Inspection on 26/01/06 for Underhay House

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 Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Underhay House 16/07/08

Underhay House 03/08/07

Underhay House 13/09/06

Underhay House 19/07/05

Underhay House 27/02/05

Underhay House 28/09/04

Underhay House 27/01/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Underhay House 639-641 Muller Road Eastville Bristol BS5 6XS Lead Inspector Sam Fox Unannounced Inspection 26th January & 4 February 2006 09:30 th Underhay House DS0000026624.V273658.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 Underhay House DS0000026624.V273658.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. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Underhay House Address 639-641 Muller Road Eastville Bristol BS5 6XS 0117 9519094 01275 372151 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) Freeways Trust Ltd Miss Claire Anne Hayward Care Home 12 Category(ies) of Learning disability (11), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: Underhay House is registered to provide accommodation and personal care for up to twelve persons, eleven with a learning disability and one specific person with a mental disorder, all aged between 18-64 years. Freeways Trust, a non-profit making organisation that has a number of care homes within the local area, operates the home. There is a satellite home, 224 Glenfrome Road, that is close to Underhay. Both houses are managed by the same person and jointly staffed. The home comprises of two semi-detached houses and is located in a busy residential area. It is close to local amenities and facilities. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the focus of which was to check on progress and to ensure residents continued to be happy and settled. The environment, alongside cleanliness, formed a major focus, as these were weaknesses identified at the last visit. In addition to this key records were examined, including health and safety and care planning documents. Evidence was gained through discussion with staff and residents and through examination of records. Not all standards were assessed during the visit and this report should be read in conjunction with others so a fuller picture of the home can be gained. Two requirements made at the last inspection were not discussed and as such are carried forward with adjusted timescales. These should not be viewed as examples of non-compliance with the regulations. What the service does well: What has improved since the last inspection? The carpets in the hallway and communal areas have been replaced and this has considerably improved the ambience and made Underhay more homely. Additional ventilation has been installed in the kitchen area, making it a more comfortable environment to cook in. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 6 The staff team have begun to develop personal plans which, once completed, will give clearer guidance about individual needs. The home now maintains a record of food and can clearly demonstrate they are providing a wide variety of nutritious meals. 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. Underhay House DS0000026624.V273658.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 Underhay House DS0000026624.V273658.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): 1,5 There is up to date information for residents to make an informed decision about moving to the home. Contracts enable them to more fully understand their rights and responsibilities. EVIDENCE: The home has a statement of purpose and service users guide. These include the aims and objectives of the home and the facilities and services to be provided. They are written in a user-friendly format with the use of symbols and picture. Each resident has received a copy of the service user guide. This meets with requirements of the legislation. Three residents files were inspected in detail. These were found to contain service user agreements, which were written in a user-friendly format. These included weekly fees and a breakdown of costs, including mobility allowance and expected contribution towards the transport. Underhay House DS0000026624.V273658.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): 6,8,9,10 Residents can expect to be supported to take calculated risks and to be consulted on in all aspects of their lives. They can be re-assured that information about them will be kept private. EVIDENCE: Underhay are beginning to develop personal plans – these were not looked at in detail during the visit and a number of them have yet to ne completed. A requirement made about this at the last inspection will be carried forward with an extended timescale. Each resident has an in-depth annual review where all aspects of their lives are discussed and their aims and wishes for the forthcoming year are recorded. Those seen were found to be written to good detail and indicated that the home takes a holistic approach to the provision of care. Residents are fully involved with this process along with significant people in their lives. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 10 The home operates a key working system whereby each resident has a named member of staff who plays more of a central role in co-ordinating the services they receive. Members of staff displayed a good awareness of their responsibilities in this respect and a number of residents knew who their key worker was and what they could expect from them. This indicates that the system works well within the home. There was information about advocacy groups and one resident explained that he is an active member of a Bristol wide advocacy group. There were individual risk assessments available, including accessing the community, handling finances and working in the kitchen. These were written to good detail. It was evident that residents at Underhay have varying levels of independence and are encouraged to take risks according to their ability. This is good practice. Freeways have a confidentiality policy and this is discussed during the formal induction period. Staff continue to display a good understanding of what this entails. In addition to this it was discussed with residents at their last house meeting. Underhay House DS0000026624.V273658.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): 11,12,13,14,15,16 Residents are supported by a skilled team to lead active and interesting lifestyles and to have a positive community presence. Their rights are respected and they are encouraged to take responsibility in their daily lives. EVIDENCE: On the first day of the inspection there were two residents at home, the others had gone out to pursue various different activities. Some were attending resource activity centres, one had gone to work and another was shopping. It was very apparent from this, and discussion with staff, that residents are supported to lead active lifestyles tailored to individual choice and preference. The second day of the inspection was on a Saturday and again many residents were out pursuing leisure activities. Some are able to do this independently whilst others need staff support. It was apparent that for those who can, there is unrestricted access to community facilities. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 12 Residents discussed what they liked to do in their spare time. This included trips to the cinema, shopping and going to places of local interest. The home has a computer which residents were observed using to access the Internet. Residents also benefit from going on annual holidays. The home has a vehicle, which was observed being used by residents. Discussion with staff, residents and records provided evidence that residents are encouraged to maintain links with people outside of the home, including family and friends. Some residents go away to visit family at regular intervals. Issues in relation to intimate personal relations are approached sensitively and appropriately. Residents explained that they are responsible for a number of household chores and they were observed maintaining the upkeep of the house at the time of this visit. It was understood that they also have an allocated day during the week when they are supported by their key worker to tidy their bedrooms and do their washing. In addition to this each have set days where they take responsibility for cooking the evening meals. This is good practice. The home is now maintaining an accurate record of food and alternatives – this meets with a requirement made at the last visit. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 Residents continue to be supported to lead healthy lifestyles. Medication records need to be improved to make them safer. EVIDENCE: Records provided evidence that residents are supported to see the relevant health care professionals and to have annual check ups. Key workers write monthly reports which highlight when appointments are due and these provide a useful tool for monitoring residents’ health. There were reports from visiting specialists, including psychologists. These records evidence that the home skilfully supports some residents with particularly complex emotional needs. The home operates a monitored dosage system for the administration of medication that is delivered at regular intervals by the local pharmacist. Records held in relation to this were generally found to be well maintained and met with the requirements of the legislation. There is a medication profile for each resident, which also details side effects of prescribed medication. This is good practice. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 14 It was noted that there is a stock of paracetamol for household use. These are not being accurately signed for. Staff should be reminded of their responsibilities in this respect. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 15 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 Residents can be confident that they will be listened to and that they will be protected from abuse. EVIDENCE: Freeways have a formal complaints procedure and all residents have been given a copy of this in a user-friendly format. This includes timescales for action and the contact number rof the CSCI to whom concerns can also be raised. There was an open atmosphere in the home and several residents consulted with spoke freely about what it was like to live at the home. It was apparent that they felt confident to speak with their key workers if they had a problem. In addition to this residents’ meetings are held at regular intervals, which enables them to have a more formal forum to comment on the services provided. The home has a protection of vulnerable adults policy and all staff receive abuse awareness training as part of their formal induction. This was confirmed through discussion with them. The manager has displayed a good understanding of issues in relation to this. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 Residents’ benefit from living in a comfortable and homely environment, which is kept clean. One bathroom needs upgrading. EVIDENCE: Underhay House comprises of two terraced houses knocked into one. It is based over three floors and blends in well with the local environment. It has a large secure back garden that was well maintained. It was noted at the last visit that the home could benefit from a programme of ongoing refurbishment and this has begun. Notably the flooring in the communal areas, hallway and dining room has been replaced. Staff and residents said this has led to significant improvements in the ambience of the home. They did say, however, that there were some frustrations about the length of time it took to complete, as with many maintenance jobs. It is recommended that Freeways review systems in place in this respect and ask staff for their views on how improvements can be made. The kitchen also required additional ventilation. This has been achieved but the room still becomes very hot and is not ideally located. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 17 One bedroom has been re-decorated since the last inspection and this was seen to be homely and reflect the occupant’s tastes. Staff said they have been asked to supply a list of bedrooms that require re-decoration to the Trust. It is hoped that they will begin this soon as, whilst a number of bedrooms are adequately furnished and decorated, they could benefit from improvement. The bathroom on the ground floor was found to be cleaned to good standard and adequately furnished. The bathroom on the first floor however, was found to be dark and poorly decorated, with peeling paint and dirty grouting. It was not a relaxing environment. In addition to this the shower was not working properly – it kept turning on when the taps were being used. This needs to be fixed. The communal areas of the house were found to be homely and comfortably furnished. All areas were found to be cleaned to an adequate standard although there some areas that could have benefited from a deeper clean. Staff explained that the situation had been made worse as a housekeeper was off sick. The home must ensure this situation is resolved before it becomes a major issue. The home has a laundry room, which has two washing machines and a dryer. These reach sufficient temperatures to wash soiled clothing. Residents were observed using these themselves. The home has a number of infection control policies. These were not looked at in detail during this inspection. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 18 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 Residents are supported by an effective staff team who communicate well and therefore can provide consistency. EVIDENCE: At the time of this visit there were sufficient numbers of staff on duty to meet with the needs of those residents currently accommodated. There were however, two people on long-term sick leave and one full timer had just left. This has led to extra pressure on existing staff and to an increased use of bank staff. It was noted, however, that the home endeavours to use the same people so there is consistency. It is hoped that this situation will be improved soon. Opportunity was taken to view handover records – these provide an important day-to-day chronology of events in the house and enable the staff to have more effective means of communication. They included planned activities, GP and specialist appointments and significant events within the hsoeuhold. These were well written. In addition to the above the manager holds regular staff meetings, although it was noted that on occasion these have not been well attended. These provide a means through which staff can be consulted with, and included, in decisionmaking processes within the home. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,41,42 The home is well run so residents can be confident that their rights and welfare will be safeguarded. EVIDENCE: The manager has run the home for a number of years and has proved herself competent in all aspects of the running of the home. She has numerous qualifications and displays a good awareness of her responsibilities under the Care Standards Act. All staff spoken with said they felt the manager was approachable and that they were listened to. They also said that they were delegated responsibilities, which gave them more confidence. Issues in relation to quality assurance systems were not discussed during this visit and a requirement made at the last inspection will be carried forward with an extended timescale. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 20 All records seen at the time of this inspection were well written and updated, where necessary, at regular intervals. The home is well organised in this respect. All confidential records are stored appropriately. The fire logbook evidenced that tests and checks of the system take place at the appropriate intervals. In addition to this all staff have had refresher fire training. The home conducts a series of house checks which are fully recorded – this enables them to regularly monitor health and safety standards. There was a work place fire risk assessment in place. There were health and safety risk assessments in place, including, for example, the storing of chemical products and going food shopping. These were written to good detail, regularly updated and relevant to household tasks at Underhay. Staff confirmed that they had had basic statutory health and safety training, including first aid, manual handling and basic food hygiene. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 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 3 2 x 3 x 4 x 5 3 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 3 25 2 26 3 27 2 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 2 x 3 3 x x 3 3 x Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 22 no 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 YA6 Regulation 15(1) Requirement Develop plans of care based on the plan drawn up by the placing authority. This is repeated from the last inspection Timescale for action 30/05/06 2. YA39 35 The home to develop a quality assurance tool. This is repeated from the last inspection 30/05/06 3. 4. 5. YA26 YA27 YA20 23(2)(d) 23(20(b) 13(2) Continue with planned redecoration of bedrooms Fix shower on first floor Ensure there are accurate stock records of all medication held on the premises. 30/04/03 28/02/06 04/02/06 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 YA27 YA24 Good Practice Recommendations Re-decorate bathroom on first floor Review systems in place for maintenance. Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Underhay House DS0000026624.V273658.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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