Inspection on 15/07/05 for 22 De Parys Avenue

This inspection was carried out on 15th 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

22 De Parys Avenue 08/01/07

22 De Parys Avenue 17/11/05

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 22 De Parys Avenue Bedford Bedfordshire MK40 2TW Lead Inspector Katrina Derbyshire Unannounced 15th July 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. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 22 De Parys Avenue Address 22 De Parys Avenue Bedford Bedfordshire MK40 2TW 01234 355133 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) THF Care Estates Ltd Mr Ian Tarr Care Home 6 Category(ies) of LD registration, with number of places 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23/03/05 Brief Description of the Service: Number 22 De Parys Avenue is a semi-detached property located close to the town centre of Bedford. The property provides long term residential care for a maximum of six adults. The house is a large building and provides accommodation on three floors. There is one large and one small lounge together with a dinning room, kitchen and utility area located on the lower floor. The first floor has a small staff room/ office and bedrooms. The third floor contains the main office. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 15th July 2005. The manager Mr. Ian Tarr was present throughout the inspection. During the inspection many of the areas within the home were visited and the inspector spent time with many of the residents’ in the sitting areas of the home and dining room. The care of three residents’ was examined in depth by looking at their records and interviewing the residents’ and staff who look after them. Observations of care practice and communication between the residents’ and staff was also made at the inspection. What the service does well: What has improved since the last inspection? Several areas in the home had been redecorated since the last inspection and this meant the home looked cleaner and brighter. All residents said that they felt the home looked a lot better; new pictures had also been bought to make the living areas feel more homely. The way the care records of residents are kept had also changed; a set format was being introduced so staff would know all the areas that they needed to write about. This means that all areas of the residents lives would be looked at 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 6 to make sure they would be receiving the care that they needed including their social lives. 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. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 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 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 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 & 4 The management and systems in place for the admission of new residents is very good and prospective residents receive a high level of information and support to help them make a decision on whether to move into the home. EVIDENCE: The homes statement of purpose had recently been revised and did include most of the required information, for example information and career history of the manager, qualifications of staff and to whom the home could provide a service. However the complaints procedure had not been included and this was discussed with the manager at the time of the inspection. Within the care records of the residents, an assessment of need was in place. Documents showed that all residents had received a comprehensive assessment prior to their admission to the home: this was sufficient in detail to ensure the home had gained enough information to be able to establish if they could meet the needs of that resident. The social physical and emotional needs of the resident had been assessed and information from the placing authority was also held on file to provide a historical element. A comprehensive policy was in place to guide and direct staff in the admission of a new resident. Advice was included from receiving a referral right through to the 6-8 week review of a resident. Entries within the care records of residents showed that they had been given the opportunity to visit the home 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 9 prior to their admission. Residents had participated at mealtimes and stayed overnight to assist them in making a decision as to whether to move into the home or not. Comments from residents when describing their move into the home included “ yes very good” and “l was nervous about moving in here, but l got to visit a lot before and that helped”. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 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) 6,9 & 10 Assessment of risk at the home is good and protects the residents from harm. However care plans contain insufficient guidance to staff and put residents at risk of not receiving continuity of care. EVIDENCE: Care plans of residents were examined and were noted to be directly linked to the assessment of the resident. Individual needs identified through the assessment process had a care plan in place. However the guidance to staff on how they should support the resident in achieving their goal or meeting their need was not sufficient. The guidance needs to be clearer in the exact actions needed to be taken by staff so that continuity of care is provided at all times for the resident. Risk assessments had been undertaken and documents outlining the findings of these assessments were also kept within the care files of residents. Areas that had been looked at included the personal safety of the residents for example when they go out from the home the measures that were in place to prevent any harm coming to the resident and how staff should support this. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 11 It was noted that all confidential information was kept in a locked and secure area. Staff were able to describe their responsibilities for maintaining the confidentiality of the residents and this matched the homes own policy on data protection. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 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) 12,16 & 17 The support and facilities available for activities is good so residents receive a varied and stimulating social life. EVIDENCE: Residents spoke of the varying activities that they participated in, one resident said “ l like going for a pint over the weekend” another resident said that they enjoyed “a game of pool”. In addition the home had a games room that the residents could use to listen to music or play darts for example. Staff confirmed that as part of the daily routines in the home social activities formed a part of this. The social needs of the residents had also been assessed and plans were in place within the individual records of the residents that identified their chosen leisure activity. The use of advocacy for the residents is in place and in addition the friends and families of the residents were involved in their care, documentary evidence of this was seen. Staff described how they kept residents informed of their rights through literature on the services provided in the home and through the reviews of the residents. All residents spoken with stated that they were aware of their rights and the way in which they should be treated. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 13 Menus in the home are drawn up with the involvement of the residents. Residents lead the preparation of the evening meal with assistance from the staff team. On examination the menus showed that a diet that included vegetables was provided. However nutritional risk assessments had not been carried out, this is required for residents with a special diet and a requirement has been made. In addition monitoring of weight needs to be in place where a risk of weight gain or loss has been identified. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 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) 19 & 20 The medication at this home is well managed promoting good health. EVIDENCE: Literature from varying healthcare professionals were noted to be in place, these evidenced that residents received regular care from General Practitioners and specialists. All service users were registered with a General Practitioner and any needed referral to access other healthcare services would be made through them following assessment and subsequent referral. The residents files seen contained medication profile sheets, these listed all medications past and present that the resident had been prescribed and included dates. Entries on these documents matched the homes medication administration records and the medication stocks for the service users. All stocks of medication were noted to be kept in a secure manner. The ordering and receipt of medication into the home was satisfactory. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 15 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) EVIDENCE: These standards were not assessed at this inspection. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 16 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 & 30 Cleanliness in the home is to a good standard making it a pleasant environment for the residents to live in. EVIDENCE: The home was indistinguishable from other homes in the area and accommodation to residents is provided over two floors. Furnishings and fittings are domestic and a programme of replacement of soft furnishings and redecoration had commenced. The dining area in the home had only just been redecorated and this resulted in a clean and bright environment for the residents. The home was clean and tidy throughout and service user rooms contained personal items, which reflected their individual personalities. However the hall carpet on the first floor of the home contained large stains and it is a requirement following this inspection for these stains to be removed. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,34 & 35 The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. EVIDENCE: Staff files examined contained the information listed in schedule 2 and 4. The home had obtained in all circumstances all matters in relation to this standard. Criminal Record Bureau checks had been received prior to the employment of an employee. Staff confirmed that they had been issued copies of the codes of conduct and practices set by the General Social Care Council. All further recruitment checks had also been undertaken. Induction checklists on the staff files seen on this inspection showed that the required areas of the staff’s roles and responsibilities had been covered and met all the Sector Skills Council specifications for induction or foundation training. The use of the Learning Disability Award Framework-accredited training needs was being accessed to provide underpinning knowledge for new care staff. Training records and staff confirmed that alongside statutory training staff had undertaken further training in relation to their roles. The home had been active 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 18 in commencing staff on a National Vocational Qualification programme and all staff had development and appraisal plans in place. Certificates of attendance were maintained for all courses undertaken. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 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 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) EVIDENCE: These standards were not assessed at this inspection. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 20 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 3 x 3 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 x x x 3 3 Standard No 31 32 33 34 35 36 Score x 3 x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 22 De Parys Avenue Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 21 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 YA1 Regulation 4(1)(c) Requirement The statement of purpose must be updated to include a summary of the complaints procedure. Care plans must contain clear guidance to staff in the support they must provide to all residents to meet their needs. The first floor corridor carpet must be cleaned to remove all stains. Timescale for action 15/10/05 2. YA6 12(1)(a), 15. 16 15/10/05 3. YA24 30/10/05 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. Refer to Standard YA17 Good Practice Recommendations Nutritional risk assessments should be undertaken on all residents at the home. 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI 22 De Parys Avenue I51 S61363 22 De Parys Avenue V239278 150705 - Stage 2.doc Version 1.40 Page 23 - 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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