CARE HOME ADULTS 18-65
Gwynfa Close (14) 14 Gwynfa Close Welwyn Hertfordshire AL6 0PR Lead Inspector
Mrs Alison Butler Unannounced Inspection 6th December 2005 1:00 Gwynfa Close (14) DS0000054490.V271366.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 Gwynfa Close (14) DS0000054490.V271366.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. Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Gwynfa Close (14) Address 14 Gwynfa Close Welwyn Hertfordshire AL6 0PR 01438 712939 01438 712939 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) Three Oaks Care Home Limited Mrs Tracy O`Dwyer Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8), Physical disability (8), of places Physical disability over 65 years of age (8) Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. This home may accommodate people with a physical disability (when associated with a learning disability) 25th April 2005 Date of last inspection Brief Description of the Service: The home was first registered with Hertfordshire County Council on 28th October 1997. Gwynfa Close is a large detached bungalow set at the end of a cul-de-sac in the village of Welwyn. The building has been extended and converted for use as a residential care home for people with learning and physical disabilities. The home provides support to individuals in developing and maintaining links with the local community. The aim is to allow individuals to have a say in how the home is run regardless of their disability. Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over the lunchtime period. The inspection focused on meeting and talking to the management, staff, visitors and residents in the home. It also checked on the requirements that were made at the previous inspection. Where standards remain the same the information has been carried forward from the previous inspection. What the service does well: What has improved since the last inspection? What they could do better:
The home must implement a quality assurance monitoring system to ensure the views of the residents; families and visiting professionals are reviewed, recorded and acted upon. A report is to be made available to interested parties and a copy forwarded to Commission For Social Care Inspection. This remains
Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 6 outstanding from the previous two inspections and failure to comply may result in legal enforcement action being taken. A bring forward system should be implemented to allow for ease of reconciliation at any point in time to be carried out. Where medication is for disposal it should be clearly marked and kept separately from all other medication to eliminate accidental administration. The manager should ensure that risk assessments are signed and dated to aid the review process. The manager should consider a review of the key worker system this would facilitate the reviewing of the residents plans as appropriate. The epilepsy protocol should be reviewed with staff and the community nurse to ensure a consistent approach is adopted at the time of a seizure happening. 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. Gwynfa Close (14) DS0000054490.V271366.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 Gwynfa Close (14) DS0000054490.V271366.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): 1&2 Residents and/or families receive information about the service, which enables them to make a choice about whether or not, they may wish to live in the home. Resident’s needs are assessed prior to admission to ensure the home is able to meet their needs. EVIDENCE: The Statement of Purpose and service User Guide have been amended to reflect the increase in accommodation and staffing. A amended copy must be sent to the Commission For Social Care Inspection. Assessments had been carried out to ensure the home is able to meet the residents’ needs. A proposed new resident is being assessed and a transition programme is being put in place to commence early in the New Year. Gwynfa Close (14) DS0000054490.V271366.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, 7, 8, 9, & 10. Individual needs are assessed and any goals are reflected within their care plans. Support and advice is given to the residents to help them make decisions about all aspects of their lives. All information is handled appropriately and confidentially. EVIDENCE: Individual needs and choices are reflected in the care plans. These are reviewed and developed appropriately. Residents are allocated a key worker who supports them in their life choices. Those care plans examined showed they had been reviewed regularly, with the exception of one. When a need has been identified and information recorded within the daily notes, this should be transferred onto the plan especially as the residents can become abusive when challenged. The information should provide detail of how the staff manage this and ensure they are consistent in their approach. Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 10 The information contained within the files has been condensed and ensures that all the information is current. Risk assessments are in place and those inspected had been reviewed and updated as appropriate. The confidentiality policy is yet to be forwarded to the Commission For Social Care Inspection and the recommendation remains in place. Staff confirmed they are aware of the need for confidentiality and that files are stored appropriately. Gwynfa Close (14) DS0000054490.V271366.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): 12, 13, 14, 15, 16, & 17. Residents are able to choose which activities to take part in the local community. They are able to engage in appropriate activities of their choosing. The rights of the residents is maintained providing them with appropriate support and assistance. EVIDENCE: The residents are supported to maintain family links and friendships within and outside the home. Feedback from visitors stated that they were always made to feel welcome in the home and were able to visit at any time. Staff were seen to provide appropriate support and good interaction was observed treating residents with respect and dignity. All the residents had been on holiday during the summer, with one being supported by staff on a cruise, which they thoroughly enjoyed. Residents are offered a healthy, well-balanced, nutritious diet. Support from dietician is obtained as appropriate. Records are maintained of food consumed and offered.
Gwynfa Close (14) DS0000054490.V271366.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): 20 Policies and procedures are in place to ensure they have their medicationadministered appropriately. EVIDENCE: Examination showed that the medication was well kept and appropriately recorded. When medication has been identified for disposal it must be clearly marked and stored separately to ensure it is not used accidentally. No residents are able to administer their own medication. Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 13 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 & 23 Views of the residents and families are listened to and acted on. Polices and procedures are in place to protect residents from abuse, neglect and self harm. EVIDENCE: The home has on display the Hertfordshire County Council Adults at Risk procedure, of which staff are all aware and of the whistle blowing procedure. The complaints procedure is on display in the entrance hall where visitors to the home can refer on it if they were unhappy with any aspect of the service provided. No complaints had been received by either the home or Commission For Social Care Inspection since the last inspection. The views of the residents are listened to and acted upon during the 1-1 sessions they have with their key workers and/or their families and friends who visit them. Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 14 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 & 30 The home is well kept and homely. To ensure safety risk assessments must be completed. All areas visited were found to be clean and fresh with the exception of one resident’s bedroom. EVIDENCE: Replacement flooring was being laid in the lounge during the inspection. The carpet was being replaced with a wood floor as this was seen as more appropriate for the needs of the residents. The manager must complete a risk assessment and identify any risks and try to ensure the safety of residents, visitors and staff. An odour was detected in one of the resident’s bedroom. Staff need to monitor this and take appropriate action to eliminate the odour. The dining room and lounge has been decorated. New flooring been laid in the dining and kitchen areas. Two residents rooms will be redecorated in the New Year. The home was cleaned to a high standard. Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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, 34 & 35 Consistent and experienced staff support the residents. EVIDENCE: Rotas showed that three staff cover the morning to support the residents in rising and attending their various day time activities. A minimum of 2 staff cover the afternoon and evening shifts. Additional staff are brought in if activities are arranged where residents require additional support. A member of staff covers the waking night and are supported by a sleep-in person who can be called upon if necessary. Once the additional room is filled additional staff will be required to ensure the health, safety and welfare of both staff and residents and to ensure their fully assessed needs are met. Staff files examined showed all the relevant information was available as required by legislation. Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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): 39 & 42 Gwynfa Close is well managed. The health, safety and welfare of residents, visitors and staff is on the whole well promoted through a series of checks and risk assessments. A quality assurance system is still to be implemented to ensure a self-monitoring review is in place. EVIDENCE: The proprietor is a regular worker and usually covers the morning shift supporting residents in attending their daily activities. The relationship between the residents and staff was seen to be kind, caring and supportive. Staff and visitors felt that the atmosphere of the home is very welcoming relaxed. A quality assurance audit and report remains outstanding from the last two inspections and a further timescale has been set. Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 17 Risk assessments must be completed detailing the risks and how these can be minimised whilst work is being carried out in the home. All records required by legislation were available and those examined were up to date and well maintained. Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 18 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 2 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 2 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Gwynfa Close (14) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 2 X DS0000054490.V271366.R01.S.doc Version 5.0 Page 19 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 YA1 Regulation 4&5 Requirement Timescale for action 31/01/06 2. 3. YA20 YA24YA42 13(2) 13(4) 4 YA39 24 The statement of purpose and service user guide must be reviewed, updated and sent to the Commission for Social Care Inspection. The medication records must 06/12/05 appropriately be maintained at all times. The manager must ensure that 06/12/05 risk assessments are carried out and record how notes can be minimised for the work that is being carried out A review must be carried out to 31/01/05 establish the quality of care provided by Three Oaks Care, a report made available to all interested parties and a copy forwarded to the Commission For Social Care Inspection. This has been brought forward as the timescale has yet to expire Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 20 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 YA6 YA6 Good Practice Recommendations A review of the key worker system should take place to ensure the completing of reviews and updating of information is carried out as appropriate. The care plan format should be reviewed to eliminate the amount of repetion within the care plans. Information no longer required should be archived and ensure the care plan files are a user-friendly document. Risk assessments should be signed and dated to ensure they are in date and are reviewed as appropriate. A confidentiality policy should be made available and a copy forwarded to the Commission For Social Care Inspection. A bring forward system should be in place to allow for reconciliation of medication at anytime. The epilepsy protocol should be reviewed with both staff and the community nurse to ensure a consistent approach is used at the time of a seizure happening. The manager should continue to work towards her Registered Managers Award. This has been brought forward from the previous inspection. 3. 4. 5. 6. 7. YA9 YA10 YA20 YA20 YA37 Gwynfa Close (14) DS0000054490.V271366.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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