CARE HOME ADULTS 18-65
135 Tennyson Road Luton LU1 3RP Lead Inspector
Mr Pursotamraj Hirekar Unannounced Inspection 25th January 2006 03:30 135 Tennyson Road DS0000014978.V272108.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 135 Tennyson Road DS0000014978.V272108.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. 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 135 Tennyson Road Address Luton LU1 3RP 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 721257 Advance Support Ltd Mrs Eileen Wright Care Home 4 Category(ies) of Learning disability (4), Old age, not falling registration, with number within any other category (4), Physical disability of places (4) 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: 135 Tennyson Road was a mid-terrace house owned by Advance Housing and Support Limited and situated in Luton. The home provided accommodation for four adults who have learning disabilities. The first floor consisted of three single service users bedrooms, a utility room, a toilet and a bathroom. The ground floor consisted of a lounge, single bedroom, ground floor toilet/shower room, and a kitchen/diner. A pay phone for service users was also available The home offered access to a bus stop at the end of the road and the buses go to Luton, Harpenden, St Albans, Watford and London. The local shops and a memorial park were available nearby. Stock wood Park was also available in ten minutes walking time and there were also churches nearby. 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out at 3.30pm on 25/01/06 by PursotamRaj Hirekar and lasted over 2 hours. Present at the inspection was the manager. The inspection methodology included study of care plans, review reports, conversation with the service users, study of related care documents, tour of the home and feedback to the manager. 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. 135 Tennyson Road DS0000014978.V272108.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 135 Tennyson Road DS0000014978.V272108.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): None EVIDENCE: 135 Tennyson Road DS0000014978.V272108.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): None EVIDENCE: 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 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): None EVIDENCE: 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 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): 18, 19 Service users received personal support; their emotional and health needs were addressed. Though the unresolved issues may cause harm to the service users. EVIDENCE: The service users received personal support from the manager and the staff as and when they required. The care plans examined have covered detailed information of assessed needs and changing needs of the service users. One service user has been causing problems to another service user in the home. The care plan review report dated 04/08/05 recorded that this service user required 24 hours supervision and a complaint was lodged by the service user’s sister in her letter dated 14/12/05 to the home manager. The manager had taken positive steps to resolve this problem. However, the problem still persists and needed urgent attention. 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 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): 22, 23 Delayed actions to meet the needs identified in the review and complaints received would put service users at risk. EVIDENCE: The home had a comprehensive complaints policy and clear procedures. The complaint received from one of the service user’s sister was actioned appropriately and the follow up measures were closely monitored. However, all the stakeholders involved including social services needed to take actions on time to meet the assessed needs. Any delay in resolving this issue would put service users at risk of harm. 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 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, 25, 30 The home was clean and hygienic and appropriate actions were initiated to make the home more comfortable. However, needed speedy action to avoid any harm to the service users. EVIDENCE: The home had taken measures to improve the physical environment by replacing 2 curtains, hallway and staircase carpets, one bedroom liner (flooring) and one new bed for a service user. The new furniture for the lounge has been ordered. The manager had said that quotations have been invited to repair the uneven paving at the rear of the garden and green house and the garden furniture would be replaced on completion of the above work. The cooker used in the kitchen was over heating the oven, has no markings on the dials and is wobbly which needed replacement to avoid any health hazard. The home was maintained clean and hygienic. 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 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): 31, 32, 33, 34, 36 The current staff were committed and provided adequate services to meet the needs of the service users. Nevertheless, the recruitment delays would cause harm to the service users. EVIDENCE: The manager and the staff have good working relations, which had a positive effect on the service users. The staff supervision meetings were held and the staff felt encouraged and motivated to give their best to the service users. The current staff were competent and work as a good team. Service users were happy with the behaviour and support they receive from the staff. The home had sound recruitment policy and procedures but the delay in staff recruitment is a cause of concern and would negatively impact upon meeting the needs of the service users. 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 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): 37, 38, 42 The manager was committed and ensured team working in the best interest of the service users. EVIDENCE: The home was well managed. The manager and the staff had good working relationships, which helped service users to communicate freely and receive adequate support as and when required. The manager had been trying her best to provide adequate services and to meet the care standards was not enough, because of delays in recruitment of additional staff to meet the changing needs of the service users. The long term development plan of the home to relocate the service users to a new place has been outstanding with very limited success and needed speedy action before any untoward incidence happens that may cause harm to the service users. 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 Page 15 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 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 1 3 X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 1 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
135 Tennyson Road Score 1 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 X DS0000014978.V272108.R01.S.doc Version 5.0 Page 16 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 YA18 Regulation 18 (1) (a) Timescale for action The home must ensure that at all 28/02/06 times suitable staff are working as appropriate for the health and welfare of service users. The home must make 28/02/06 arrangements to prevent service users being suffering from abuse or being placed at risk of harm. The home must ensure suitable 28/02/06 staffs are working in such numbers as appropriate for health and welfare of service users. The home must undertake 31/03/06 appropriate consultations with the authority responsible for environmental health having regard to changes in the service users’ needs and circumstances. Requirement 2. YA23 13 (6) 3. YA33 18 (1) (a) 4. YA24 23 (5) and 14 (2) 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 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 Page 17 135 Tennyson Road DS0000014978.V272108.R01.S.doc Version 5.0 Page 18 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
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