Inspection on 23/06/05 for Santa Maria

This inspection was carried out on 23rd June 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

Santa Maria 30/09/08

Santa Maria 20/03/07

Santa Maria 14/02/06

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 Berks RG40 1RD Lead Inspector Stewart Mynott Unannouced 23 June 2005 9:50am rd 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 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 Stationary 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 H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Santa Maria Address 268 London Road Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Wokingham Berks RG11 1RD Atlas Project Team Limited Mr Grahame Lawrence Dillon Care home only (PC) 3 Category(ies) of Learning disability (LD) registration, with number of places SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1 February 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 Young 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 H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place in the morning and lasted for 3 ½ hours. The first 45 minutes were spent with 2 service users and a staff member on duty, which included a tour of the premises. After this time service users and the staff member left the premises for a planned outing that service users were preparing for on the inspectors arrival. The remainder of this inspection was spent looking at records and discussion with management. This inspection concentrated on personal and healthcare support, complaints and protection and the environment. Care records and risk assessments were also assessed. 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 H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 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 standard(s) Standards 1-5 were not assessed during this inspection. EVIDENCE: SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 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 standard(s) 6 and 9 Service users are supported in their lifestyle within a risk assessment framework. Individual plans clearly display needs and future goals. EVIDENCE: Service users have behavioural support plans in place, which are detailed and clearly identify risks and action required to minimize them. Each service user also has separate risk assessments, which focus on aspects of lifestyle that entail a degree of risk to them. These are individual and clear to the reader as to the support required in each case. They are signed as having been read by staff and are reviewed on a regular basis. Service user risk assessments seen were supportive and not too restrictive on lifestyle. Each service user has a detailed formal annual review. The outcomes of this review are directly transferred into aims and goals contained in a Care Program Plan Summary. One service user requires the use of a communication board to aid verbal skills. Details are included on an action plan to meet those needs. The staff on duty was clear in its use and understood this plan. SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 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 standard(s) Standards 11-17 were not assessed during this inspection. EVIDENCE: SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 18, 19 and 20 Service users are supported within their personal and health care needs and are protected by the homes policy and procedures when dealing with medications. EVIDENCE: Care “guidelines” are in place alongside “daily routines”. These provide clear and detailed records of service users personal choices and needs and conveyed a strong sense of staff knowledge of the individual. There were also references to staff training in one “guideline” and cross gender policy in another “daily routine” which supported service users as needed. Each service user has an annual health check and a “my health booklet” is utilized and completed with key workers as part of this process. This booklet covers all health topics in a person centred manner with sensible and achievable aims and goals to keep healthy. There is a clear record of GP appointments including annual medication reviews. Care records demonstrate access to all NHS healthcare facilities in the local area. Routine health screening also takes place. The medication system was fully explained by the Registered Manager. The medication cupboard was viewed and medicines were stored appropriately. The home uses the Boots MDS system. Medication records were examined with SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 Page 11 clear evidence of safe system for ordering stock, checking and disposal of medicines operated by the Registered Manager and Deputy. Medication administration records were clear, up to date and signed for by staff that have administered medications. A “drug error sheet” was seen to be used (i.e. if a service user dropped medication) which clearly demonstrated a safe and open culture within the home. The Home has a medication policy and medication reference book. Staffs administering medication undergo “Drug assessment for House Supervisors” which ensures competency in each area. SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 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 standard(s) 22 and 23 There is a clear complaints policy in use within the home. Service users are protected from abuse, neglect and harm. EVIDENCE: The complaints, abuse and physical intervention policies were viewed at the home. These were clear and protected service users and staff. Quality assurance documentation was also viewed which serves to protect service users through monitoring systems within the Home. Training logs indicated staff had attended training to protect service users, which included protection of vulnerable adults, anti discriminatory practises and SCIP training. These training sessions are available on a rolling program. Service user records included the use of “body maps” as well as “guidelines” for management of behaviour. One guideline viewed was very clear, methodical and very detailed which protected the service users and others around them. Observation and discussion with the staff on duty demonstrated their clear understanding of this guideline. The staff member and manager clearly understand the support required to ensure the protection of service users. SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 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 standard(s) 24, 26, and 30 Service users live in safe, comfortable and clean home. EVIDENCE: A tour of the building and grounds was conducted by a staff member with some involvement of two of the service users. Service users showed their bedrooms to the inspector with a staff member present. These were clean, well furnished and personalised. One service user clearly indicated involvement with choosing the wall colour. The remainder of the home was viewed with the staff member on duty and included all communal areas. The home was observed to be very clean and tidy in all areas. A cleaning rota was seen and was up to date. Some “deep cleaning” of the home takes place at night by staff which is unobtrusive to service users. Many tasks during the day involve service users and staff together. The laundry is located at one end of the garage, this was seen to be well organised with no washing or drying outstanding. The staff on duty described a good laundry system, which includes the non-mixing of service user clothes and service user participation when using the washing machine. Work was being done in the garden to provide a trampoline for service users enjoyment; this project was identified in the business plan. SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 Page 14 The home has continued with redecoration and the inspector was informed that the dining room had been decorated since the last inspection. The landlord of the home has recently changed and the manager and a regional manager informed the inspector that a program to continue with redecoration would be agreed in due course. A previous requirement was made in relation to unguarded radiators. There was a comprehensive risk assessment, which addressed this issue. A preference by the management team for low surface temperature radiators to be installed rather than covering radiators to maintain a homely feel will be explored with the new Landlord in due course. SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 31 to 36 were not assessed during this inspection. EVIDENCE: SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 37 to 43 were not assessed during this inspection. EVIDENCE: SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 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 x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 SANTA MARIA Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 Page 18 No 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 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 Good Practice Recommendations SANTA MARIA H52-H01 S11363 Santa Maria V226536 230605 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale, Berkshire 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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