Care Home: 39 Hawthorne Grove

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Annual service review Name of Service: 39 Hawthorne Grove The quality rating for this care home is: The rating was made on: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Alison Duffy Date of this annual service review: 0 9 0 2 2 0 1 0 Annual Service Review Page 1 of 7 Information about the service Address of service: 39 Hawthorne Grove Trowbridge Wiltshire BA14 0JF 01225767441 01225767441 Telephone number: Fax number: Email address: Provider web address:   www.voyagecare.com Milbury Care Services Ltd Name of registered provider(s): Conditions of registration: Category(ies) : learning disability physical disability sensory impairment Number of places (if applicable): Under 65 Over 65 3 3 3 0 0 0 Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service 39 Hawthorne Grove is a 3 bedded home for adults with a learning disability and/or a physical disability. The registered provider is Voyage Care Services Limited. Selwood Housing owns the property. The manager is Ms Holly Caswell. Ms Caswell is also the manager of another care home, within the organisation. Ms Caswell has not as yet completed the process with us to become the registered manager. 39 Hawthorne Grove is located within a residential area of Trowbridge, near to local amenities. All people who use the service have a single bedroom. One bedroom has an en-suite bathroom. There is a spacious lounge and a separate conservatory. The kitchen has a dining table, where people usually eat their meals. There is a secluded garden to the rear of the property. Annual Service Review Page 2 of 7 Staffing levels are maintained at two staff on duty during the waking day. At night, two staff provide sleeping in provision. An on call management system is available at all times. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection. This included: 1. The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. 2. The previous key inspection, which took place on the 7th March 2008 and the last annual service review that was undertaken in February 2009. 3. Surveys returned to us by one staff member and one health/social care professional. 4. What the service has told us about things that have happened in the service. What has this told us about the service? The AQAA stated that each person had an individual support plan, which they provided input into. The plans were in a new format and showed the persons individual preferences and support requirements. This included areas such as health, personal care, mobility and decision making. The AQAA stated that the plans and risk assessments were reviewed on a six monthly basis and updated as necessary to reflect any changing needs, choices or aspirations. Ensuring each person had a copy of their individual support plan in a format appropriate to their needs, was something the service said they could do better. Within the AQAA we saw that people were enabled and supported to make decisions in all areas of their lives. They were also enabled to take responsible assessed risks. The AQAA stated we support service users to lead the lifestyle they choose and to pursue their hobbies, interests and opportunities to access new activities and experiences. In order to improve outcomes for people, the AQAA stated that individuals would be supported to organise weekly individual activity plans. It was expected that this would further exercise peoples rights and control over their lifestyle choices. It was also expected that an activities co-ordinator would be designated within the staff team to ensure effective planning of activities. The AQAA stated that over the last twelve months, new Health Action Plans and My Hospital guides had been completed. Good methods of recording behaviour and aspects of maintaining a healthy lifestyle such as fluid and food intake had also been developed. We saw that a new medication system had been introduced. Providing people and their families with a clear and effective complaints policy and ensuring people knew how to use it were areas the service said they did well. People were provided with a letting us know what you think policy and I am worried cards. The AQAA stated that house meetings were facilitated to enable people to express their views or concerns. We saw that a robust procedure for responding to any suspicion, allegation or evidence of any form of abuse was in place. The AQAA confirmed that there had been no formal complaints or safeguarding referrals within the last year. The AQAA stated 39 Hawthorn Grove is a homely, clean, hygienic, safe and Annual Service Review Page 4 of 7 comfortable environment that meets the individual needs of the service users and current legislation. We provide a home that is well located to access local facilities and transport networks and is fit for its purpose. The AQAA stated that within the last twelve months the bathroom and lounge had been redecorated and new furnishings and a kitchen had been fitted. We saw that further redecoration to hallways and the toilet and laundry area were planned. In relation to what the service did well, the AQAA stated staff have clear roles and responsibilities. Staff are appropriately trained and qualified. Voyage provide a robust recruitment policy and practice adhering to relevant current standards and legislation. All staff are supervised and appraised on a regular basis. 83 per cent of the staff team have an NVQ 2 or above. Staff retention within the home is good with no vacancies. In relation to what the service could do better, the AQAA stated request more specialised training to meet the changing needs of the service users, such as diet and nutrition and aspects of ageing. The AQAA stated [we] provide service users with a well run home with an effective manager that respects the individuals rights and ensures their best interests are safeguarded. Service users views underpin monthly monitoring and annual service reviews. Policies and procedures are in place to ensure health, safety and welfare of the service users are protected. Within their survey, one staff member told us that they were given up to date information about the people they supported. They had training related to their role and often met with their manager to gain support and discuss their work. They said their employer carried out checks such as CRB and references before they started work. The staff member said that they knew what to do if someone had concerns about the service. They said there were sometimes enough staff to meet the individual needs of people. In relation to what the home could do better, the staff member said provide new furniture and equipment for service users e.g. decoration of rooms, new sofa etc. Within their survey, a health/social care professional told us that peoples social and health care needs were sometimes properly monitored, reviewed and met by the care service. They said that staff usually sought advice and acted upon it to meet peoples needs and improve their wellbeing. The health/social care professional told us that people were sometimes supported to live the life they chose. They also said that staff sometimes had the right skills and experience to support peoples social and healthcare needs. In order to improve the service, they said Communication via the communication book is not always filled in and read. Communication is often a problem with Hawthorne Grove staff. This needs to be addressed as we need to be mindful of working in a person centred way. We have not been notified of any incidents which have affected the wellbeing of people using the service. We were informed that a new manager had been appointed to the service in September 2009. The process to become the registered manager has not as yet been fully completed. We saw that in January 2010, Wiltshire Fire and Rescue Service completed an inspection of the service. The report showed the the home did not fully comply with the Regulatory Reform (Fire Safety) Order 2005. This was because the escape routes and Annual Service Review Page 5 of 7 exits could not be used as quickly and safely as possible. As a result of the inspection, it was recommended that all fire doors be fitted with a positive action self closing device suitable for the weight of the door. No self closing door was to be held open by any means other than an automatic door release of an approved type. A timescale of three months was given to address these areas. The last annual service review, which was undertaken in February 2009 identified that the service continued to provide a range of good outcomes for people. What are we going to do as a result of this annual service review? The information available, gives evidence that 39 Hawthorne Grove is continuing to provide good outcomes for people. Subject to any changes in registration and inspection practice following implementation of the Health and Social Care Act 2008, our current plan is to do a key inspection by 2011. However, we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 6 of 7 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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