Inspection on 16/02/06 for 120 High Street North

This inspection was carried out on 16th February 2006.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

120 High Street North 26/03/09

120 High Street North 23/03/07

120 High Street North 14/03/05

120 High Street North 02/08/04

120 High Street North 18/11/03

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

CARE HOME ADULTS 18-65 120 High Street North Dunstable Bedfordshire LU6 1LN Lead Inspector Georgia Chimbani Unannounced Inspection 16th February 2006 13:00 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 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 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 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. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 120 High Street North Address Dunstable Bedfordshire LU6 1LN 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) 01582 750940 01582 537316 H4037@mencap.org.uk Royal Mencap Society Lisa Marie Carr Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2005 Brief Description of the Service: The home is a 6-bed service run by Mencap. The home is a semi-detached house to the north of Dunstable town centre. Shared and private accommodation is over four floors of the property. There is a spacious garden to the rear that can be accessed via the kitchen or utility room. The home is situated opposite a convenience store and is within walking distance of Dunstable town centre and public transport links. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted one and a half hours. Present at the inspection were 2 service users, the manager Ms Lisa Carr and 1 member of staff. All persons present participated fully and willingly in the inspection process. Feedback from 2 service users on the quality of life at the home was very positive. The home had 1 vacancy at the time of this inspection. The manager left the home before the inspection ended but the inspector was able to discuss the majority of findings with her before she departed. There were no requirements issued at the last inspection. 4 requirements are issued following this inspection relating to quality assurance and health and safety. The inspector is confident that the registered persons will achieve compliance within the stated timescales. 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. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 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 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 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): 2 The high level of support available to service users makes them feel their goals and aspirations are important and valued by staff. EVIDENCE: The inspector was able to view a “person plan” for one service user living at the home. Evidence on file confirmed that the service user had been consulted regarding their goals and aspirations for the year. There was evidence that a discussion had been held with the service user about what they would need to achieve this goal, what might stop them from achieving this goal and how these problems could be overcome. Discussions with a service user present at the time of the inspection revealed that staff were very supportive particularly in building skills. This service user gave the inspector an example of cooking. They stated they wanted to improve their cooking skills but were afraid of doing it on their own in case “something went wrong.” Staff were available to give what this service user called a “gentle push” to help them along. The inspector was able to see evidence of this support as the service user was given money to purchase their ingredients following which they had a discussion with staff about the menu they were going to make. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 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): EVIDENCE: The key standards relating to this section were inspected at the last inspection. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 9 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): EVIDENCE: The key standards relating to this section were inspected at the last inspection. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 10 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): EVIDENCE: The key standards relating to this section were inspected at the last inspection. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 11 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): 23 Comprehensive adult protection policies and procedures together with welltrained staff ensure that service users live in a safe and comfortable environment. EVIDENCE: A comprehensive adult protection policy for Mencap was available for inspection as well as one from the local authority. There was also sufficiently detailed information on the process to be followed by staff in the event of allegations of abuse being made. The manager informed the inspector that adult protection training is incorporated into the induction and foundation training that is mandatory for all staff. A sample foundation-training file for a current member of staff was viewed. This contained evidence of pre and post course work as well as a certificate of completion. Discussions with two service users confirmed that they felt safe and well cared for in the home. One service user told the inspector that they felt listened to by staff. “When you are unhappy or upset they ask what’s the matter…. because everyone has a few upsets.” 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 12 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 and 30 The home is maintained to a very high standard and provides a welcoming, safe and comfortable for all service users. EVIDENCE: The inspector was taken on a tour of the home by one of the service users. All communal areas were viewed together with bedrooms of the two service users present in the home at the time. The living environment is homely, comfortably furnished and very high standard of cleanliness was evident. Feedback from service users regarding their living environment was very positive. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 13 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): 35 The level of investment in staff training by the home is commendable and ensures that staff with the appropriate skills and competencies care for service users. EVIDENCE: Staff training records examined indicated that staff working in the home regularly receive a wide range of training relevant to their jobs. The home currently has 4 members of staff with the newest member employed at the home since the beginning of February 2006. Records of staff training indicated that they all have up to date training in the core areas relating to their work such as first aid, moving and handling, fire safety, food hygiene and infection control. There was evidence of other training in mental health legislation, dementia awareness and epilepsy. Discussions with the newest member of staff confirmed that they were booked on various training courses in the next few weeks. This member of staff also showed the inspector their induction training pack and the progress they had made so far. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 14 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): 39 and 42 The home must actively seek the views of service users and stakeholders to give them the assurance that their views are respected and will be acted upon. More work is required by the home to demonstrate their commitment to the health and safety of service users. EVIDENCE: Discussions with the manager revealed that a quality assurance exercise had been carried out recently at the home but records available indicated that this was completed in September 2004. The documentation relating to this exercise was of a high quality and indicated that a comprehensive review had been carried out. The inspector informed the manager that the quality assurance process had to be carried out annually and should include the views of relatives and visiting professionals. Discussions with service users confirmed that regular residents meetings were held where service users could give feedback on any matters relating to their life in the home. The registered persons must ensure that a quality assurance process is completed to seek the views of service users, relatives and other stakeholders. A report of any 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 15 findings must be made available to service users and the CSCI. Documentation relating to health and safety was examined. There was evidence that recent checks had been undertaken on gas, portable appliances and fire equipment. Discussions with service users indicated that they were aware of the procedure to be followed in the event of a fire. Records were seen confirming successful completion of fire alarm tests and fire drills. A fire risk assessment was seen but this was dated January 2004. This must be reviewed. There was no evidence of checks on electrical installations or of water storages tanks and legion Ella. This is required. The inspector observed a large number of disinfectants and other substances that could be hazardous to health in the ground floor toilet. These must be stored in a locked area. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 16 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 X 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 X 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X 2 X X 2 X 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 17 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 YA39 Regulation 24 Requirement Timescale for action 16/06/06 2 YA42 3 4 YA42 YA42 The registered persons must ensure that a quality assurance process is completed to seek the views of service users, relatives and other stakeholders. A report of any findings must be made available to service users and the CSCI. 13(4)(c) The registered persons must 16/06/06 ensure that there is documentation available to confirm that recent and successful checks have been carried out to electrical installations and water storage tanks including legionella. 13(4)(c), The registered persons must 16/06/06 23(4)(c) ensure that the fire risk assessment is reviewed. 13(4)(a)(c) The registered persons must 16/06/06 ensure that COSHH [control of substances hazardous to health] chemicals are kept in a locked area. 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 18 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 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 120 High Street North DS0000014913.V281043.R01.S.doc Version 5.1 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. 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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