Inspection on 19/10/05 for Vale Road (15a)

This inspection was carried out on 19th October 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vale Road (15a) 05/11/08

Vale Road (15a) 08/05/08

Vale Road (15a) 10/05/07

Vale Road (15a) 27/07/04

Vale Road (15a) 10/02/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Vale Road (15a) 15a Vale Road Ash Vale Nr Aldershot Hants GU12 5HH Lead Inspector Joseph Croft Unannounced Inspection 19th October 2005 10:00 Vale Road (15a) DS0000013452.V250352.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 Vale Road (15a) DS0000013452.V250352.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. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Vale Road (15a) Address 15a Vale Road Ash Vale Nr Aldershot Hants GU12 5HH 01252 334880 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.unitedresponse.org.uk United Response Wayne Cooksey Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 40-60 YEARS OF AGE 4th July 2005 Date of last inspection Brief Description of the Service: 15a Vale Road is a purpose built bungalow, which is owned by English Churches Housing and managed by United Response. The home is situated in a quiet residential cul de sac in Ash Village. The home is close to local amenities and the railway station, and there are good road links to the nearby towns of Aldershot, Farnborough and Guildford. The home provides accomodation for five residents with learning disabilities, some of whom have physical disabilities. All residents have their own bedrooms and there are two supported bathrooms available. The home has a communal dining room and lounge and there is easy access to a well maintained garden.The home has parking for several cars and a minibus. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of the year 2005 – 2006. It will be necessary to view both inspection reports for 2005 – 2006 to obtain a full understanding of the extent to which the home meets The National Minimum Standards for Younger Adults. This unannounced inspection was undertaken on the 19th October 2005 by one inspector. The duration of the inspection was four hours. As part of the inspection process in depth discussion took place with the registered manager and two members of staff were interviewed. At the time of the inspection there were three residents present in the home. The residents are non - verbal, and their level of understanding is very low. Discussions with residents were not undertaken during this inspection. However, one resident allowed the inspector to view his bedroom whilst he was present and with a member of staff. The inspection included sampling of policies and procedures, records, care plans, health care records, statutory records, training records and the menu. Issues in regard to health and safety have been identified and the registered provider and the home’s manager must address these. Staff were observed to be interacting with the residents in a positive manner. One immediate requirement, fourteen requirements and three good practice recommendations have been made at this inspection. Four requirements made at the previous inspection have been carried over and must be complied with. What the service does well: The home is clean, tidy and free from offensive odours. Staff were observed interacting with the residents in a positive manner, calling residents by their first names and providing support with tasks as required. Residents are able to spend time on their own in their bedrooms. Residents’ physical and emotional health needs are being met. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Vale Road (15a) DS0000013452.V250352.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 Vale Road (15a) DS0000013452.V250352.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): EVIDENCE: These key Standards were assessed at the previous inspection. Vale Road (15a) DS0000013452.V250352.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): EVIDENCE: These key Standards were assessed at the previous inspection. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 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 the following standard(s): 16 and 17 The home respects the rights and decisions of the residents and offers a varied and healthy menu. EVIDENCE: The manager stated that due to the residents’ very low understanding needs, they are not able to hold keys for their bedrooms. The reason why residents are unable to have bedroom keys must be recorded on their care plans. Bedroom doors are kept open through the use of fire safety closing devices that will close when the fire alarm is activated. During discussions staff stated that they knock on residents’ bedroom doors before entering. This practice was observed during the inspection. Staff stated that they open residents’ letters with the resident present. Residents have unrestricted access to all communal parts of the home including the garden and kitchen. However, the manager must write a risk assessment in regard to residents having access to the kitchen. Staff were observed interacting with the residents in a positive manner, calling residents by their first names and providing support with tasks as required. During discussions, staff stated they communicate with the residents through Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 Page 11 body language, pointing, facial expressions and behaviour. One resident took hold of the inspector’s hand and began to take him to the front door. The manager stated this was his way of communicating that he wanted to go for a walk. Staff stated they support residents to partake in light household tasks such as basic cooking and tidying of bedrooms. Residents were observed to be able to spend time on their own in the lounge and their bedrooms. The manager stated that the home has a no smoking and no alcohol policy. However, it was observed that staff smoke on the patio outside the lounge patio doors. The inspector discussed this practice, in particular the effects this could have on residents, especially during the summer months when the patio doors and windows are probably left open. A requirement has been made that the manager must review this practice in regard to residents’ health and safety. The home has a four-week rolling menu that was evidenced during the inspection. Residents are offered four meals a day. The main cooked meal is served at the end of the day when residents have returned from attending day centres. The menu observed offered a variety of meals. Special dietary needs are catered for. Cooked breakfast is prepared at weekends. It was noted that the menu did not specify what was available for dessert each day. A good practice recommendation has been made in regard to this. A request was made for the inspector to observe residents having their lunch. However, this did not take place on this occasion, but this will be addressed during the next inspection. The manager stated that nutritional needs are assessed by the dietician or as when required. However, the manager stated this was last undertaken eighteen months ago. A requirement has been made in regard to this. Vale Road (15a) DS0000013452.V250352.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): 19 and 20 Residents’ health needs are considered and staff manage residents’ medication. EVIDENCE: There was evidence that residents had access to all National Health Services. Health care records were sampled and contained a medical profile, information on mobility and dietary needs. Records of visits to the GP, dentist, optician, continence nurse, hearing, sight and other health care professionals were observed. Risk assessments evidenced included epilepsy, mobility, eating, personal care and the use of safety sides on beds. Risk assessments observed had been reviewed in June 2005. The risk assessments on the safe use of bedsides were reviewed on 9th September 2005. Risk assessments must explain the action to be taken when the resident becomes exposed to the specified risk. During discussions, the manager stated that the GP will only see the residents if they require medical attention. The manager had written a letter to the GP for the home on the 2nd June 2005 requesting that he conducts annual health checks on all residents. The inspector viewed this letter. Due to the very low levels of understanding, residents are unable to administer or control their medication. Medication records were sampled. It was noted Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 Page 13 that the dates had not been written on the MAR sheets. A requirement has been made in regard to this. A good practice recommendation has been made that specimen signatures of staff who dispense medication should be kept on file in the home. One resident’s medication was evidenced; the medication matched with the records maintained. The manager stated that the Lloyds Pharmacist visits the home twice a year, checks all the medication, and gives a talk to staff responsible for the dispensing of medication. Evidence of the last visit made by the Pharmacist was observed to be 14th June 2005. The manager also stated that United Response provide in-house training on the safe handling of medication. The home follows the United Response medication policy. The home had a risk assessment for the dispensing of medication that was dated May 2005. The home does not maintain a record of medicines that are received into the home, or that are returned to the pharmacy. A requirement has been made in regard to this. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 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): EVIDENCE: These key Standards were assessed at the previous inspection. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 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): 24, 25, 26, 27, 28, 29 and 30 The home is clean, pleasant and generally well maintained, however, health and safety issues identified must be addressed. EVIDENCE: A tour of the premises was undertaken. The home was observed to be clean, tidy and free from offensive odours. However, it was observed that some flagstones on the footpath in the garden were uneven. It is important for health and safety reasons for staff and the residents that these are made safe. One garden shed had a broken windowpane that must be replaced. Requirements in regard to these have been made. The home has a large kitchen with the appropriate facilities for storing and cooking food. It was observed that one fridge had a broken shelf that must be replaced or repaired, the freezer was in need of defrosting, and the worktops in the kitchen were stained and had cuts caused by the use of kitchen knives. The inspector observed that staff use chopping boards for preparing foods. A requirement has been made that the manager must ensure that all appliances used in the kitchen are appropriately maintained or replaced. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 Page 16 The home has a lounge and dining room. A requirement has been made in Standard 16 in regard to staff using the patio area outside of the lounge as a smoking area. The bathrooms were viewed and found to contain the necessary adaptations for residents to use. It was observed that items of COSHH substances were inappropriately stored in one bathroom. An immediate requirement has been made that all COSHH substances must be securely stored in a locked cupboard. One of the baths had a pool of water underneath it. A requirement has been made that the manager ensures that this bath is not leaking. The air vents in the home must be regularly cleaned. Bedrooms were appropriately decorated and furnished, with residents having their own personal belongings. It was noted that one resident did not have photographs of his parents or family in his bedroom. A good practice recommendation has been made for this to be investigated. The home has a laundry that is domestic in nature, was clean and has a washing machine with a sluice facility. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These key Standards were assessed at the previous inspection. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 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): 42 The manager of the home must attend to the health and safety issues identified during this inspection to ensure the health, safety and welfare of residents are promoted. EVIDENCE: The home uses the United Response health and safety handbook that was reviewed in May 2004. General risk assessments for the home included COSHH, electrical equipment, garden area, food and infectious diseases. The following records were evidenced: Fire alarms and emergency lights were inspected on the 15th June 2005, fire extinguishers were inspected on the 17th February 2005, fire risk assessments reviewed on 12th May 2005, last recorded fire drill was on the 18th September 2005. Portable electrical appliances were inspected on the 12th September 2005 and the gas inspection took place on the 10th October 2004. The manager stated that the home has not had the water tested for Legionella. It is important that this is undertaken. A Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 Page 19 requirement has been made in regard to this. Daily records of the fridge, freezer and cooking of food were observed. The home has not had an inspection undertaken by the Environmental Health Office. A requirement has been made in regard to this. Evidence of mandatory training for staff was observed. Other health and safety issues have been identified in this report, and these must be addressed by the home’s manager and registered provider. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 2 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Vale Road (15a) Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000013452.V250352.R01.S.doc Version 5.0 Page 21 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 YA5 Regulation 5 (1) Requirement Service users must have signed and dated tenancy agreements and copies of local authority contracts must be held on file. This is a requirement carried over from the previous inspection and must be complied with. Reason why residents are unable to have bedroom keys must be recorded on their care plans. The manager must ensure that all residents have their nutritional needs assessed by a qualified person. Risk assessments must explain the action to be taken when the resident becomes exposed to the specified risk. The manager must record the dates on the MAR sheets. The manager must make arrangements for recording medicines received and returned to the pharmacy. The registered person must ensure that the flagstones on the footpath are evenly laid. DS0000013452.V250352.R01.S.doc Timescale for action 25/11/05 2 YA16 12 (4) 19/11/05 3 YA17 12 (1) 19/12/05 4 YA19 13 (4) (C) 19/11/05 5 6 YA20 YA20 13 (2) 13 (2) 26/10/05 26/10/05 7 YA24 23 (2) (0) 19/12/05 Vale Road (15a) Version 5.0 Page 22 8 9 YA24 YA24 10 11 12 13 14 15 16 17 18 19 YA28 YA27 YA30 YA30 YA30 YA34 YA34 YA39 YA42 YA42 The registered person must replace the broken window in the garden shed. 16 (2) (g) The manager must ensure that (h) all appliances used in the kitchen are appropriately maintained or replaced. 13 (4) (c) Risk assessments must be written for residents having access to the kitchen. 23 (2) (b) The registered person must ensure the identified bath is checked for leaks. 13 (3) (4) All COSHH substances must be kept secure in locked cupboards. 13 (4) (C) Air vents in the bathrooms must be kept clean. 12(1)(a)(3) The manager must review the (4)16(2) smoking area for the home in regard to health and safety. 19(4)(i)Sch The provider must record 2(6) satisfactory written explanation of gaps in employment. 19(4)(i)Sch2 The provider must obtain proof (1) of identity all staff employed in the care home. 24 The registered person must develop an annual quality assurance questionnaire. 13 (4) (c) The manager must have a Legionella test undertaken on the water. 23 (5) The manager must ensure that the Envirnomental Health Office undertakes an inspection. 23 (2) (0) 26/10/05 31/10/05 20/11/05 26/10/05 19/10/05 26/10/05 26/10/05 26/10/05 26/10/05 19/11/05 19/12/05 19/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000013452.V250352.R01.S.doc Version 5.0 Page 23 Vale Road (15a) 1 2 3 YA17 YA20 YA26 The home’s menu should specify what the day’s dessert is. The home should have specimen signatures of staff who administer medication. The manager should explore the reason why one identified resident did not have photographs of his parents/family displayed in his bedroom. Vale Road (15a) DS0000013452.V250352.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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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