Inspection on 26/07/05 for South Road (38)

This inspection was carried out on 26th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 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) 02/05/07

South Road (38) 14/11/05

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 South Road Bishops Stortford Hertfordshire CM23 3JJ Lead Inspector Angela Dalton Unannounced 26 July 2005 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. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service South Road Address 38 South Road, Bishops Stortford, Hertfordshire, CM23 3JJ 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) 01279 461 131 01279 466 332 Home Farm Trust Mrs Catriona Bacon CRH Care Home 10 Category(ies) of LD-10 registration, with number of places Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6 January 2005 Brief Description of the Service: 38 South Road is a large house in a residential street providing 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 generous 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 and has been open about twelve years and some of the service users have lived there since then. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector conducted this unannounced inspection on 26th July 2005 between 10.45am and 4.15pm. Overall the inspection was positive and service users spoke highly of the care and support that they receive. South Road belongs very much to the service users and staff take their lead from the service users. South Road is a busy house. Service users went out to Saffron Walden for coffee in the afternoon; one service user left for a work placement whilst another was doing their laundry. Preparations were underway for a fortieth birthday party later in the week and staff were working closely with service users to ensure that the occasion is a success. What the service does well: What has improved since the last inspection? The manager has familiarised herself with policies and procedures and has an understanding of the quality assurance process which was required in the previous inspection. Chiropody visits now take place in private and records of service users wishes are being kept. A requirement to test fire alarms regularly has been met and records evidenced that this was the case. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 Page 6 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. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4&5 Staff are not aware of prospective service users’ needs. Service users have access to information about the home to enable an informed choice to be made about where they live. EVIDENCE: The manager is reviewing the Statement of Purpose and Service Users’ Guide. This will ensure that existing and potential service users requirements are met. The home was preparing for a service user who was staying overnight to see if they wanted to move in. An assessment has been completed but a copy was not in the home. The Inspector identified that it was therefore difficult for staff to be aware of individual needs and were reliant upon the home manager to hand over relevant information. Home Farm Trust employ a Social Worker to conduct assessments. A requirement has been made to ensure the home has a copy of the assessment. Existing service users stated that the home met their needs and gave examples of how this was achieved on a daily basis. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 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 standard(s) 6,7,8,9&10 Service users’ individual requirements are met. Care plans reflect that individual choices have been identified and are monitored. EVIDENCE: Care plans are currently being collated. This is to ensure that person centred planning is meeting individual needs and a new format has been introduced. A training day for staff is scheduled for August to provide guidance on completing the new documentation. Two care plans were examined and held comprehensive information. Information held is current and reviewed regularly. The collation will enable all pertinent information to be kept in one file. Risk assessments provide guidance for staff on challenging behaviour and how service users can be best supported through consistent practise. Service users are encouraged to express their wishes and feel comfortable to do so e.g. the Inspector asked if she could visit a service user’s bedroom and was asked if she would ask someone else. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16&17 The home enables service users to maintain appropriate and fulfilling lifestyles. EVIDENCE: Each service user is assigned an individual member of staff as a keyworker. This enables service users to work alongside a member of staff to ensure that their preferences are recorded and met. The wide range of daily activities through work and college placements demonstrated that routines are tailored to the individual. Where formal day services are unavailable or inappropriate one to one staff support has been made available. Because service users can make their needs known there is a wide range of leisure activities on offer. One service user had walked into the town centre to do some personal shopping. A group of service users have recently been on holiday to Spain. On the day of inspection some service users were listening to music, watching television or enjoying the garden. Service users plan a rolling menu and participate in the food shopping. Meal alternatives are available if required. Staff work closely with families and this was evident in the birthday plans that were being made. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 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 standard(s) 18,19,20&21 Medication practise does not safeguard service users. Care plans do not reflect individual funeral wishes. EVIDENCE: Medication requires some attention and a requirement has been made to ensure the following: Medicines must not be stored in a domestic refrigerator and topical cream is being kept alongside food. The temperature of medicines must be recorded to ensure appropriate storage. Medication must be dated on opening. Administration directions on the MAR (Medication Administration Record) sheet must reflect the prescribed details and be signed by a member of staff in the absence of a G.P. A doctor or pharmacist must sign the homely remedies policy. As stated earlier there is little availability of toilet roll in the home as a service user removes them. This impacts upon the dignity of service users and staff. A requirement has been made to provide toilet roll through specialist dispensers to prevent their removal. A recommendation has again been made to ensure that service users’ wishes regarding funeral arrangements have been recorded. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 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&23 Service users are supported in making a complaint and making their views known. EVIDENCE: A user friendly complaints procedure is in place. Service users are aware of how it works and it is in easy to understand language accompanied by symbols. The complaints procedure forms a booklet for each complaint made where the action and outcome is recorded evidenced by the participation of the service user. The home has Hertfordshire County Council’s Adult Protection policy in place. Staff have good knowledge of this. Finances are securely stored using a plastic seal system. The seal can only be used once and is referenced by an individual code which is recorded in service users’ accounts. Regular house meetings take place enabling service users to express their opinions and resolve any disagreements. Minutes reflect the regularity of meetings. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 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) 24,25,26,27,28,29&30 Infection control is not fully observed within the home. The home reflects the personalities of service users. EVIDENCE: With exception of one area of flooring the home was clean and odour free. A bedroom carpet was stained and a requirement has been made to inform the Commission of measures taken to address this. Service users’ rooms are lockable with a lockable space to store valuables. There is a lounge and large dining room where service users can relax. The garden is well kept and furniture is available for use. A requirement has been made to ensure infection control is observed in the home with the provision of paper hand towels and pump action soap. Bedrooms are personalised and service users decided on the furnishings and décor of the communal areas of the home. A sample chair is on order for the lounge to allow service users to choose the fabric. Paintings by service users have been framed and are on display throughout. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35&36 Continuity of care is ensured within the home. Staff are equipped to meet the needs of the service users but communication skills could be enhanced with further training. EVIDENCE: Some staff vacancies currently exist but the home uses consistent agency staff to provide continuity of care. A recruitment drive is underway to fill vacancies. The home uses relief staff employed by Home Farm Trust to ensure that the rota is always sufficiently covered. So that verification of the recruitment procedure can eb undertaken the required recruitment documentation is stored in the home. Storage is an ongoing issue and additional furniture is on order for the office to address the problem. Staff attend regular training and a record was available for inspection. An NVQ programme is underway in the home but the numbers of staff who held the qualification have reduced due to staff leaving. The manager plans to address this when the staff team is up to full complement. Regular supervisions and staff meetings take place to ensure that issues within the team are addressed and staff are aware of any developments within the home. Because of a turnover of staff not all members of the team are able to use sign language (Makaton). A recommendation has been made that training is provided, thus to enhance communication with service users. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 Page 15 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) 37,38,39,40,41,42&43 The home fulfils its objectives and the majority of service users needs are met. One aspect of an individual’s health and safety is not observed and they are exposed to risk. EVIDENCE: The manager is approachable and operates an ‘open door’ policy which was observed during the inspection. A board is on display with photographs of who is on duty for the coming week. Service users use this to reassure themselves as to when they will next see their keyworker. Home Farm Trust operates a quality assurance system where views are sought from service users and their relatives. If the results coincide from the audit the home manager may incorporate them into the reviewed Service Users’ Guide. A requirement has been made for the manager to submit an application for Registration with the Commission as she has demonstrated her ability to manage challenging situations. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 Page 16 One service user prefers to keep their bedroom door open during the daytime. A requirement has been made for a safe and approved method of keeping the door open to be employed if this practise is to continue. Records checked were found to be in good order (accident, fire, supervision, recruitment, complaints). Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 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 3 2 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Name Score 2 3 1 2 Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 2 3 I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 Page 18 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1)(b) Requirement Timescale for action 30/07/05 2. 3. YA18 YA20 12(4)(a) 13(3) 13(4)(c) 13(2) 4. YA30 23(2)(d) A copy of service users assessments must be held in the home. This is essential in assisting staff to meet the needs of service users who are potentially moving into the home. Toilet roll must be accessible to 31/08/05 all service users and staff. Specialist holders are advised. A foolproof medication system 31/08/05 must be in place. Medicines must not be stored in a domestic refrigerator and topical cream must not be kept alongside food. The temperature of medicines must be recorded to ensure appropriate storage. Medication must be dated on opening. Administration directions on the MAR (Medication Administration Record) sheet must reflect the prescribed details and be signed by a member of staff in the absence of a G.P. A doctor or pharmacist must sign the homely remedies policy. The stained bedroom carpet 30/09/05 must be cleaned. It must be replaced if cleaning fails to remove the stains. Version 1.40 Name I52 s19529 South Road v240201 260705 Stage 4.doc Page 19 5. YA30 6. YA37 7. YA42 Infection control must be 30/09/05 observed by the provision of paper hand towels and pump action soap. Infection control training would further assist in this process. 8(1)(a) An application must be received 31/08/05 by the Commission for Social Care Inspection for registration of a manager. THIS REQUIREMENT HAS BEEN MADE PREVIOUSLY 13(4)(c) An appropriate door closer 31/8/05 23(4)(c)(ii system must be implemented on i) the bedroom door that is wedged open by the service user. Advice must be sought fron the Community Fire Safety Officer. 13(3) 13(4)(c) 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. Refer to Standard YA21 YA32 Good Practice Recommendations Service users wishes in how they will be cared for at the end of their lives and after death should be recorded. THIS RECOMMENDATION HAS BEEN MADE PREVIOUSLY. Makaton training and updates should be made available to all staff. Name I52 s19529 South Road v240201 260705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts AL7 3BQ 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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