Inspection on 10/08/05 for 25 Horsegate

This inspection was carried out on 10th August 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

25 Horsegate 05/09/06

25 Horsegate 25/01/06

25 Horsegate 08/02/05

25 Horsegate 05/08/04

Similar services:

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Applegarth

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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 25 Horsegate Deeping St James Peterborough PE6 8EW Lead Inspector Mick Walklin Unannounced 10 & 17 August 2005 10:00 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. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 25 Horsegate Address Deeping St James Peterborough PE6 8EW 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) 01778 347037 01778 347037 horsegate@sense.org.uk Sense East Mr Albert Pearce Care home only 6 Category(ies) of SI Sensory Impairment (6) registration, with number LD Learning disability (0) of places 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) 6 sensory impairment/learning disability Date of last inspection 08 February 2005 Brief Description of the Service: 25 Horsegate is a modern house, built around 7 years ago. It is situated in the village of Deeping St James, approximately one mile from the centre of Market Deeping. There are a range of shops and pubs nearby, and the centres of Peterborough, Stamford and Bourne are within a short driving distance.The home is of a domestic appearance, and situated in a residential area. It is registered to provide accommodation for 6 people with a sensory impairment and/or learning disabilities. The aim of the home is to provide a safe and supportive environment, based on best care values. The home is part of a group of homes managed by SENSE East. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was over a period of two days, lasting 7 hours. The main method of inspection used was called case tracking which involved tracking the care the three residents receive, through the checking of their records, discussion with them, the care staff and observation of care practices. The manager completed a pre-inspection questionnaire, and one comment card was received from a relative, which contained positive feedback. A tour of the premises was conducted. Documentation within the home was also inspected. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 There are good procedures for the assessment and admission of residents to the home, which ensure that staff have the information necessary to meet the needs of residents. EVIDENCE: The home has had no recent admissions, so it was not possible to assess the current admission procedure. However, the Statement of Purpose clearly sets out the criteria for admission, and the admission procedure. All referrals to SENSE East are via a referrals officer, and an Assessment Co-ordinator will visit the prospective resident to conduct an assessment in their existing home prior to admission. A Placement Committee would then consider the assessment. Prospective residents would be expected to make an informed choice to access the service as part of their Person Centred Plan. The home provides long-term care, so new admissions would be rare. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9. Care plans and risk assessments require updating so that they reflect the current needs of residents. Staff have a good knowledge of the needs of residents. They are trained in alternative communication methods, and know how to communicate with residents effectively. EVIDENCE: Residents files contained a range of background information, and there was evidence of six-monthly reviews being held, which included parents and placing Social Workers. However, it was sometimes difficult to link specific care plans and risk assessments directly with the reviews, and some care plans and risk assessments had not been re-written since 1999. There are good daily logs, which travel with residents to the resource centre, ensuring continuity of care. There are detailed behavioural plans, which staff have signed to confirm that they have read and understood. Residents have significant communication difficulties, and staff employ a variety of techniques to ascertain choices. They demonstrated a good knowledge of the communication methods to used by each resident. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 17. There are good occupational, recreational and leisure opportunities available for residents to ensure that they have a varied and interesting timetable. EVIDENCE: Residents attend Peterborough Resource Centre (PRC), and have a varied timetable designed to promote independence. All activities undertaken at PRC have detailed aims and objectives. A new resource centre with better facilities is planned to open next year in Bourne, and residents will transfer to this. Some residents also have home days, when they participate in a variety of household tasks and 1:1 outings. The home has use of a mini bus, and there are regular outings. PRC closes for 3 weeks in the summer, and staff from the home have organised a varied programme during the closure. Residents have been to Rutland Water, Burleigh Park and Skegness this week. All have had holidays in Derbyshire and Norfolk this summer, and some also go on holiday with their families. Catering arrangements are of a domestic nature, and enable individual needs to be catered for. Eating and drinking guidelines are in place for some residents, and a record of food served is kept to ensure a good diet is 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 10 maintained. One resident is sometimes reluctant to eat, so a supply of tempting foods are kept in stock to encourage him to eat. Staff again complained about the cooker being inadequate for the volume of catering required. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 11 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. There are good arrangements with local health care providers to ensure that residents health needs are met. EVIDENCE: All residents are registered with the local GP practice. Psychiatric cover is available from the Gloucester Centre in Peterborough, and audiology is available via referral from the GP. One resident attends out patient appointments in London for periodic checks. Local opticians and dentists are used. Sense East employs a person to conduct visual and hearing assessments, and copies of detailed reports were seen on file. There was also evidence of regular weight checks. There are good systems for medication storage and stocktaking. The home uses a Nomad system, where tablets are pre-packed by the pharmacist, and there are detailed medication policies. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 12 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 are satisfactory procedures in place to ensure that service users are protected from abuse, and complaints are dealt with effectively, but procedures should be easily accessible to staff. EVIDENCE: There have been no complaints since the last inspection. SENSE East produces detailed policies and guidelines regarding concerns/complaints, grievances, harassment and bullying. The home’s ‘Resolving Issues’ guidelines contain contact details for the Commission. SENSE East has a Protection Committee, which reviews all reports of adult abuse within the organisation. Staff are given a questionnaire to complete at their annual appraisal, which checks their knowledge of the adult protection procedures. This information is then reviewed by a manager. Adult protection is also an agenda item at staff meetings. Staff were clear on their reporting responsibilities, and said that they would refer to the ‘Emergency File’. However, there were no clear guidelines or contact numbers in the file for staff to follow and it is recommended that these be included. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 13 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. Some improvements have been made to the environment, which have made the home more comfortable for residents. EVIDENCE: The home presents as a domestic dwelling in a residential street. The previous inspection highlighted a number of maintenance issues, and a majority of these have been attended to. The kitchen work surface has been replaced, and a broken sink has been replaced in one of the residents bedrooms. A new window has been installed in the staff sleep-in room to aid ventilation, and the fire door near the kitchen has been painted. Other improvements have included a new shower, and re-tiling in the kitchen. The two settees and one armchair still have some coasters missing, making them lopsided, and the manager confirmed that new furniture was on order. The bedrooms that has suffered a high level of damage by the resident occupying it still requires refurbishment, although it is in better condition than on the last visit. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 14 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) 33 & 36. Staffing levels are currently affected by vacancies and absences, but safe levels are being maintained for residents. Staff supervision should be on a more regular basis. EVIDENCE: One member of staff is on long-term sick leave at present, and one is on maternity leave. Staff commented that staffing levels were “not good” at present, and the home is 88 hours short per week. Staff said that they work well together to provide cover, and bank staff are used to fill gaps, so that safe staffing levels are maintained. Staff said that supervision is not occurring regularly, although the manager is very accessible if staff have a problem. The two Team leaders are being trained so that they will be able to supervise staff. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 15 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) 38 & 41. The home is well managed, but the Manager does not have sufficient supernumerary time at present, which is affecting the organisation of some documentation. EVIDENCE: Monthly staff meetings are held, and staff said that morale and teamwork is good. No new staff have been employed since the last inspection. However, some staff files kept in the home still do not contain the information required, such as copies of identification, photographs and employment details. The main staff files are kept in the Human Resources Department, in Market Deeping, who should ensure that the correct documents are available for inspection in the care home. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 16 SENSE East uses a self-assessment format as part of their quality monitoring and quality assurance process. This was last completed in January 2005 and audited against the SENSE operational standards. Several residents have purchased their own furniture, but this was not recorded on an inventory. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x x 3 x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 25 Horsegate Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 x x 2 x x C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 18 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 6 Regulation 15 Requirement Timescale for action 31/12/05 2. 24 23(2) 3. 41 19 Schedule 2 & 17(2) Schedule 4 The registered person must ensure that care plans and risk assessments are updated and reviewed. The registered person must 31/10/05 arrange for the chairs and settees in the living room to be replaced.(This requirement is outstanding from the inspection on 8th February 2005). The registered person must 31/10/05 ensure that the documents outlined in Schedule 2 are obtained prior to employment, and the documents in Schedule 4 are kept in the care home. (This requirement is outstanding from the inspection on 8th February 2005). 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 23 Good Practice Recommendations It is recommended that a quick reference guide and contact numbers is included in the Emergency File. C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 19 25 Horsegate 2. 3. 36 38 It is recommended that staff receive supervision six times per year. It is recommended that the manager be allocated sufficient supermumerary time to fulfill his role. 25 Horsegate C53-C04 S2655 25Horsegate V243360 100805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 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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