Inspection on 05/07/05 for 198 Rossendale Road

This inspection was carried out on 5th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

198 Rossendale Road 19/04/07

198 Rossendale Road 25/07/06

198 Rossendale Road 11/01/06

198 Rossendale Road 01/12/04

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

CARE HOME ADULTS 18-65 198 Rossendale Road 198 Rossendale Road Burnley Lancs BB11 5DE Lead Inspector Marie Dickinson Unannounced 5 July 2005 10.00 th 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. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 198 Rossendale Road Address 198 Rossendale Road Burnley Lancs BB11 5DE 01282 425668 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) Voyage Ltd Care Home 13 13 13 13 Category(ies) of Mental disorder MD registration, with number Physical disability PD of places Sensory Impairment SI 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must at all times, employ a suitably qualified and experienced manager who is registered with the Commission 2. The staffing levels in the home must at all times consist of a minimum of 1 staff member to 2 service users during the day, on average, and 1 waking watch and 1 sleep in staff member at night. With no more than 10 people sharing a staff group. Date of last inspection 1st December 2004 Brief Description of the Service: 198 Rossendale Road is registered with the Commission for Social Care Inspection to provide personal care and accommodation for thirteen people. The home is operated specificallyas a specialist provision for adults who have an acquired brain injury. Voyage Limited , which is part of Paragon Healthcare Group, owns and operates the home. Accommodation offered is in thirteen large specially adapted single occupancy bedrooms. All rooms are en suite, and some include a small kitchen and dining area. There are several spacious lounges and dining and kitchen facilities. Specialist modern bathing facilities are also provided. The upper floor can be accessed by a passenger lift. Staff support is based on individual needs of service users living at the home. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out over a two day period. The Inspector looked at written information and records relating to residents and staff. People who live at the home, visitors and staff on duty were spoken to for their views. The Inspector also looked at how service users views were obtained by those responsible for the home and how these could be used to improve their quality of life. The care given to service users was looked at and the Inspector asked service users about their personal experiences and of life in the home. The previous inspection showed areas of the running of the home that needed to improve. The progress on these was looked at. What the service does well: What has improved since the last inspection? Some policies and procedures have been developed for staff guidance. Recruitment of staff is better managed. Supervision of staff was regular. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 6 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. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 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 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 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) 1,2,3,4,5. For service users to have a better understanding of the facilities and care they can expect to receive at the home, the statement of purpose, service user guide and terms and conditions of residence must be given to them. People living at the home have the benefit of specialist care. The home finds out as much information as they can through visiting people and asking them what they would like to achieve living at the home. EVIDENCE: A revised statement of purpose and service user guide specific to 198 Rossendale Road was in draft, awaiting final adjustments before being made available for people making enquiries about the home. Information was available about the service in the organisations production of ‘Voyage’ homes and services. To have a clearer understanding of service users needs, the manager should ensure those people referred through care management have an assessment of their needs. Service users however, had benefited from the homes own assessment and care plans showed how care needs were regularly reviewed. From these assessments an individual plan of care was written and agreed with everyone concerned. People living at 198 Rossendale Road have the benefit of specialist care for people with an acquired brain injury. All staff work directly with other 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 9 professionals in health care. Good communication is an important part of service users assessment. Before anyone is admitted, they can spend time in the home on visits. They can look at the facilities, meet with staff and other people who live there. If they decide to move into the home, a short stay of three months is offered. After this time everyone meets together to discuss if living at the home is satisfactory and the care given is suitable. Service users should be given a contract with the terms and conditions of residence. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 10 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) 6,7,8,9,10. Service users benefited from specialist assessments to ensure that all their needs was considered. Being involved in writing their own care plans meant they could have personal goals that staff knew about and helped them achieve safely. To help service users to be better involved in all aspects of life in the home, information such as policies and procedures should be given to them. EVIDENCE: Three care plans were inspected. Information from the assessments was used to write care plans. Specialist evaluations, for example speech and language, physical disability and psychiatric, helped to ensure all areas of need was covered. Service users benefited from being involved in their own care plans. A member of staff referred to as a key worker was assigned to help them in special programmes. In addition to this all the staff who worked in the home read each service users care plan. To enable service users to make meaningful decisions about their lives, guidance and support from independent advocacy services was available. However support in money management should be better documented and reviewed. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 11 Whilst service users had the benefit of one to one discussions with staff, the home should make available, up to date information on for example policies and procedures, or house rules. Risk taking was evident as being part of everyday life. This was recorded properly. Risk analysis showed service users were involved in decisions on how to manage risks that affected them. Good practice was observed in confidentiality of information. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 12 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) 11,12,13,14,15,16,17. Service users living in the home were given opportunities to live a fulfilling lifestyle that included social activities and learning new skills for personal development. Staff followed clear instructions from service users how they wished to be treated. EVIDENCE: Service users were given opportunities for personal development. This was seen in care plans. Service users said they had help from other people such as speech therapy. Some of the service users had complex multiple disabilities. Their care programme showed how additional help had been commissioned to help them. There was evidence that staff helped service users go to college for adult learning. One service user was currently doing voluntary work. Staff said they went out with service users as part of their care. This was at any time suitable for the service user. Service users had weekly planners of activities they followed. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 13 Service users said they had different interests. Bedding plants were nicely arranged outside in planters. The service users said they had done these recently in a gardening course. They had enjoyed the work and activities were in general ‘ok’. Service users said they pleased themselves what activity they joined in. Relatives and friends were made welcome to the home. Very good practice was noted in how the service users rights were respected in their daily lives. Service users said they had made it clear what staff should and should not do, and how they wanted staff to speak to them. This information was recorded in their care notes. They were generally pleased with how the staff respected these wishes. During the inspection service users planned and prepared snacks and meals. This had involved budgeting skills, shopping, preparation and cooking. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 14 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) 18,19,20,21. The quality of recording individual preferred routines, likes and dislikes allowed service users to experience personal care in a dignified manner. Service users said staff always considered their privacy. Medication was managed correctly. In order to verify service users wishes, consent to medication must be recorded. Caring for service users ill and dying considered all world faiths. EVIDENCE: Service users said their routine was special to them. Personal care was given in private, and their key worker mainly helped them. If they wanted they could change their carer. Every person in the home had technical aids they needed. Staff said they were trained in operating this equipment. Staff also confirmed they were involved with other professional people involved in service users care. This included healthcare and part of the staff role was to help the service users attend medical appointments. The individual records outlining preferred routines, likes and dislikes was of a high standard. Medication was managed correctly, however consent to medication must be recorded on service users care notes. In addition to this retaining medication 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 15 for seven days in the event of a death of a service user should be included in the medication policy. The manager said training was to be provided for staff to deal with ageing and death. The policy and procedure in the home was good and included dealing with all world faiths. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 16 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. Service users felt their interests were protected. They were confident in the manager to deal with complaints properly. However the complaints procedure should be made easy to understand for all service users, including those people who may have difficulty in understanding written English. EVIDENCE: The complaints procedure in the service users handbook referred them to a leaflet on how to make a complaint. The procedure was written in too much detail. The print was small and the telephone numbers provided for Voyage were not local or free phone. In addition to this there was no reference to advocacy services. However service users in the home were aware they had the right to make a complaint should the need occur. They said they were confident in the manager to listen to them. Comments received from service users said they ‘felt safe’ in the home. Abuse procedures had been discussed with staff and were part of their training. Staff talked about their responsibility to ensure all the service users were protected from abuse. They had also signed a declaration excluding them from any financial gain from service users. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 17 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) 24,25,26,27,28,29,30 The home is designed and fitted with appropriate aids for most service users to live as independently as possible. Standards of hygiene were high and bathing and laundry facilities were suitable to the needs of the service users. EVIDENCE: 198 Rossendale Road is a spacious purpose built home to accommodate people with complex physical needs. This included overhead tracking for hoists, passenger lift, and specialist equipment specific to individuals. The furnishings and fittings were ‘homelike’ in style and of a good quality. All the bedrooms are single occupancy. The residents had their rooms furnished to their own individual taste and needs. One service user was currently decorating his bedroom. Some people had items of their own furniture. Whilst all bedrooms were lockable, some service users in wheelchairs were dependent on staff to hold open their doors for them. The option of an opening device was discussed with them. One service user said this would benefit her. The overall provision however, of specialist equipment for physical disability was to a high standard. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 18 The service users said they liked their own bathrooms. They also had other specialist-bathing facilities to use in the home. The standard of hygiene and the laundry facilities were very good. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 19 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) 31,32,33,34,35,36. Good staff recruitment procedures were followed. Service users benefited from one to one care by trained staff. EVIDENCE: The home was fully staffed during the inspection. The current level of staffing was linked to the needs of the service users who benefited from one to one care. The service users were very happy with the staff in the home. They said they always had time for them. Staff files showed correct recruitment procedures had been carried out. References had been applied for and Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) check had been obtained prior to staff working in the home. In addition to this applicants are required to spend time with service users during the interview process to enable them to be part of the recruitment of staff. All staff had attended basic training including specialist training for acquired brain injury. Staff enjoyed their work and said the content of training sessions was good. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 20 Staff also said they were encouraged and supported to attend training and they received supervision regularly. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 21 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) 37,38,39.40,41,42,43. The manager for the home must be registered with the Commission. Staff and service users expressed confidence in the manager, and the benefit of having good management support. The health, safety and welfare of service users was given priority in day to day management. EVIDENCE: A new manager, who has not yet been registered with the Commission, had been appointed since the last inspection Staff and service users expressed their confidence in his leadership and in his management style. Service users said they spoke to him individually and he was involved in their care. ‘ They were able to talk to him easily, he always listened to them’. Staff said they had regular meetings, and had the opportunity to discuss work issues with him. He was also supportive with training. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 22 Every month a senior manager employed by Voyage visits the home and conducts a ‘spot check’. The reports of these visits are sent to the Commission. Confidential records were locked away. Service users would benefit from having up to date relevant policies and procedure. The views of the service users are considered important. The health, safety and welfare of service users are a shared responsibility between Voyage and the manager. Insurance cover was in place and the manager said sufficient funding was available for maintenance. The manager makes sure a weekly check on the environment safety is carried out. The company makes sure any safety issues are dealt with. Training in health and safety is also provided for staff to help them at work. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 23 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 2 2 3 3 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 2 2 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 2 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 2 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 198 Rossendale Road Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 3 3 F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 24 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. 2. 3. 4. Standard 1 5 22 Regulation 4,5 (1)(2)(3) 5(1)(b)(c) 22(2) Requirement a statement of purpose and service user guide should be made available for the home. all service users should be given a contract. the complaints procedure should be accessible, accurate and available. Timescale for action 30/09/05 30/09/05 31/09/05 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. 4. 5. 6. Refer to Standard 2 7 8 16 20 20 Good Practice Recommendations It is recommended that all service users referred to the service by care management have a needs assessment. It is recommended money management for service users be better defined. It is recommended service users receive up to date information they can understand about policies and procedures It is recommended rules on smoking, alcohol and drugs be included in house rules It is recommended consent to medication be recorded. It is recommended retaining medication for seven days in the event of a death be included in medication policy. F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 25 198 Rossendale Road 7. 8. 9. 22 29 40 It is recommended advocacy services be included in the complaints procedure. It is recommended that according to service users needs automatic door openers for wheelchair users be fitted to allow for independent access to bedrooms. It is recommended all policies and procedures are up to date and available for staff reference. 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 198 Rossendale Road F57 F07 S60125 198 Rossendale Rd V223677 240505 Stage 4.doc Version 1.30 Page 27 - 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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