Inspection on 08/12/05 for 21a & 21b Johnson Avenue

This inspection was carried out on 8th December 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

21a & 21b Johnson Avenue 26/09/07

21a & 21b Johnson Avenue 09/06/06

21a & 21b Johnson Avenue 18/08/05

21a & 21b Johnson Avenue 27/10/04

21a & 21b Johnson Avenue 23/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 21a Johnson Avenue Spalding Lincolnshire PE11 2QE Lead Inspector Mr Toby Payne Unannounced Inspection 8th December 2005 02:15 21a Johnson Avenue DS0000002491.V270007.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 21a Johnson Avenue DS0000002491.V270007.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. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 21a Johnson Avenue Address Spalding Lincolnshire PE11 2QE 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) 01775 767472 www.sense.org.uk Sense East Mrs Patricia Morris Care Home 4 Category(ies) of Learning disability (0), Sensory impairment (4) registration, with number of places 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2005 Brief Description of the Service: 21a Johnson Avenue is one of a pair of detached houses owned by Sense East. Sense have just recently celebrated their 50th Anniversary. The property is domestic in design and in keeping with other houses in the road. The home is situated in a residential area of the market town of Spalding and is within walking distance of the town centre. The home is registered to provide personal care for up to 4 people with dual sensory impairments. It is part of a group of homes in the area, managed by Sense. There is a small garden/patio area to the back of the home and all of the residents live in single bedrooms. Pat.morris@sense.org.uk 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 2.15 p.m. It took place over two and three quarter hours. The inspector spoke to 3 members of staff and the manager. In view of the communication needs of the 4 residents living in the home at this inspection, the inspector relied on observations between staff and the person, information provided by staff members and records as evidence as to whether standards were being met. The main method of inspection was called “case tracking”. This involved tracking the care for the one resident. This was done by the checking of records, discussion with the care staff and observation of how their care was delivered. What the service does well: What has improved since the last inspection? One bedroom has been redecorated. All toilets and shower rooms have been repainted. All carpets have been cleaned. New beds have been provided for a resident and for the member of staff who provides sleep in cover at night. New arrangements have been put into place in order to ensure that medication is safely administered. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 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. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 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 the following standard(s): 1, 2 and 4 Residents living at 21a Johnson Avenue receive clear information to enable them or their relatives/advocates to make an informed choice as to whether or not they wish to live in this home. Staff receive comprehensive training to understand the needs of people living in to the home. EVIDENCE: There is a statement of purpose and service user’s guide for the home. These can be produced in large print, Braille, CD Rom, pictorial symbols and languages other than English. No new person had been admitted since 1993. Any new person coming into the home would be assessed by a competent person prior to admission to the home. The Sense Assessment Co-ordinator and then the Referral Team would undertake this assessment initially. The manager would then undertake an assessment of need. Staff, as part of their induction receive information about the people living in the home to enable them to support them. Information would be obtained where possible from the resident, their family and other relevant people. Written confirmation would also be sent to confirm that the home could meet their assessed needs Prior to admission, residents are encouraged to visit the home and meet staff and other people living in the home. A trial visit can last up to 4 weeks. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 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 the following standard(s): 6, 8 and 10 There is detailed care planning which includes risk assessments. The health, personal and social care needs of people living in this home are fully met. EVIDENCE: Each resident has a detailed care plan. This is developed wherever possible with the involvement of the resident, their family/advocate and other relevant people. Care plans included a pen picture, which outlined their background, skills and abilities, emotional needs, hobbies and interests, food preferences, their daily routine and a daily record. There are also comprehensive risk assessments covering all aspects of daily living activities. All staff receive deaf and blind awareness training and are made aware of the importance of involving the residents in decision making. People living in the home are involved in cooking, cleaning, ironing and shopping. This being done following a risk assessment and within their capabilities. Care plans showed evidence of this. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 10 All staff as part of their induction, receive training regarding the importance of handling information in a confidential and sensitive manner. Sense also have a policy on confidentiality. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 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 the following standard(s): 12 and 17 People are involved in meaningful, appropriate activities, which include educational and recreational activities. They also receive a varied, nutritious and wholesome diet. EVIDENCE: 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 12 All residents attend the purpose built Glenside Resource Centre in Pinchbeck operated by Sense. The activities available include cookery, pottery, horticulture, creative art, office skills, personal and social development, music, numeracy and literacy, local history and citizenship. A mini-bus takes residents to the centre between 09.30 and 16.00 hours Monday to Friday. Arrangements can also be made for massage and there is a physiotherapy/sensory room and coffee shop. The weekly “at home” day allows residents to decide and choose what they wish to do. This can include shopping, visits into town, hairdressers, gymnasium, swimming and horse riding. Residents also go on holidays and spend time with their family. Arrangements had been made for residents to spend Christmas with their family. When being admitted to the home details are obtained concerning each person’s food preferences and likes and dislikes. Three of the service users as part of their risk assessment cook with staff supervision. At breakfast there is a choice including a hot meal. At lunch, when attending the Glenside Resource Centre (run by Sense), there is a packed lunch and an evening meal provides a hot meal including a choice. People can choose what to eat and the menu is in Braille. The week’s menu is also displayed in pictures. Meals are taken in the dining area in the lounge on the ground floor. All staff are required to prepare meals and all have food hygiene training provided. The nutritional content of the menu is monitored. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 13 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): 19, 20 and 21 Resident’s health and emotional needs are met. Medication is safely and correctly administered. EVIDENCE: Where required, the Community Nurse provides any nursing care. Residents can be referred to GPs, Community Nurse, Dentists and Opticians. Where required, other services can be obtained. Sense have a very detailed and clearly written medication policy. As a result of a recent incident of a drug error, which caused no ill effects to a resident new systems, have been introduced in order to ensure that this does not occur again. Staff responsible for the administration of medication have been retrained. Audits have also been introduced. The CSCI have been fully informed. On account of their sensory impairments, none of the residents were self-medicating. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 14 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 and 23 Any complaints received are taken seriously and residents are protected from abuse EVIDENCE: Sense East have produced a “Resolving Issues” policy, which gives written and pictorial guidance concerning how a resident can raise any issues. This can be provided in Braille, tape or other languages other than English. No complaints have been received by the CSCI and the home since the last inspection. The home has an adult protection policy and all staff as part of their induction receive abuse training. They also receive a yearly refresher training programme in the form of a questionnaire at their appraisal. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 15 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, 26, 28 and 30 People live in a safe, clean and well decorated, comfortable home. EVIDENCE: The home is a domestic house with a small garden with patio furniture and shed at rear. All residents have their own bedroom. All people living in the home are mobile and because of this, there is no stair or shaft lift. Records kept by the Commission shows that bedroom sizes range from 9.82 to 12.10 square metres. The statement of purpose and service user’s guide contains information that one bedroom is below the minimum size required and one bedroom does not have a wash hand basin. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 16 All residents are encouraged to bring personal possessions into the home. This can include a bed, furniture, television, HiFi, pictures and personal mementoes All bedrooms apart from one on the first floor have a washbasin. The reason for this on account of it not being possible to install a waste pipe. All bedrooms have locks to enhance the resident’s privacy. The home however, has a master key for staff to use in case of an emergency. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 17 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, 33, 34, 35 and 36 There are safe levels of staff and staff know how to meet the resident’s needs by a comprehensive programme of education. Staff are supported in their work. EVIDENCE: All staff employed by Sense have job descriptions and person specifications outlining their job. During the interview process and their induction, staff receive training regarding their role. During the inspection, the inspector spoke to 2 members of staff who showed awareness of their role and spoke of their commitment to the home and people living in the home. The home has a detailed and comprehensive recruitment and equal opportunities policy. All staff have been recruited in accordance with the regulations. All staff have received checks by the Criminal Records Bureau. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 18 Each member of staff has an individual training programme. Training includes, induction, foundation and training in care (NVQ). The home has a training budget. All staff receive a detailed induction programme. Other training can be provided to meet the changing needs of the residents. Each member of staff receives formal supervision sessions every month. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 19 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, 40, 41, 42 and 43 Staff are lead by an experienced, competent and committed manager who supports the staff and residents. Staff have confidence in the management. EVIDENCE: The manager has worked for Sense East since 1991 and has a wide experience in care and management. This has included learning disability, sensory impairment and mental disability. She has been the registered manager since the 25/4/2005 and has care, education and management qualifications. She is also an assessor. The home has comprehensive policies and procedures, a number of which are in line with the National Minimum Standards. Sense also have their own comprehensive quality standards. A number of these procedures were reviewed in 2005. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 20 Records examined on the day of the inspection were available, well maintained and up to date. Servicing documents of essential equipment were also available. Sense also undertake monthly unannounced monitoring visits and detailed reports have been sent to the Commission. Internal audits are carried out every 6 months, the last taking place in June 2005. The home has a comprehensive and detailed health and safety policy together with detailed risk assessments covering all aspects of daily living activities. A detailed fire risk assessment had also been carried out. There were regular tests of the fire system as well as regular fire drills. Radiator covers have been installed throughout the home in all areas which are accessible to people living in the home. 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 21 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 3 3 x 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 x 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 3 x 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 21a Johnson Avenue Score x 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 x x 3 3 3 3 DS0000002491.V270007.R01.S.doc Version 5.0 Page 22 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. 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. Refer to Standard Good Practice Recommendations 21a Johnson Avenue DS0000002491.V270007.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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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