Inspection on 26/01/06 for St Georges Road (67a)

This inspection was carried out on 26th January 2006.

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

Other inspections for this house

St Georges Road (67a) 22/11/07

St Georges Road (67a) 26/09/06

St Georges Road (67a) 29/09/05

St Georges Road (67a) 03/02/05

St Georges Road (67a) 13/09/04

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 09/07/2008.

CARE HOME ADULTS 18-65 St Georges Road (67a) 67a St Georges Road Semington Melksham Wiltshire BA14 6JQ Lead Inspector Malcolm Kippax Unannounced Inspection 26th January 2006 10:45 St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 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 St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 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. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Georges Road (67a) Address 67a St Georges Road Semington Melksham Wiltshire BA14 6JQ 01380 870168 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) Ordinary Life Project Association Mrs Margaret Jean Kemp Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1) of places St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who may be accommodated in the home at any one time is 3 Only the one, named, female service user currently being accommodated may be over the age of 65 years 29th September 2005 Date of last inspection Brief Description of the Service: 67a St. Georges Road is one of a number of care homes that are run by the Ordinary Life Project Association (OLPA). The West Wiltshire Housing Association owns the property. The service users receive support from a manager and a permanent staff team. Relief staff and agency carers were also being used on a regular basis at the time of this inspection. 67a St Georges Road is situated in the village of Semington, between Trowbridge and Melksham. The property is a spacious, detached bungalow with a large garden. The service users have their own rooms. The communal areas consist of a lounge and a dining room. There is always one member of staff working in the home and additional staff members are deployed at particular times of day. The home has its own vehicle for trips out. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was arranged at short notice at a time when the manager was present. It took place from 10.45 am until 3.05 pm. The inspection focussed on a number of key standards that were not looked at during the previous inspection of the home. There were two service users living at the home. A third person had moved out of the home in the previous week. One service user and a staff member were met with. The service user was having a home-based day. She spoke about what she did and what it was like to live in the home. The staff member had worked in the home for several years. Records, including care, health, medication, staff training and recruitment were looked at. This inspection focussed on a number of key standards that were not looked at during the last inspection of the home. What the service does well: What has improved since the last inspection? What they could do better: The process of induction would be improved by the provision of an accredited programme for staff who are new to working in a learning disability service. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 6 There is a lack of quality assurance and action plans for improvement. OLPA has not yet produced a comprehensive policy on personal care and gender. It is recommended that OLPA develop a policy that reflects good practice and the range of factors that need to be taken into account. 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. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 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 St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 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): These standards were not looked at on this occasion. Standard 2 did not apply at this time as no new service users have moved into the home for a number of years. (Standard 5 was inspected and almost met a the last inspection). EVIDENCE: St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 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): 9 Independence is encouraged although risk factors are affecting the level of independence that can be achieved. (Standards 6 and 7 were inspected and met at the last inspection). EVIDENCE: The service user met with requires the support of a staff member when outside the home. She talked about the social activities that she attends during the week, including P.H.A.B. and Gateway clubs. Some of the activities involve independence from the home, with support being provided from people outside the home. The service user has enjoyed some outings with people from one of the day centres that she attends. She goes food shopping with one of the staff. It was explained that the service user is able to spend some time by herself in the supermarket choosing her own things to buy, while staff remain at a discreet distance. This was a way in which staff could give the service user a degree of independence whilst ensuring that support is on-hand if needed. Both service users attend hairdressers in the community. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 10 The service user met with likes to help with baking cakes, although the manager said that both service user stayed outside the kitchen because of the risk of hot surfaces and other hazards. There is a doorway between the kitchen and the dining room. It would be beneficial to assess whether changes can be made in the kitchen, or when it is used, which will reduce the hazards and enable a service user to spend time in the kitchen. The manager and staff member said that the relationship between the two service users was ‘up and down’. Sometimes the service users need to spend time separately and this affects how much the service users can act independently within the accommodation. One service user was out at a resource centre at the time of the inspection. It was recommended at the last inspection that all sections of the Shared Action Plan forms, including ‘achieve dates’ are consistently recorded. It was seen that ‘on-going’ has since been added in some of the date achieved columns. This is not a clear way of recording whether the goal has been achieved and whether any further action needs to be taken. Progress with the system of shared action planning will be looked at during the next inspection. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 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): 16 Service users are encouraged to treat the home, however there are limitations on how independent they can be. (Standards 12, 13, 15 and 17 were inspected and met at the last inspection). EVIDENCE: A cordless phone is kept in the dining room and the service user said that she could use this in the privacy of her own room. She has family and friends who she keeps in regular contact with. The service user has chosen not to have a key to her room. The door can be locked from the inside, with a key being needed on the outside. The manager was unsure about the whereabouts of the key to this door and it was agreed that a key needs to be available for staff to use in an emergency. The manager said that the other service user had been offered the chance to have a front door key and to manage this by himself, although he had made it clear that he did not want the responsibility. As reported under standard 9, there are some limitations on what the service users can do because of concerns about their safety and how they will get on with each other. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 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): 19 and 20 Service users receive the support that they need with their health care and medication. (Standard 18 was inspected and met at the last inspection). EVIDENCE: The service users are registered with different GPs at a local surgery. The manager said that they received good support from the surgery and there was no problem with accessing health care services. Both service users have been supported with accessing routine check ups that are available for people of their particular age and gender. Health care matters are reported in a section of the service users’ individual files. The meeting minutes showed that health related matters are discussed in team meetings and that staff members are observant of the service user’s moods and signs which may indicate a change in their well-being. Diet and losing weight had been discussed at a recent ‘tenants’ meeting. This was recorded in the meeting minutes. One service user sees a dentist in Chippenham and the other has a dentist in Devizes. One service user has regular appointments with a chiropodist, which the manager said were paid for by OLPA. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 13 Service users receive support with the safekeeping and management of their medication. Both service users had signed consent forms in connection with this. The home’s medication file included a range of relevant documentation and guidance for staff about the service users’ prescribed medication. The list of one service user’s current medication was in need of updating. This was brought to the attention of the manager, who removed it from the file in order to make the necessary changes. Medication received and its administration was being appropriately recorded. GPs had signed the record of administration when a change had been made in the dosage of a particular drug. The staff member met with was involved in administering medication and all staff do this after receiving in-house training in OLPA’s procedures. Some specialist input or externally arranged course would also be beneficial in this area. It was recommended at the last inspection that a statement on personal care is produced to include the organisations policy on gender and personal care and to provide details of any limitations and restrictions that may apply in the provision of personal care. The manager said that the service users had been asked whether they mind having a male carer bathing them. It is important that the views of service user are taken into account, however not all service users may have the capacity to make an informed choice. Other factors are also relevant and may justify limiting, on the basis of gender, the involvement that staff have in intimate personal care. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 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): 22 Service users have the opportunity to raise concerns although would need the support of others if making a formal complaint. (Standard 23 was inspected and almost met at the last inspection). EVIDENCE: OLPA have produced a written complaints procedure. Service users have been given a copy of the complaints leaflet to keep in their rooms. The manager said that the service users would probably not know how to make a formal complaint. The manager said that one service user can get impatient and complains informally about the other service user and that this is symptomatic of their ‘up and down’ relationship. The manager and staff member also said that the service user is given some individual time each evening to talk things and that this was beneficial. The service user met with mentioned people inside and outside the home who she could speak to if not happy with something. The need for compatibility between service users will be very important when the admission of a new service user is being considered. OLPA will need to ensure that a service user’s behaviour is not placing a more vulnerable service user at risk and adversely affecting their well-being when in the home. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 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): 30 Service users live in clean and domestic surroundings. (Standard 24 was inspected and met at the last inspection). EVIDENCE: The areas of the home seen during the inspection looked clean and tidy. Support workers take the lead in the cleaning of the home and there are rotas and job lists for particular tasks such as in the kitchen. Key workers support service users with their own rooms. There is a utility room with laundry facilities off the kitchen. Assessments have been undertaken in respect of some environmental risks. Guidelines on infection control were available in the office cupboard. The manager said that she was concerned about M.R.S.A. and was going to provide staff with some written guidance. OLPA provides training for staff in health & safety (including infection control) and in food hygiene. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 16 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): 34 and 35 The recruitment arrangements help to protect service users from unsuitable staff. Staff training is provided through in-house activities. The benefits for service users are reduced by the lack of an accredited programme of induction for new staff. (Standard 32 was inspected and met at the last inspection). EVIDENCE: A new support has started working in the home since the last inspection. The recruitment records showed that appropriate checks, including written references, C.R.B. and P.O.V.A. list check had been undertaken prior to the staff member starting in the home. The C.R.B. documentation was kept with the staff member’s training records, rather than with the other recruitment documentation. The manager was advised to keep the C.R.B. information confidentially for as long as it is required. The staff training records show that staff members participate in a range of courses as part of the OLPA programme of training. This primarily covers statutory areas of training although one staff member had recently attended a training event in palliative care for people with a leaning disability. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 17 The involvement of staff in this type of specialist training event is very positive. Further opportunities for developing the staff training programme in this way should be looked at. The new staff member had completed an OLPA induction and foundation programme. She had started working in the home on 20 December 2005 and attended an OLPA Induction day on 21 June 2005. This would be at the end of the staff member’s six-month probationary period and the staff member had therefore been working in the home before having the information and guidance that is provided on the induction day. Learning Disability Award Framework accredited training is not being provided. This is recommended for staff who are new to working in a learning disability service and can be used to provide the underpinning knowledge for progress towards achieving NVQs. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39 Service users have benefited from continuity in the running of the home, prior to the appointment of a permanent manager. There is a lack of quality assurance within the home. (Standard 40 and 42 were inspected and almost met at the last inspection). EVIDENCE: Mrs Kemp has extensive experience of working in the home and her knowledge and good understanding of the service users’ needs was evident during the inspection. A service user has received support with moving to another home because of her changing needs. Mrs Kemp described how she had worked with the new home to ensure that the service user feels at home in her new room and has familiar things around her. Mrs Kemp who has been working on a relief basis until a permanent appointment is made, said that she was leaving her position during the last St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 19 week of March 2006. This period of notice will enable OLPA to have a new manager in post without the need for temporary arrangements. There was no evidence provided of an action / improvement type plan or of an organisational approach to quality assurance that is in line with National Minimum Standards. Some shortcomings identified at the last inspection in connection with standard 42 have received attention. It was reported by the manager at the last inspection that she was waiting for the radiator in the dining room to have a cover fitted. This has not yet been done. The manager confirmed that a cover did need to be fitted and that this continues to be raised with the housing association that owns the property. Health and safety was discussed with the manager in respect of the service users’ needs. The manager said that moving and handling assessments have not been completed although service users do have needs concerning their mobility and / or transfers. Risk assessments are included in the service users’ personal files. Some sectioning within the files would help to find and identify the different subjects and documents that are included on the files. Policies and procedures were not looked at on this occasion. St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 20 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 X 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 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X 1 X X X X St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 21 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 YA39 Regulation 24 Requirement The Commission is supplied with a report of the most recent review re: quality assurance that has been carried out in accordance with Regulation 24 of the Care Homes Regulations 2001. The registered person must ensure that risk assessments are undertaken in relation to radiators and covers are provided as required (outstanding from the last inspection) The registered person must confirm with the Commission the action being taken to cover the remaining radiator(s) that need attention. A moving and handling assessment must be completed in respect of each service user Timescale for action 30/04/06 2. YA24 13 28/02/06 3. YA42 13 31/03/06 St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 22 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 YA5 Good Practice Recommendations That a third party, usually the service users care manager, is involved in agreeing and signing any terms and conditions statements. (Outstanding from the last inspection). That the licence agreements include all items that are specified under Standard 5.2 of National Minimum Standards. (Outstanding from the last inspection). That all sections of the Shared Action Plan forms, including ‘achieve dates’ are consistently recorded. (Outstanding from the last inspection). That a statement on personal care is produced to include the organisations policy on gender and personal care and to provide details of any limitations and restrictions that may apply in the provision of personal care. (Outstanding from the last inspection). That an appropriate outside professional, e.g. a pharmacist, contributes to the training that staff receive in medication procedures and drug usage. That L.D.A.F. accredited training is provided for staff who are new to working in a learning disability service. 2. 4. 5. YA5 YA6 YA18 6. 7. YA20 YA35 St Georges Road (67a) DS0000028335.V280864.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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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