contained all the Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 Page 15 required pre-employment checks to include completed application forms, health declaration, appropriate references, identification and evidence of enhanced CRB checks to safeguard service users. The registered manager, staff member and the regional manager explained the training arrangements at the home. The regional manager provides the home with up to date information of each staffs training that has been undertaken and takes responsibility of booking ongoing training on a rolling basis according to staffs needs. This information was readily available in the home and was further examined to demonstrate that staff have been provided with training surrounding mandatory topics as well as more specialist topics relevant to the assessed needs of service users to include communication. The staff member on duty is currently undergoing development and training towards becoming a house manager. He described a supportive environment and was enthusiastic and clearly motivated participating in this program. The home provides an appropriate induction to the home and the “trainee” manager has further developed the induction information that has been used as part of the introduction process. The records for the latest staff member’s induction was viewed and currently in the process of completion. Santa Maria DS0000011363.V271447.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): 37, 39 and 42 The home is well managed in an inclusive and open manner. There is a good approach to monitor and evaluate the quality and effectiveness of systems within the home relevant to outcomes for service users. There are appropriate procedures in place to monitor and protect the health, safety and welfare of service users. EVIDENCE: The registered manager of the home is highly experienced and holds all the relevant qualifications for this post to include the registered manager award. The regional and registered manager confirmed that a full survey using questionnaires had been completed last year to include service users, their representatives including care managers and staff. During the previous inspection a quality assurance audit had been viewed which was of a thorough standard and a unit/premises checklist was viewed on this occasion. The registered manager and trainee manager had a month-by-month business plan identifying action to be taken on a variety of topics to ensure systems and care within the home are being appropriately maintained and reviewed. This Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 Page 17 included the actions taken to meet identified areas. This was viewed as a very organised approach to ensuring consistent quality within the home. The staff within the home monitor the systems to ensure the continued health, safety and welfare of service users and staff. Records were examined to include fire safety, food hygiene, hot water temperatures, gas and electrical safety and risk assessments undertaken to provide safe working practises. These were completed and up to date in all cases. Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X 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 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Santa Maria Score X X X X Standard No 37 38 39 40 41 42 43 Score 4 X 4 X X 3 X DS0000011363.V271447.R01.S.doc Version 5.0 Page 19 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. 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. Refer to Standard Good Practice Recommendations Santa Maria DS0000011363.V271447.R01.S.doc Version 5.0 Page 20 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. 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