Inspection on 13/10/05 for Self Unlimited Blackerton House

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Self Unlimited Blackerton House 21/02/07

Self Unlimited Blackerton House 16/05/05

Self Unlimited Blackerton House 18/10/04

Self Unlimited Blackerton House 10/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 CARE Blackerton House CARE Blackerton House East Anstey Tiverton Devon EX16 9JT Lead Inspector Sue Dewis Announced Inspection 13th October 2005 10:00 CARE Blackerton House DS0000021899.V260552.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 CARE Blackerton House DS0000021899.V260552.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. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service CARE Blackerton House Address CARE Blackerton House East Anstey Tiverton Devon EX16 9JT 01398 341252 01398 341591 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) CARE (Cottage and Rural Enterprises Ltd) Thelma Sadako Hartas Care Home 36 Category(ies) of Learning disability (36) registration, with number of places CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To allow one named service user, over the age of 65 years of age, to remain in the home Upon termination of this placement, the registered person will notify the CSCI and the conditions of registration will revert to those which apply on 30 June 2004 16th May 2005 Date of last inspection Brief Description of the Service: CARE Devon provides accommodation and personal care for up to 36 younger adults who have a learning disability, and are between the ages of 18 – 65 years. The Registered Provider, CARE Ltd, have worked with people with learning disabilities since 1966, and developed a number of communities throughout the country.CARE Devon aims to create an environment that encourages personal development, confidence and self-esteem. Service users are encouraged and supported to live as independently as possible. The home is situated in the rural location of East Anstey, near to the market town of Tiverton. Accommodation is provided in four cottages, Forbes, Groves, Crowberry and Courtyard. Each offers single bedrooms and communal living space, for up to 10 service users. There are facilities in each of the cottages for laundry and for making meals and snacks. There are opportunities on site for service users to participate in a range of day activities and workshops, which include, woodwork, pottery, textiles, horticulture and catering. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours in early October 2005, by three inspectors. The home had been notified that an inspection would take place within three months and had returned a pre-inspection questionnaire, information from which was used to write this report. Eight staff and twelve residents were spoken with at length and many other residents were spoken with in passing. Comment cards were received from 4 relatives/visitors, (one of which was followed up by telephone) and thirteen residents. Inspectors were warmly welcomed by staff and residents. What the service does well: There is a warm and friendly atmosphere around the home and a general buzz of activity. Generally positive feed back was received from residents and visitors. All residents spoken with liked living at the home and one said, “I have all my friends here”. All felt well cared for and safe at the home. Residents appeared happy on the whole and well cared for. They were certainly seen to move around freely and were happy to see us!! There was very good interaction between residents, who were keen to look after each other. Residents work in various workshops, producing many lovely items that are sold in the shop to raise money for CARE. Other residents help maintain the grounds and one resident told the inspector they had been dismantling a greenhouse. Another resident said that he was responsible for recycling at the home. Relatives wrote ‘We have never been less than entirely happy with my sister’s care. All staff take every care possible to keep her well and happy.’ CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 6 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. CARE Blackerton House DS0000021899.V260552.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 CARE Blackerton House DS0000021899.V260552.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 residents are assured that their care needs can be met. EVIDENCE: The new assessment format is good and is presented in a way that residents can understand, using symbols, and encourages residents to complete the assessment as much as possible themselves. However, the new format has not yet been fully implemented for each cottage. Assessments provided good detail about residents’ needs and preferences. Careful consideration, and consultation with residents, is given to the admission of new residents to ensure that each cottage maintains it’s homely relaxed feel. CARE Blackerton House DS0000021899.V260552.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, 8, 9 and 10 There is a clear and consistent care planning system in place to adequately provide staff with the information they need in order to satisfactorily meet the needs of the residents. There is the potential for residents’ confidentiality to be compromised. EVIDENCE: Four care plans were inspected three were in the new format. Care plans are generally good, they are detailed and give a clear picture of the residents’ needs and preferences, ensuring that staff are aware of individual needs and goals. It is particularly good to see that such things as how residents express pleasure; sadness and anxiety are recorded as well as goals and aspirations. One resident explained to the inspector how they had completed their plan themselves and was responsible for keeping it safe. Residents have developed individual weekly activity programmes and are supported by staff, where necessary, to achieve their personal goals. For example, managing their own medication or securing job and college opportunities. The care plans examined had been reviewed and three residents CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 10 confirmed that care plans are discussed with them. Some residents who are able have signed their own care plan. One resident said that they were attending their review tomorrow. The home operates a key worker system and residents spoken with were aware of their key worker. Staff spoken with were aware of the individual needs and preferences of the residents’. One staff member said they ‘make sure follow care plans to the letter’. One form for handover between staff contained personal information on all residents. Therefore should a resident request their personal information they could not see all of it without the privacy of other residents being compromised. Risk assessments had been reviewed since the last inspection and are completed both generally and in relation to individual risks. One behavioural risk assessment highlighted hazards and the control measures in place to reduce risk, for instance, staff were using a monitoring device to alert them to one resident’s movements at night but were keen to explore other control measures to keep the resident safe. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 11 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): None of these standards were inspected on this occasion. For more information see the report of the inspection on 16 May 2005. EVIDENCE: CARE Blackerton House DS0000021899.V260552.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, 19 and 20 The health needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. Personal support is not always sufficient as to promote residents’ dignity. Whilst medication is stored securely in all parts of the home, some areas of medication handling have the potential to place residents at risk. EVIDENCE: The health and personal care needs of residents are well met with good evidence of the necessary input from health professionals. Residents are registered with a GP and have regular optician and dental appointments. Staff showed awareness of one resident’s health needs and recognised the necessity to act quickly in certain situations to limit problems. Details of how personal care is to be provided are included in care plans and staff demonstrated a clear understanding of residents’ preferences. Where staff assist residents with intimate care, consent has been obtained from the resident. Residents confirmed that they were well cared for; one said, “I trust the staff”. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 13 However, concerns have been raised by relatives that due to staff shortages some aspects of personal care, for example hair and nails has been neglected. New staff have been recruited and relatives hope that this will improve the situation. Some medicines are being re-dispensed weekly for supply to the individual units. Paracetamol for “Homely Remedy” is not stored in its original box containing batch number, expiry date and dosage instructions. When a variable dose is prescribed the actual dose administered is not always recorded. Some records made on the MAR chart were only in pencil and not indelible. The record of current medication in some resident’s care files was seen to be in need of updating. All staff administering medication by specialised techniques have received the appropriate training. Clear records are kept for the receipt of medicines into the home and for supply of weekly medication to the individual units. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 14 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 The home has a satisfactory complaints system with evidence that complainants’ views are listened to and acted upon. EVIDENCE: Copies of the complaints procedure are displayed in each of the cottages, and the application pack also contains the procedure. Some residents who have requested them, also have their own copies. There is a central log of complaints with brief details recorded, showing that five complaints had been received this year. The inspector looked at two of these in detail. Both complaints were well recorded and contained copies of correspondence and outcomes. One complaint had been substantiated and one had not. CSCI contact details were shown on both final response letters. Finances were discussed with the Bursar who manages all residents’ monies. Newer residents have their own bank accounts, but those who have been at the home for some time, generally do not. A separate account is maintained for residents’ personal allowance monies, and all residents have separate accounts within this main account. Residents request a sum of personal allowance each week, depending on their needs and activities or outings. This money is then collected from the bank and allocated to each resident via the cottage staff. Residents also have a savings account within the main account. A computer programme is used to proportionally allocate interest from the main account into individual residents accounts. All details of the residents’ finances are confidential between the resident, bursar and home manager. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 15 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 and 30 The standard of the décor within some areas of the cottages is poor, with little evidence of major improvement through maintenance or future planning. The home does not therefore, present as a comfortable and clean environment for residents. EVIDENCE: Several areas of Courtyard have been redecorated since the last inspection, including the hallways, sitting room and kitchen. New furniture has also been acquired for the communal sitting room, which residents helped to choose. One bedroom has been redecorated and new carpet laid. One resident told the inspector that new colours and carpet had been chosen for their room and he was looking forward to the changes. One shower room has been refurbished and new ventilation installed to minimise condensation. Several areas of Grove require attention, including wall coverings in showers (bits of the wall peeling, shower rooms damp) and the first floor toilet needs redecorating. The stair carpet is a little threadbare in places. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 16 There has been some work completed in Forbes but the stair carpet remains very badly stained. Crowberry has had some redecorating, but the communal areas remain shabby. Each cottage has a cleaning rota, which is undertaken by residents and care staff. Areas of all the cottages inspected were in need of cleaning; some communal areas had dirty floors and carpets and some table surfaces were dirty and sticky. Light switches were also very grubby. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 17 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): 33 and 34 hen fully staffed the deployment and numbers of staff available are sufficient to meet the needs of the residents. The procedures for the recruitment of staff are robust and offer protection to residents. EVIDENCE: Each of the four cottages has its own staff team consisting of a manager (40hrs), an assistant manager (40hrs) and three care staff (100hrs total). Overnight one staff sleeps in with another on call. Staff are usually only in the cottages during the day when a resident is staying at home due to sickness. When the cottages are fully staffed there are sufficient staff to ensure the personal and social care needs of residents are met. However, there have recently been staff vacancies across the cottages and there were comments from visitors, that there was not always enough staff on duty and that their relatives’ personal care needs were not being met. The manager felt that sometimes the lack of visible staff was because they were off site doing things with residents. New staff have recently been recruited, one of which was spoken with. They confirmed that they had had a satisfactory CRB (Criminal Records Bureau) check and a thorough induction. Though this had been difficult to arrange due to staff sickness. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 18 Four staff files were examined and all (including those of overseas staff) contained the required information including CRB (Criminal Records Bureau) and POVA (Protection Of Vulnerable Adults) checks. The manager said that residents are involved in the recruitment and selection of staff. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 19 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): 38, 39 and 42 Communication with relatives could be improved. The systems for resident consultation are good, with a variety of evidence that indicates that residents’ views are sought and acted upon. The home is well managed and this generally results in practices that promote and safeguard the health, safety and welfare of the residents. EVIDENCE: Comments were received on visitors’ cards that communication within the home and between relatives and the home was poor. The manager said that ‘Family Forums’ were held regularly and that ‘The Bugle’ had been started in order to improve communication. Families are invited to yearly reviews where matters such as this are discussed. The manager said that she understood the concerns of families and the home did its best to encourage residents to maintain contact with their families. However, it was the decision of the resident as to whether their families should be informed and the home had to CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 20 respect this right. Within the home, a residents’ committee meets every two months, there is a focus group to look at new policies, regular cottage meetings and workshop meetings. Residents themselves did not raise concerns about communication. Minutes of resident meetings are available in each of the cottages to demonstrate the involvement of residents and the minutes of these meetings are available in a user friendly format. Evidence was also seen of resident involvement in planning activities and meals in the individual units. Residents confirmed that they prepare a menu weekly and on the day of inspection was resident and one staff were out shopping for food. Residents spoken with were aware of the procedure in the event of a fire alarm. The inspector was told that fire drills are conducted every 3 months or so. Recent PAT testing had been completed but not all appliances had the ‘upto-date stickers’ to confirm, for example, the stereo at Courtyard indicated 04. This was discussed with the manager and she was to check the records to confirm this. A range of records relating to health and safety issues were inspected. These included, Fire alarm tests and Fire Drills seen, temperature monitoring of Fridges and Freezers, water temperature delivered from thermostatically controlled outlets and flushing records. Data sheets and risk assessments were also seen for all products controlled by the COSHH regulations. CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 21 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 X 3 3 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 CARE Blackerton House Score 2 3 2 X Standard No 37 38 39 40 41 42 43 Score X 2 3 X X 3 X DS0000021899.V260552.R01.S.doc Version 5.0 Page 22 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 YA20 Regulation 13 (2) Requirement You are required to make arrangements for the safe administration of medicines. (This refers to the need for medicines to be administered to service users from the packaging in which they are supplied by the pharmacy.) You are required to ensure that records of the amount administered are recorded for all medicines prescribed with a variable dose. You are required to ensure that the care home is kept in a good state of repair externally and internally You are required to ensure that all parts of the care home are kept clean and reasonably decorated Timescale for action 30/11/05 2 YA20 13 (2) 30/11/05 3 YA24 23 (2)(b) 31/03/06 4 YA30 23 (2)(d) 31/03/06 CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 23 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 3 4 5 Refer to Standard YA10 YA18 YA20 YA20 YA38 Good Practice Recommendations You are recommended to ensure all written information relating to residents is kept confidential to them You are recommended to ensure residents receive appropriate personal care at all times You are recommended to ensure that the lists of current medication be updated on residents’ care files. You are recommended to ensure that all entries on the MAR charts are made in ink so as to be indelible. You are recommended to consider ways to improve communication with relatives of residents CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 CARE Blackerton House DS0000021899.V260552.R01.S.doc Version 5.0 Page 25 - 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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