Inspection on 28/08/07 for Wendover Road (87)

This inspection was carried out on 28th August 2007.

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

Other inspections for this house

Wendover Road (87) 27/08/08

Wendover Road (87) 10/07/06

Wendover Road (87) 21/11/05

Wendover Road (87) 19/04/05

Wendover Road (87) 24/01/05

Wendover Road (87) 06/08/04

Wendover Road (87) 11/02/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Wendover Road (87) Stoke Mandeville Aylesbury Bucks HP22 5TD Lead Inspector Kate Harrison Unannounced Inspection 28th August 2007 11:00 Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 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 Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 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. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wendover Road (87) Address Stoke Mandeville Aylesbury Bucks HP22 5TD 01296 615403 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) 87wendrd@nildram.co.uk Hightown Praetorian & Churches Housing Association Vacant Care Home 4 Category(ies) of Learning disability (4), Physical disability (2) registration, with number of places Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home may care for two service users with a Learning Disability, who also have a Physical Disability. That this condition applies to two specific service users, and should the service users in question leave the home for whatever reason this condition will cease to apply. That no further users with a physical disability are admitted to the home unless the home applies for a further variation to their registration. Date of last inspection 10th July 2006 Brief Description of the Service: 87 Wendover Road cares for 4 female service users with a learning disability. The home is located in a residential area about one mile from the centre of Stoke Mandeville. The home is a bungalow situated in relatively secluded grounds, with a large rear garden. All of the bedrooms are single and there is a kitchen / diner and a separate sitting room. The home has its own transport and is accessible to local amenities. Fees for this service are £1735.44 per week, according to information supplied with the pre-inspection questionnaire. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 11.00 hours and was in the service for 4 hours. This inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service, and any information that the Commission has received about the home since the last inspection. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standards of the service. The inspector saw most areas of the home, observed staff interactions with the individuals living at the home, spoke to staff members and looked at records and documents relating to the care of the individuals. Staff recruitment records were also seen. There is no registered manager for the service at present, and a new manager is being recruited. The previous manager had been on sick leave for several months before leaving. An experienced manager from another home is overseeing the management of the home and was at the home on the day of the inspection visit. Other staff posts are also vacant, and recruitment is taking place to make sure that all the posts are filled. The lack of a registered manager has had some impact on the home, though improvements have been made. The inspector asked the views of the people who use the services and of relatives and healthcare professionals connected with the home, but no replies were received. The inspector saw the four individuals living at the home and observed their care during the visit. From the evidence seen during the inspection visit, this service is able to meet the diverse needs of individuals from different cultural, religious and ethnic backgrounds, and of different physical ability. What the service does well: The home has good access and parking facilities and this means that getting out of the home is made easy for individuals and staff members. People living at the home have an individual plan of activities to suit their needs, and are able to take part in social, leisure and learning opportunities in the local community. The healthcare needs of individuals are recognized and staff members make sure that individuals have access to the health service when they need it. Personal support is tailored to the individual, and the staff members show respect for their wishes. The home is able to meet the religious and cultural needs of individuals. The organisation is committed to staff training so that people living at the home can enjoy better care, and new employees agree to enrol on the National Vocational Training (NVQ) Level 2 in Care, if they do not already have the qualification. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 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 Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager of the home has clear procedures to follow, so that the home is able to meet the needs of people admitted to the home. EVIDENCE: Nobody has been admitted to the home since 2001, but there is a clear procedure for admission to the home. The home’s manager conducts an assessment of need, including discussing the goals and aspirations of the individual, so that it is clear that the home can meet the needs of the individual. The individual can visit the home as often as necessary, with relatives and friends as preferred. Consultations with the other individuals living at the home and their advocates are carried out, so that the home remains harmonious, and the needs of all the individuals living at the home are met. The home is currently meeting the needs of the four individuals living there. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are being made in keeping documents updated, so that the individual care plans and risk assessments are more up to date. EVIDENCE: The service supports the individuals at the home to be in control of their lives as far as possible, and the individuals have advocates to make sure that their wishes are understood. Individuals have a key worker assigned to them, so that good relationships can be fostered. The inspector checked two individuals’ care plans and found that one file documented the needs and preferences of the individual. A plan of activity was in place showing how the individual’s needs were met, and the plan consisted of a mix of group and individual activity. Risk assessments were in place to make sure that any risks were recognised and minimised. All the information had been recently reviewed and documented. The other file also contained all the important information about the individual’s needs, but had not been updated. The acting manager explained that she was in the process of reviewing the other three individuals’ files, and Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 10 that this piece of work is a priority for her, due to the outstanding requirements from previous inspection reports. She intends to complete the work by 14/09/07. The care plans should be developed so that they reflect a more person centred approach, focus on strengths and preferences, and are owned by the individuals. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to live their daily lives as they want to. EVIDENCE: People living at the home are supported to take part in activities leading to personal fulfilment. Each individual has a plan of daily activity to suit their needs, and two individuals spent most of the afternoon of the inspection visit out in the local community. One individual’s choice of activities was appropriate to support her cultural and religious preferences, and families are encouraged to keep in touch with the home. Opportunities are provided for the individuals to meet their peers in social settings, so that new relationships can be formed. The rights and responsibilities of the people living at the home are supported by policies and procedures, staff training and through the key worker role. Meals are prepared in the kitchen and individuals usually eat in the dining room. Menus are planned with nutritional advice and the preferences of individuals in mind. The religious and cultural requirements of one individual Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 12 are carefully managed. Individuals are welcome to help in the preparation of food, and risk assessments are in place to make sure that they can be safe in the kitchen. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home receive the appropriate health and personal care, and are treated with respect. EVIDENCE: The personal support and healthcare needs of the individuals living at the home are documented. Each individual is registered with a local general practitioner, and staff members accompany individuals to appointments, to make sure that there is effective communication about the issues. Other healthcare professionals are referred to when the need arises, such as the physiotherapist and occupational therapist. Personal support is tailored to the individual, and the staff members show respect for their wishes. As there is usually one member of staff available for each individual, staff members are able to offer emotional support as part of the daily routine. The medication for each individual is kept securely in the bedrooms, and the inspector checked the medication and records for one individual. All the medication checked was appropriately accounted for, and the records are well maintained. Only staff members who are trained to manage medication are given the responsibility in the home, and a local pharmacist conducts an audit visit regularly. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 14 Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home can rely on their supporters and the home’s procedures if they want to complain, and they are protected from harm by the home’s procedures and by the home’s trained staff members. EVIDENCE: The home’s complaints procedure is available in pictorial and text forms. The text form contains all the information required by regulation, including the details of the Commission, and relatives have received a copy of the procedure. The pictorial format did not contain these details, and the acting manager acted quickly to include the details. None of the individuals living at the home were able to express their views about the home to the inspector, and the inspector did not receive any information from advocates about the home. Through the Commission’s comment cards one family member said that the home ‘always’ responded appropriately if concerns had been raised, and that she/he knew how to make a complaint. The Commission has not received any information about concerns since the last inspection. Key workers work closely with the individuals at the home, and are skilled to understand if an individual is unhappy with life in the home. Each individual has an advocate, and the advocate would be able to approach the home with concerns. The home has a policy and procedure about safeguarding vulnerable people, and the procedure refers to the local procedures, so that staff members know whom to contact if necessary. Staff members receive training in how to protect the individuals at the home. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 16 Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and safe, and provides a homely environment for the people living there. EVIDENCE: The bungalow is on a residential road, fits easily in its surroundings and provides comfortable homely accommodation for the four people living there. Bedrooms are large and well decorated, and personalised. Communal areas are clean and bright and the maintenance is managed from a central department. The longstanding issue about water damage from the bathroom has been resolved. The home has a good garden area, and plans have started to improve the gradient into the garden from the dining room, so that one individual can manage her wheelchair alone. The front area is used mainly for parking, including parking for the home’s transport, which has easy access for all the individuals. The home is clean, hygienic and well ventilated. Infection control procedures are in place, and the home’s laundry is well managed. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are supported by the home’s policies on staff training and recruitment. EVIDENCE: New staff members are being recruited to fill the vacant posts, and enough staff members are available to meet the needs of the individuals. The organisation is committed to improving the skills and knowledge of the workforce, and as part of the contract, new employees agree to enrol on the National Vocational Training (NVQ) Level 2 in Care, if they do not already have the qualification. The home is meeting the standard to have 50 of the care staff qualified to NVQ Level 2. The inspector saw staff members’ files to check the home’s recruitment procedure. Some of the staff were employed by the previous provider, before the home came into existence, and their employment was transferred to the home’s provider. Some of their records have been archived, but evidence was seen that appropriate checks were made at the time. One member of staff has not had a new Criminal Record Bureau (CRB) since 2003, and the inspector recommends that new checks be carried out on existing staff members every three years. There was not appropriate proof of identity available for one newly recruited member of staff, and the acting manager is taking steps to Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 19 make sure that the information is available at the home. All the information about people working at the home required by legislation must be available at the home, including proof of identity. The home’s induction training is to the appropriate standard and the home is developing the training programme for staff, particularly through e-learning. All staff members have training about awareness of physical and learning disability, and have the mandatory training and updates. Staff members are also being offered training on the implications of the Mental Capacity Act, and this is good practice. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42. Standard 37 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of a registered manager has some impact on the home, though improvements have been made. EVIDENCE: There is no registered manager currently at the home, and the home has been effectively without a registered manager for some months. The recruitment process is taking place to find an appropriate person to put forward to be registered. The acting manager is experienced and skilled, and has support from her line management, but also has continuing responsibility for another home. Two of the requirements from previous inspection reports have not been fully met. Unannounced monthly visits by a member of the senior management team are also carried out to monitor key aspects of the service. An internal quality assurance audit is carried out regularly to monitor the quality of the service, but the views of others are not sought. The home must seek the views of Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 21 people living at the home, their relatives, healthcare professionals and advocates in the quality review of the service. This will improve the quality of the information and will be more focussed on the outcomes for the people living at the home. A requirement was made in the previous inspection report that significant events be notified to the Commission, and the acting manager is aware of the requirement to notify. The home has a health and safety policy statement, and provides training for staff members to keep them safe at work. The current gas and electricity safety certificates were seen. Training on fire safety has been provided for staff members. There is a fire risk assessment in place for the home but this was not immediately available at the home, and the manager needed to arrange for it to be sent from the relevant department. All the documents relating to the health and safety of the home must be available at the home, so that staff members can easily refer to them. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 22 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 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X N/A X 2 X X 3 X Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation 15 Requirement Service user files including the pen picture and lifestyle plan must be kept updated to reflect changes in service users needs and to ensure continuity of care. Previous timescales of 31/03/06 and 01/10/06 not met. Service users’ risk assessments including moving and handling risk assessments must be kept up to date and reviewed. Previous timescales of 31/01/06 and 01/10/06 not met. All the information about people working at the home required by legislation must be available at the home, including proof of identity. The quality assurance system must include consultation with the people living at the home and their representatives. All the documents relating to fire safety must be available at the home, including the fire risk assessment, so that staff members can easily refer to them. DS0000023084.V348636.R01.S.doc Timescale for action 14/09/07 2. YA9 13 14/09/07 3 YA34 Schedule 2 14/09/07 4 YA39 24 (3) 31/03/08 5 YA42 23 (4) 14/09/07 Wendover Road (87) Version 5.2 Page 24 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 YA34 Good Practice Recommendations The care plans should be developed so that they reflect a more person centred approach, focus on strengths and preferences and are owned by the individual. New Criminal Record Bureau checks should be carried out on existing staff members every three years. Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Wendover Road (87) DS0000023084.V348636.R01.S.doc Version 5.2 Page 26 - 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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