Inspection on 17/08/05 for 1 Larch Road

This inspection was carried out on 17th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

1 Larch Road 09/03/09

1 Larch Road 07/11/06

1 Larch Road 16/01/06

1 Larch Road 06/01/05

1 Larch Road 21/10/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1 Larch Road Eckington Sheffield Derbyshire S31 9ED Lead Inspector Rose Veale Unannounced Inspection 17 August 2005 at 1:45pm 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 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 Stationary 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. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Larch Road (1) Address Eckington, Sheffield, Derbyshire, S31 9ED Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01246 431158 Derbyshire Care & Home Support Limited Mrs Simone Crossley Care Home 4 Category(ies) of Learning Disability (4) registration, with number of places 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 06/01/2005 Brief Description of the Service: 1 Larch Road is situated in Eckington, approximately 6 miles from Chesterfield. The home provides personal care and accommodation for 4 residents with learning disabilities. The home is spacious and accesible, providing ground floor accommodation with single bedrooms and a pleasant garden area. The home adjoins another care home for adults with learning disabilities. The home is near to local shops, pubs and public transport. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over two hours. Four residents were accommodated in the home on the day of the inspection. The manager and a support worker were on duty. The care records of the residents were examined, plus other documents related to the staffing and management of the home. A tour of the home was undertaken. The manager of the home had completed a pre-inspection questionnaire which had been received by CSCI prior to the inspection. What the service does well: What has improved since the last inspection? What they could do better: Although each resident was provided with a written contract, this did not appear to be appropriate for a care home and did not contain all the information required. The providers should consider revising the contract to make it more relevant. The providers should make every effort to ensure that at least 50 of the care staff are working towards NVQ Level 2 in Care by the end of 2005. The providers should ensure that the manager has sufficient supernumerary time to fulfil managerial duties and responsibilities. Although an annual quality assurance audit was carried out by the providers, no report of the findings was available in the home. The providers must ensure that a report is made available to residents / their representatives. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 6 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. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 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 standard(s) 5 Although each resident was provided with a written contract, more information was needed to ensure that residents or their representatives were clear about the specific terms and conditions of residence in the home. EVIDENCE: The statement of terms and conditions for residents was examined. There were two documents, an agreement with the providers and a breakdown of what the fees covered. The breakdown of what was covered and not covered by the fees was clear. The terms and conditions did not specify the room to be occupied, and did not detail any policies or rules which may limit the personal freedom of residents, such as the smoking policy. The agreement with the providers did not appear particularly relevant to a care home. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 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 standard(s) 6, 8 and 9 Care plans and risk assessments were clear and detailed, ensuring that staff were aware of the action to be taken to meet residents’ needs. Residents were supported and encouraged to participate in the running of the home. EVIDENCE: The care records for all four residents were examined. All the records contained detailed information about residents and an individual care plan. The information included in the care plans was clear and comprehensive to ensure staff were able to meet residents’ needs. The assessments and care plans had all been reviewed regularly up to date. An assessment of the capacity of each resident to understand and consent to various procedures was included. Risk assessments were included for each resident as appropriate, such as going out on trips, going on holiday, helping with domestic tasks, and smoking. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 10 Residents were encouraged and supported to help with domestic tasks in the home and to help with the weekly supermarket shopping. Residents were consulted about meals each day and the menu and shopping changed accordingly. The home had a policy about the involvement of residents in the recruitment of new staff. The manager said that interviews for the last staff vacancy were held at the home and all prospective staff were introduced to residents. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15 and 16 Residents were enabled to maintain appropriate and fulfilling lifestyles inside and outside the home. EVIDENCE: The home was situated on a housing estate, near to local shops. Residents were encouraged and supported to use the local shops and had also visited local pubs. Social activities were recorded in residents’ notes and included trips to Chesterfield or other shopping centres and day trips. Residents had been away on holiday, two to Great Yarmouth and two to Eastbourne. Residents were supported to maintain contact with family and friends through visits and telephone calls. The care records contained details of residents’ preferred routines and how staff could promote independence. This was also observed during the inspection and in discussion with staff and residents. For example, a resident was assisted and encouraged to do some ironing, another resident was assisted to go to the local shop to buy ingredients for the tea-time meal. Residents’ permission was sought before staff entered their bedrooms. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 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 standard(s) 18 and 19 There was an emphasis in the home on the choices and preferences of residents, demonstrated through the attitudes and awareness of staff. Residents’ physical and emotional health needs were well met with good liaison with local services. EVIDENCE: The care files detailed residents’ preferred routines. Staff were well aware of residents’ preferences, demonstrated in discussion with staff and observation of the interaction between residents and staff. It was clear that good relationships had been established. Routines at the home were flexible to suit residents’ daily choices and preferences. The care files contained information about the healthcare needs of the individual residents. Residents had been referred to other services as appropriate, such as GP, optician, dentist, and physiotherapist. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 22 The complaints procedure was clear and robust, ensuring that residents and their representatives could be sure that any complaints would be effectively dealt with. EVIDENCE: Each resident had a copy of the home’s complaints procedure in an appropriate format. The complaints procedure was clear and included details of how to contact CSCI. The home kept a complaints book but no complaints had been received. Residents were given the opportunity to air their views through service user questionnaires and at care reviews. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24, 26 and 30 The home was clean, well decorated and well maintained, providing a pleasant environment for residents. EVIDENCE: The home was clean and fresh on the day of the inspection. All rooms were well decorated and comfortably furnished. The home appeared well maintained. Residents all had single bedrooms which were individually decorated and personalised with their own photographs and possessions. Residents had been encouraged to choose curtains and bed linen for their own rooms. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 and 36 Residents at the home were supported by a competent and effective staff team. Although staffing levels in the home were satisfactory, the providers needed to ensure the manager had sufficient supernumerary time to fulfil managerial responsibilities. EVIDENCE: The staff training records were seen. Staff had received training in all the required areas – such as fire safety and administration of medication – plus other training relevant to the needs of residents – such as epilepsy awareness and equal opportunities training. Only one member of staff had achieved NVQ Level 2. The manager said that NVQ training was planned for other staff, but there was currently a lack of NVQ assessors available. Staff training records included records of supervision sessions held six times per year. Staffing levels in the home were satisfactory, with two staff on duty during the day. However, the manager was included in the staff on duty and had no supernumerary time to complete managerial duties and responsibilities. Staff records were seen. These contained all the required items and information, including a photo and identification, and two written references. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 39 The home appeared well run. To ensure a more effective quality assurance system, a report of the findings of the annual audit needed to be made available in the home. EVIDENCE: The manager of the home had started working towards NVQ Level 4 in Care, having already achieved the Registered Manager’s Award. The manager’s job description was seen which covered all the required areas, with the exception of the budget for the home. The manager said that an annual quality audit was carried out by the providers. Questionnaires were seen which had been completed by residents for this audit. A report detailing the findings of the annual audit was not available. Quality assurance was also monitored through the monthly visits of the provider and through regular care reviews. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 17 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 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x x 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x 3 3 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1 Larch Road Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x x x C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 39 Regulation 24(2) Requirement The registered person must make available to residents / their representatives the results of the quality assurance audit Timescale for action 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 5 32 33 Good Practice Recommendations The statement of terms and conditions for residents should be in a form apropriate to a care home and should specify the room to be occupied by the resident. At least 50 of care staff should be working towards NVQ Level 2 in care by the end of 2005 The providers should ensure that the manager has sufficient supernumerary time to fulfil managerial duties and responsibilities. 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby, DE1 3QT 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 1 Larch Road C52 C02 S20034 1 Larch Road V243487 150805 Stage 4.doc Version 1.40 Page 20 - 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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