Inspection on 08/12/05 for Wilcot Road (19)

This inspection was carried out on 8th December 2005.

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

Wilcot Road (19) 31/01/08

Wilcot Road (19) 15/05/06

Wilcot Road (19) 02/06/05

Wilcot Road (19) 24/01/05

Wilcot Road (19) 14/09/04

Wilcot Road (19) 25/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Wilcot Road (19) 19 Wilcot Road Pewsey Wiltshire SN9 5EH Lead Inspector Ms Sally Walker Unannounced Inspection 10:10a 8 December 2005 th Wilcot Road (19) DS0000028332.V261555.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 Wilcot Road (19) DS0000028332.V261555.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. Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wilcot Road (19) Address 19 Wilcot Road Pewsey Wiltshire SN9 5EH 01672 562746 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) Keepence Homes Mrs Raine Marie Goadby Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd June 2005 Brief Description of the Service: The home is a large detached house within easy walking distance of Pewsey. It is run by Keepence Homes and managed on their behalf by Raine Goadby. The home provides care and support to 4 younger people with learning disabilities. It is anticipated that the residents will live at the home long term. All residents’ accommodation is single bedrooms to the first floor. Their s a bathroom to the first floor and the staff sleeping in room/office. To the ground floor there is a relaxation room with some sensory equipment, a large kitchen, a sitting room with separate dining area and a conservatory. There is also an accessible shower room with toilet. To the rear of the property there is a large enclosed garden. The home has its own transport for residents use. Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 10.10am and 1.00pm. Mrs Goadby was present together with another member of staff. Two of the residents were spoken with. The care records, medication records, staff training records, petty cash and residents cash accounts were inspected. A tour of the building was made. What the service does well: 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. Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 6 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 Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 7 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): X None of these standards were inspected as no new residents had been admitted to the home for sometime. EVIDENCE: Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 8 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 & 9 Residents had detailed care plans which identified all their current care needs. The new reporting format allows staff to show how they have assisted residents with decision making and choice. The language used shows that the focus is on what residents are able to do. Risk assessments do not put unnecessary restrictions on residents. EVIDENCE: Each resident had a care plan showing their current care and support needs. All of the care plans were focussed on the positive aspects of what residents like to do and in particular what they preferred to do for themselves in their personal care routines. The care plans identified methods of communication and comprehension, choice and decision making, activities, nutrition and household tasks. Residents risk assessments had been reviewed in October 2005 and they include all tasks and activities which residents may be involved in. Risk assessments do not appear to restrict residents from being involved in or experiencing new activities or from doing things they like to do. The inspector advised that where residents may be involved in an activity on their own without staff support, for example, bathing or showering, the agreed length of time that they are unassisted in documented in their care plan together with how staff were to supervise this activity. One resident’s assessment stated that they were never left on their own in the shower. The Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 9 requirement that staff must report on how they were meeting residents’ needs as described in the care plans had been actioned. Mrs Goadby had produced forms to identify those areas of the care plan which required reporting upon daily. The daily reports now show a better picture of how the care is being provided. Specific formats were used if any aspect of residents’ condition or behaviours needed monitoring; for example, food and fluid intake. Care plans were regularly reviewed and Mrs Goadby aimed to get the residents care manager involved in the reviews but this was reported to be difficult when a resident did not have a named care manager. Wilcot Road (19) DS0000028332.V261555.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): 14, 16 & 17 Residents enjoy a good range of activities and leisure time both at the home and in the locality. Residents who may have autism spectrum disorder have a more structured day based on specialist advice. Residents now do not pay for meals taken outside the home which are included in the contract. EVIDENCE: When the inspector arrived at the home one resident was at their day service, one was doing art work and the other 2 residents were still in bed having a lie in on their day at home. Mrs Goadby reported difficulties finding suitable day services and for securing funding. Each resident had an activity for when they were not at day services both at the home and in the locality. The home had its own vehicle for residents use. More staff available who could drive the vehicle meant that residents were not all having to get up to go in the minibus when other residents were taken to day services. The requirement that residents did not pay for meals that they had already paid for as part of the contract had been actioned. If residents have a meal when out it is paid for by the petty cash imprest and there was evidence of this in the records. Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 11 The recommendation that consideration should be given to a more structured daily programme with those residents who may have a diagnosis of autism spectrum disorder had been actioned. Mrs Goadby had sought advice from the senior community nurse for people with learning disabilities and agreed plans were being used with clear benefits for the residents. A pictorial plan had been produced for each day, Monday to Friday. Wilcot Road (19) DS0000028332.V261555.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): 18, 19 & 20 Care and support is delivered in the way that residents wish. Residents have good access to healthcare professionals. The home’s medication policy now directs staff to notify the Commission when a medication error occurs. EVIDENCE: Mrs Goadby had sought advice for dealing with behaviours from the senior nurse for people with learning disabilities and guidance was now available to staff. Structured programmes were in place to support residents with managing and lessening these behaviours and it was reported that significant progress had been made. Staff were seen to be using this guidance. The requirement that the medication error policy was amended to include the statement that the Commission must be notified if any maladministration occurs had been actioned in part. The policy had been amended but the guidance to staff in the residents’ files did not have this statement. Each resident had a record of what was prescribed together with the reasons and any precautions or side effects. There was clear guidance on medication which was prescribed to be taken when needed not on a regular basis, including the maximum dosage. Each resident had a list of which homely remedies they were able to take with prescribed medication. Staff were regularly given updated training in administering invasive treatments by the community psychiatric nurse. Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 13 Wilcot Road (19) DS0000028332.V261555.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): 22 &23 The home investigates all complaints and responds to complainants with information of any action taken. Staff have copies of the local vulnerable adults policy but training could not be accessed. EVIDENCE: The complaints log showed that all complaints were investigated thoroughly and written responses to complainants detailing outcomes or action plan in line with the home’s complaints procedure. The recommendation that staff training in the procedure for the Protection of Vulnerable Adults was outstanding. Mrs Goadby said that she had tried to secure training from the Vulnerable Adults Unit who could no longer provide the training. It was agreed that at least one person should receive the training from another reputable source and cascade to other members of staff. Mrs Goadby reported that all staff had a copy of the local vulnerable adults procedure. Wilcot Road (19) DS0000028332.V261555.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 & 30 Residents live in well maintained, clean and comfortable home. The providers continue to improve the environment for residents. EVIDENCE: The home was clean, bright and airy. The flooring to the shower room had been replaced with a more suitable surface which was easier to clean. Residents’ bedrooms were individually decorated and furnished to reflect their personality. The communal rooms were decorated and furnished with modern furniture to reflect the tastes of younger people. A new sofa and new curtains were proposed for the sitting room. Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Residents are supported by a stable and qualified staff team who are well known to them. Staff have good access training when it can be secured. A robust recruitment process is now in place for the protection of residents. EVIDENCE: The staffing rota provided for a minimum of 2 care staff throughout the waking day and one staff sleeping in at night. Staff are involved in cooking and cleaning as well as care. There was a policy in place with regard to male staff working with female residents with no personal care being provided by male staff. The requirement that documentary evidence of staff’s qualification and training was retained in the home had been achieved. The requirement that staff received updated training in managing challenging behaviours was outstanding. Mrs Goadby said that she was trying to find a suitable provider; the community psychiatric nurse may provide training in dealing with behaviours and breakaway. Staff had also not received training in autism spectrum disorder and this should now be sought. All staff held NVQ Level 2 and the deputy held NVQ Level 3. Staff were trained in infection control, moving and handling, administration of medication, first aid and epilepsy The requirement that new staff did not commence working without a PovaFirst confirmation if the Criminal Records Bureau certificate was delayed, that they must not work alone and that they were supervised by an appointed qualified Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 17 and experienced member of staff, and that they could not be considered part of the staffing rota until a negative Certificate was obtained, had been actioned. Mrs Goadby said that she had obtained all the necessary documents for a new member of staff due to start in the new year. The inspector advised that as this new staff was not yet 21 and had no previous experience of care work, they cold not carry out the sleeping in duty of be left in charge of the home. Wilcot Road (19) DS0000028332.V261555.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): 37, 40, 41, 42 The home is run in the best interests of the residents. Risk assessments are in place for the protection of residents. Staff have updated training in health and safety. EVIDENCE: A deputy manager has been employed to cover the delegated role when Mrs Goadby has her designated days off. The requirement that all staff were regularly trained in moving and handling was in good progress with some staff having completed the training in July 2005. The requirement that a policy and accompanying risk assessment was produced with regard to staff who may be pregnant had been actioned. All the policies and procedures had been reviewed in October 2005 and staff were expected to sign up to them. The recommendation that the home should consider the use of vague statements such as “inappropriate behaviour” and “uses body language to Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 19 show feelings” had been actioned. The recording was more specific in detailing what was actually presented or observed with in some examples, a list of possible behaviours. The recommendation that a nominated person should take delegated charge when the manager has designated time off had been actioned. A deputy manager had been appointed. Mrs Goadby was an appointee for some residents’ savings accounts and records and receipts were kept of all transactions. The finances were regularly checked by the proprietor. Wilcot Road (19) DS0000028332.V261555.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 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wilcot Road (19) Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X 3 3 3 X DS0000028332.V261555.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 YA20 Regulation 13(2) Requirement Timescale for action 31/01/06 2 YA35 3 YA23 4 YA33 4 YA9 The person registered must amend the medication error policy to include the statement that the commission must be notified if any maladministration occurs. (Actioned in part in that the policy has been amended. The guidance in residents’ files must also include this statement). 18(1)(c)(i) The registered person must ensure that staff receive updated training in managing challenging behaviour. (Not actioned at 8th December 2005). 18(1)(c)(i) The person registered must ensure that staff are trained in the procedure for the Protection of Vulnerable Adults. (This was previously a recommendation) 18(2) The person registered must ensure that staff left in charge of the home, particularly at night, are at least 21. 13(4)(b) The person registered must ensure that the risk assessments identify and record timescales when residents are involved in activities without staff support. 01/04/06 01/04/06 08/12/05 08/12/05 Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations The registered person should consider transferring the medication error policy statement about notifying the Commission to the guidance found in residents’ files. Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wilcot Road (19) DS0000028332.V261555.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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