Inspection on 02/05/07 for South Road (38)

This inspection was carried out on 2nd May 2007.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

South Road (38) 01/05/08

South Road (38) 14/11/05

South Road (38) 26/07/05

South Road (38) 15/06/05

South Road (38) 06/01/05

South Road (38) 30/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 South Road (38) 38 South Road Bishops Stortford Hertfordshire CM23 3JJ Lead Inspector Judith Kent Unannounced Inspection 2nd May 2007 10:00 South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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 South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Road (38) Address 38 South Road Bishops Stortford Hertfordshire CM23 3JJ 01279 461 131 01279 466 332 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) www.hft.org.uk Home Farm Trust Mr Clive William Kidd Care Home 10 Category(ies) of Learning disability (10) registration, with number of places South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2005 Brief Description of the Service: 38 South Road is a large house in a residential street on the outskirts of Bishops Stortford. It provides a care home for ten people with a mild to moderate Learning Disability. All the residents have their own rooms, which reflect their individual personalities, and all make full use of all the local community has to offer. The home has communal accommodation, which is well used by this well-established group of service users. Emphasis is given to active, positive quality lifestyles at the limit of each service users ability and independence. The home is owned by the Home Farm Trust a voluntary organisation. The current fees for the residents, who are all sponsored by a local authority, range from £494 to £689 per week according to need. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit took place over six hours during the morning and afternoon - all the service users were at home at some time during the inspection. We spoke to staff members and service users, both individually and in groups and looked around the home. Some time was spent in discussion with the manager and records and care plans were looked at. Questionnaires have been completed by service users with help from keyworkers and other staff members and their comments and responses are reflected in this report. Service users who wished to talk to us were responsive and spoke confidently about their daily lives; they told about the holidays that are planned for this year, their visits home and their friendships. One relative returned a questionnaire expressing some concerns about personal care and inappropriate dress, but saying that the home had helped their relative to ‘live independently to the best of their abilities’ and has ‘developed confidence and social skills’. Also that ‘the majority of the staff team offer a wonderful service’. Only key standards were inspected on this occasion. What the service does well: What has improved since the last inspection? What they could do better: While risk assessments are included in care plans there is sometimes no guidance on how risks are to be minimised. The home has regular visits from a representative of the Home Farm Trust and relatives have been asked for their views on the service provided; however, South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 6 service users have not been formally surveyed about their views of life in the home. The manager must be alert to health and safety issues around the home. 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. The summary of this inspection report can be made available in other formats on request. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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 South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users’ needs are assessed before a place in the home is offered – this process ensures that the home will be able to meet their care needs. EVIDENCE: No new people have moved into the home since the last inspection. The report of that inspection confirmed that an appropriate admission procedure had been followed for the last person to move into the home. The Statement of purpose has been revised to include up to date information and the complaints procedure in picture format. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by the home’s staff to achieve the goals set out in their individual care plans and to make choices and decisions about their lives. EVIDENCE: The emphasis in the home is on supporting and enabling people to be as independent as possible and to maintain their health, and the care plans looked at during the inspection set out how this was to be done. The manager said that the home is moving towards a person centred planning approach which will enable each person to be more fully involved in contributing to, developing and reviewing their plan and the further development of forms and records in picture format will help service users to achieve this objective. Each service user has a named key worker who will link closely with them and support them in their daily lives. It was noted during the inspection that while daily notes of each person’s activities are written, there were few recent records of progress towards achieving goals. There were risk assessments for individual activities in care plans, but in some cases there were no management plans for identified risks. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 10 The relationship between the support staff and service users was relaxed and instances of people making decisions about their daily lives were heard; the manager has introduced a system for ensuring that such decisions are recorded and followed through. Responses in the questionnaires showed that on the whole, people make their own decisions and choices about their lives. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are helped to take advantage of leisure facilities and have a wide range of activities available to them, both within the home and in the wider community. Meals in the home are nutritious and varied. EVIDENCE: All the residents have an individual programme of day care activities and planned time at home for activities such as shopping and managing their money. The residents programme attendance ranges from three to five weekdays according to their need and venues include two local day centres as well as classes at colleges in Harlow and Ware. People can enjoy a wide range of activities outside the home, supported by staff if needed – examples of the activities include outings to theatre, bowling, swimming pool, pubs and horse riding. Several service users are able to use public transport to attend college and meet with friends. One person said in South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 12 their questionnaire that they would like to go out more in the evenings and at weekends; others were happy with the level of activities offered. Service users spoke to us about the holidays that are planned for this year and the outings they are able to go on. Links with families are maintained and many service users spend weekends and holidays with their families. In accordance with the promotion of independence, service users are expected to help with the smooth running of the home and there is a rota of household tasks which they may do alone or with help from staff; these include keeping both their own rooms and communal areas clean, shopping, meal preparation and laundry. People who spoke to us were aware of their responsibilities and seemed to take pleasure in helping around the house. Menus are planned by service users at their weekly meetings and show an awareness of healthy eating - fresh ingredients are prepared and cooked on the premises and special diets are catered for. One person decided on a large salad for lunch and said that it was their favourite meal. Meal times during the day are varied to suit service users’ lifestyles. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are helped to access health services and to maintain their health. Medication is well-managed, minimising risk of harm to service users. EVIDENCE: Most of the people living in the home manage their own personal care, although staff support is available if it is needed. Care plans showed that people’s health needs are met with regular visits to dentists, opticians etc. Consultations with their GP or with specialist services are fully recorded in their care plans. Medication in the home is managed well; records were seen to be accurately and clearly completed and there is a daily audit of medication to make sure that errors, should they occur, are identified and dealt with immediately. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their concerns and complaints will be listened to and that appropriate action will be taken to resolve them. EVIDENCE: There have been no complaints received by the CSCI since the last inspection, although the home has recorded several which have been dealt with in accordance with the Home Farm Trust’s robust procedure. The procedure has been produced in picture format and the manager said that the service users in the home are very aware of how to make their concerns known to staff members, who help them if necessary. Support staff have received training in safeguarding people and no instances or allegations of abuse have been reported. Service users responded in questionnaires that they were aware of how to make a complaint or who to talk to if they had concerns about their care. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable home that is suitable for their needs, although health and safety matters around the premises are not always attended to. EVIDENCE: The home is comfortably furnished and is equipped to enable people to learn the skills they need to be independent. Service users rooms are furnished and decorated to reflect each person’s choice and personal taste. Although the home is generally maintained safely, there were several areas of concern which were discussed with the manager at the end of the inspection. Specifically – the door to the boiler was insecure and hinges had broken making it vulnerable to intrusion; one refrigerator looked at had an out of date PAT test label and the manager was unable to confirm that annual tests had been completed; a requirement by the Environmental Health Officer to replace doors leading from the kitchen had not been completed. The manager agreed to look into all these issues. The lounge carpet was stained and grubby, but South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 16 the manager reported that this was already in hand and that the carpet would either be deep cleaned or replaced Service users take responsibility for keeping their own rooms and communal areas clean and are supported by the staff to do these tasks. . South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by an experienced staff team, who have the skills and experience to meet their needs. The recruitment process makes sure that staff are recruited safely. EVIDENCE: Staffing levels in the home are sufficient to meet service users’ needs and there is very little use of agency staff. The home has vacancies which are covered by regular relief staff, ensuring that service users benefit from knowing the people who work with them. Training records and discussion with staff members showed that there is a wide range of training available for support and management staff, although the proportion of staff members who have the National Vocational Qualification (NVQ) Level 2 in Care has fallen since the last inspection. The induction training records for new staff seen at the inspection show that national guidelines are followed which give a good grounding in caring for this group of people and prepare staff for gaining further qualifications. The home follows a satisfactory recruitment procedure, ensuring that the necessary checks are completed and information sought to show that staff are recruited safely – recruitment records were looked at during the inspection and found to be in order. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 18 Records showed, and staff confirmed, that there is regular supervision for all staff and the manager said that annual appraisals are to be reinstated during the year. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are able to give their views about the care they receive, although at present there is no method for them to do this anonymously through a questionnaire. Most aspects of the home are managed well, although there is a need to be alert to health and safety matters in order to safeguard service users and staff. EVIDENCE: The home’s manager, Mr Clive Kidd, has now been registered with the CSCI and is currently completing the Registered Managers Award, which he hopes to finish by August this year. He has been with the Home Farm Trust for some years and has considerable management experience. Staff spoken with said that they felt well supported in their work by the manager and the senior South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 20 support worker and that the staff team works well together in the best interests of service users. The manager has developed a plan to tackle the issues arising from the last inspection report which is currently being rolled out to the staff group for action. The home has monthly visits from the Home Farm Trust, records of which are held in the home, and an audit of a different aspect of the home’s management takes place every six months. Reports of the latest audits are still awaited by the home; copies should be forwarded to the CSCI as soon as they become available. Service users’ families are asked to complete a questionnaire about the home, and if necessary, action is taken on any issues arising. The latest survey shows a good level of satisfaction in most areas. There is as yet no means for service users to give an anonymous opinion about the service they receive, but the manager reported that a questionnaire in picture format is currently being developed. However, there are regular weekly house meetings which are made full use of by service users to talk about how the home is run – the manager and staff reported that these meetings are well used by service users to express their views. The environmental safety issues referred to in Standard 24 need to be attended to. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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 Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 2 x South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13(4) Requirement Timescale for action 02/05/07 2 YA39 24 3 YA39 24(5) 4 YA42 13(4) Risk assessments for service users’ activities must set out the control measures required to minimise the risk of harm. A copy of the most recent quality 30/06/07 assurance report is to be sent to the CSCI as soon as available. (This requirement has been brought forward from the last inspection report) The quality assurance system 30/09/07 must seek and record the views of service users as well as relatives. The premises and equipment 30/06/07 must be maintained safely and hazards must be rectified. 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 YA6 Good Practice Recommendations Progress towards goals agreed with service users and set out in their care plans, should be recorded. DS0000019529.V337695.R01.S.doc Version 5.2 Page 23 South Road (38) 2 3 YA24 YA34 The lounge carpet should be thoroughly cleaned or replaced. The proportion of staff members holding NVQ Level 2 should be increased as soon as possible. South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 South Road (38) DS0000019529.V337695.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!