Inspection on 05/06/05 for 18 London Road

This inspection was carried out on 5th June 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

18 London Road 18/06/08

18 London Road 05/07/06

18 London Road 05/02/06

18 London Road 15/10/04

18 London Road 04/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 18 London Road Luton Beds LU1 3QU Lead Inspector Nicholas Allen Unannounced 05 June 2005 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. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service 18 London Road Address Luton Beds LU1 3QU 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) 01582 877383 Fairholme Care Group Anette Robinson care home 6 (6) Category(ies) of Learning Disability (LD) registration, with number of places 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2004 Brief Description of the Service: 118 London Road was registered provide long term personal and social care for up to 6 adults with a learning disability aged over 18 years. . At the time of the inspection, all the service users were both male and female with an age range spaning about 40 years. The home is a large detached property situated on a busy main road and adjacent to local amenities. A range of communal space was available. All service users have their own bedroom, but share bathing facilities. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was un-announced and lasted over 6 hours. There were 6 service users accommodated at this time. A tour of the communal areas of the home took place. Over the course of the inspection two of the staff on duty, plus the registered manager were spoken to, four of the service users also contributed to the inspection process. Documents were read and care practice observed. What the service does well: What has improved since the last inspection? What they could do better: Ensure that all staff is trained to safely administer medication. The registered manager should complete appropriate training. Service users meetings should be recorded. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 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 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 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) 2 & 5 The admission procedure for new service users ensured that all information about their care needs was obtained before they arrived. This enabled the staff to have a clear understanding of what they needed to do for them. Service users had clear information about the terms and conditions of their stay at 18 London Road. EVIDENCE: There had been no new admissions since the last inspection. However documentation had been developed to assist with the process. The staff at London Road had documented written information, on all service users, which gave a clear picture of the needs and abilities. Other professionals involved had also contributed written information to assist in the process. The inspector was told, “ I like living here”. “ People are nice.” The inspector saw that service users had a completed and up to date contract in place. One person required additional staff hours. The registered manager was following this up with the local authority social services department. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 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 , 7 and 9 The care needs of service users were identified and documented. Service users individual needs were known by staff. Policies and practices enabled service users to make decisions about their lives. Regular reviews of care plans ensured that any changes were regularly documented any action needed was taken. The risk assessment and management framework supported service users to take responsible risks. EVIDENCE: Person centred plans were in place for each service user. The plan case tracked included a behaviour support plan, communication profile, personal and social support. All service users had an allocated key worker. One service user said how much they liked their key worker and that they “help me do all the stuff that I want to”. Care plans had been reviewed, and service users took place in this process. Service users talked to the inspector and observations were made demonstrating a number of ways in which they made decisions about their daily lives, for example, there were a number of minor variations to the menu 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 Page 10 to accommodate everyone’s personal tastes to the lunch served on the day of the inspection. The policy of the home was to promote responsible risk taking and freedom of choice limited only by assessment. Individual plans contained risk assessments and management strategies. The risk assessments were signed and one person indicated to the inspector that they understood that risk assessments were a way of minimising risks. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 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) 12, 15 &16 The home was run to make sure the service users enjoyed their life and had opportunities to fulfil their potential. Service users were involved in their local community. Service users had opportunities to maintain family links. Service users were respected and felt valued as individuals. EVIDENCE: The inspector saw evidence of the daily activity programmes. On the day of the inspection staff and service users had just returned from the local pub. People were encouraged to keep in touch with friends or families. Personal relationships were supported and facilitated, and there were policies and practices in place to support this. Service users said they felt that their rights and wishes were respected and that they usually felt valued as individuals, although there were occasions when service users had disagreements between themselves. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 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) 19 & 20 Personal support was offered in accordance with resident’s wishes, and in a way that promoted privacy dignity and independence. Service users could, with appropriate risk management strategies in place, administer their own medication. Policies and practices for managing and administering medication were generally in good order. EVIDENCE: The service user case tracked had a health check document in place. There was a risk assessment in place with this regard. Policies and practices for managing and administering medication were in place. Accredited training for staff regarding the safe administration of medication had not yet taken place for all staff. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 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 & 23 There were clear complaints and protection policies and practices in place and evidence that the service users views were sought and acted upon. Staff spoken to had a good understanding of adult protection issues and how to deal with complaints made by service users. EVIDENCE: All the service users spoken to could explain the homes complaints procedure to the inspector. They said they felt comfortable in raising issues of concern with staff. The Commission had received no formal complaints. Policies and practices regarding concerns, complaints and protection were in place. Two staff spoken to by the inspector knew what to do if they had any concerns about service users wellbeing, and had an awareness of the Whistle blowing policy. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 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 & 27 Overall the standard of décor and furnishings provided a comfortable and homely environment for service users. There were areas that could be improved upon when funds were made available. EVIDENCE: The inspector conducted an inspection of the communal areas of the home. The home was clean and odour free. A number of improvements had been made including some to the outside of the property. There were further works required. There were enough bath/shower rooms available to the service users. It was noted that there was an amount of substance, left by the contractors for pest control, in the attic rooms that required removing. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 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) 31, 32, & 36 Staff spoken to and observed by the inspector demonstrated a good understanding of the needs of the service users. There were sufficient staff members on duty to meet service users needs. Staff should continue to complete their NVQ training. Other appropriate training was also being undertaken. Staff members were receiving regular management support and development meetings. Appropriate staff recruitment records were in place. EVIDENCE: The inspector case tracked 2 recent employees who had most of the information required available to the inspector. The inspector was told that staff were undertaking NVQ training. The registered manager has yet to complete their NVQ4 training. There was one 37-hour vacancy at the time of the inspection. Interviews were due to take place in the near future. This meant that the registered manager was spending more time that expected working on the rota. The inspector noted that the staff member’s case tracked had had regular management support and development meetings. Two staff members spoken to confirmed that there was always a senior staff member on duty, and that any issues or concerns were discussed as they arose. The staff also told the inspector about the fire evacuation practices, the complaints and protection of 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 Page 16 vulnerable adults procedure. The staff also knew where the policies and practices files were. A staff member told of their induction when they started working at the home and said, “it was the best and most thorough induction I’ve ever had”. The inspector noted on the staff members’ case tracked had undertaken a number of appropriate health and safety and autism specific training. The inspector observed service users and staff having positive and supportive interaction. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 Page 17 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 & 39 The attitude of the staff and management is to run the home with the needs and wishes of the service users as the highest priority. Service users were regularly consulted in a number of ways. EVIDENCE: The registered manager has begun her management element of NVQ4 training, and is expecting to complete this by the end of 2005. Service users meetings did not take place on a formal basis. More often, discussions took place with 2 or 3 service users at meal times. These discussions were not recorded. The registered manager agreed to do this in future. The Commission received Regulation 26 reports each month. There was an Annual plan in place completed by the Area Manager. 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x x Standard No 11 12 13 14 15 18 London Road x 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 3 x x x 3 Version 1.20 Page 19 I51 s14932 18 LONDON RD v219043 050605 stage 4.doc 16 17 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x x x 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 Page 20 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. 2. Standard Regulation Requirement Timescale for action 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. 4. 5. 6. Refer to Standard Good Practice Recommendations 18 London Road I51 s14932 18 LONDON RD v219043 050605 stage 4.doc Version 1.20 Page 21 Commission for Social Care Inspection Clifton House 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. 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