Inspection on 15/03/06 for 3-4 Glebe Lane

This inspection was carried out on 15th March 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3-4 Glebe Lane 25/06/07

3-4 Glebe Lane 09/08/05

3-4 Glebe Lane 15/03/05

3-4 Glebe Lane 12/06/04

3-4 Glebe Lane 26/02/04

Similar services:

Ruskin Lodge

Clover House

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Parkside

Park Lodge

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

CARE HOME ADULTS 18-65 3/4 Glebe Lane Distington Workington Cumbria CA14 5SQ Lead Inspector Gordon Chivers Unannounced Inspection 15th March 2006 09:45 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 3/4 Glebe Lane Address Distington Workington Cumbria CA14 5SQ 01946 831629 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) West House Mrs Fiona Elizabeth Dixon Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 8 service users to include: up to 8 service users in the category of Physical disabilities (PD) up to 8 service users in the category of Learnig disabilities (LD) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 9th August 2005 Date of last inspection Brief Description of the Service: West House is the Registered Provider for 3 & 4 Glebe Lane which are two adjacent properties situated in a residential area close to the centre of the village of Distington on the West Coast of Cumbria. The properties provide accommodation and care for eight people who have a learning disability, some of whom may also have a physical disability. Number 3 Glebe Lane is a purpose built bungalow that has been built next door to the house, which is number 4 Glebe Lane. Each building has its own garden area and car parking is available to the front of the house and to the side and rear of the bungalow. Both properties look similar to the neighbouring houses in Glebe Lane. The home operates as two separate units. The house provides communal living space for service users together with an office / sleep - in room on the ground floor with private bedrooms and a bathroom on the first floor. The bungalow has level access into the hallway that is designed to assist service users who use wheelchairs to enter the building. All the communal rooms and private bedrooms are equipped to meet the needs of the service users. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, commencing at 09.45 and lasting six and a half hours. The inspection took place in the presence of the manager, Fiona Dixon. The inspection included a tour of the premises, reference to a range of documents including a sample of service users’ case files, and talks with members of staff, two relatives who were visiting and to service users. The inspection focused upon the standards which drew forth requirements and recommendations, and the standards which were not assessed, by the last inspection. The inspector would like to thank the service users and staff of 3 and 4 Glebe Lane for their welcome and cooperation during this inspection. What the service does well: What has improved since the last inspection? The home has a copy of the Westhouse admissions policy and procedure. Most of the service users have a signed contract of residency. The home has a record of the preferred funeral arrangements of most of the service users. Staff are being trained to protect service users from abuse and neglect. The new staff team is stable and working well together. More than half of the staff have qualified to NVQ level 2 or above. The paintwork in the bathroom in No. 4 has been renewed. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 6 The new manager has improved the overall running of the home. The first Annual Service Plan has been developed. 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. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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): 2,4,5 Full assessments are carried out and regularly updated on all the service users. They all have a contract of residency in their file. EVIDENCE: The home undertakes a full range of assessments of need and personal risk assessments on new service users and these are reviewed and updated regularly. The home also develops a person-centred plan with each service user and these record a lot of information about their hopes and wishes for the future. The home has a copy of Westhouse’s Admission policy and procedure. Each service user has a contract of residency in their case file but not all of them have been signed by the service user or their representative. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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): 6,9 The home develops care plans to meet the assessed needs of the service users, and staff help them to do new things or do things differently which increases their confidence and sense of independence. EVIDENCE: Plans of care are developed to meet the service users’ assessed needs. The home undertakes a range of reviews at different times on different aspects of each service user’ needs and plans. Some reviews focus on the changing needs, and others focus on the goals of the care plans and/or the actions of the staff to achieve those goals. However, the records in the files do not reflect a clear process from needs to plans to actions to reviews. There is little coordination between all the reviews done on each service user so it is not possible to get a whole picture of each service user from time to time. The manager informs the families of the service users when a review is due to take place and some attend when they are able or when there is an important issue to be discussed. The manager was able to give several examples of how the home has supported the service users in gaining new skills and having wider experiences through doing things they have never done before or doing things in a different way. Important amongst these are the recent reduction in the range of 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 10 medication taken by some of the service users. This was planned together with their doctors. This has had the effect of ‘freeing-up’ those service users’ physical and mental senses and they now do things which were previously ‘blocked-off’ by their medication. Other examples range from having a holiday in a new environment to making simple snacks and drinks on the kitchen. Each example, big or small represents a step towards more independence and wider social opportunities. Unfortunately the home has not recorded all of these events, or they have not recognised the importance of these achievements by clearly linking them into assessments and care plans. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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): 12,15 The service users take part in a range of activities and social and leisure pursuits. They all have contact with their families, some have personal friendships, and their sexual feelings are respected. EVIDENCE: The home no longer employs a dedicated activities organiser. This role is now shared amongst all of the staff with key-workers responsible for ‘their’ service user. The manager and all the staff are happy with this system and the manager thinks this is the best use of her staffing resources. All of the service users have person-centred plans which record what activities would meet their personal goals and aspirations. They also have weekly and monthly plans which set out their daily activity schedule and the wider social leisure pursuits including holidays. Not all the service users attend day services every day, and the staff look for ways to stimulate them in the home mainly through one to one contact and conversation. The staff attempt to arrange activities which are linked in some way to service users’ assessed needs and care plans. All of the service users have positive and beneficial contact with their families to varying degrees. Some of the service users are able to visit their families. The home supports this with sensitivity and respect of each family’s circumstances. Relatives who returned comment cards as part of this 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 12 inspection and the two relatives who visited the home during this inspection all commented positively upon the support the service users receive from the new staff team. Several of the more active service users have friendships with people from outside of the home who they have met at day services or social events. This will extend to visiting each other in their own homes. The person-centred plans show how staff support the service users to maintain appropriate relationships. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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): 18,19,20,21 The service users receive personal care and support in the ways they prefer. Their health needs are met and their medication is administered appropriately. The home has a record of their preferred funeral arrangements. EVIDENCE: The case files have records of some of the ways in which service users prefer to receive personal care and support, although the manager feels that perhaps these need to be reviewed so that new staff who don’t know the service users can be sure of finding all of the guidance they might need. Each service user has a personal health record, and there are records of referrals to and contact with doctors and community therapists and health specialists. The staff in the home are clearly very attentive to the health needs of the service users. The senior support worker has engaged the help of a specialist community physiotherapist to develop exercises to improve the mobility of those service users who are confined to wheelchairs. Key health issues form part of the care plans. The home and one of the specialist community nurses are due to develop a Health Action Plan for one of the service users. The manager might consider developing specific health action plans for all of the service users to form a focused health sub-section of the main care plan. The staff have learnt to recognise when the service users are upset or distressed in any way through experience and observation, and will offer them comfort and reassurance. However it is not easy to identify the cause of this distress in the service users who have communication difficulties. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 14 Staff therefore focus upon tried and tested ways of calming them and/or lifting their mood. Both the house (No. 4) and the bungalow (No.3) have the required medication cabinets sited in locked cupboards. All but one service user have their medication administered through dosage systems. MAR sheets record the administration of medication. Records are kept of the receipt and disposal of medication. Reference has already been made to the planned and authorised reduction of medication taken by some of the service users. The staff are due to receive accredited training in the administration of medication although the manager has yet to informed by Westhouse when this will actually take place. The families of all but one service user have indicated their preferred funeral arrangements for the respective service users. This information is kept secure in the office; there is a cross-reference to it the individual person-centred plans. Staff are liaising with the family of the service user whose preferred funeral arrangements have not yet been received. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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 the following standard(s): 23 Staff are being trained to protect service users from abuse and neglect. EVIDENCE: Eight of the staff team have received recent training in the protection of vulnerable adults, and the others are due to receive this training. All staff have been checked by the Criminal Records Bureau. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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 the following standard(s): 24,30 Both the house and the bungalow are homely and comfortable, clean and hygienic. EVIDENCE: A recommendation was made in March 2005 that the provider and the landlord arrange for the kithen units in the bungalow to be replaced, and this was converted in to a requirement at the last inspection with a timescale for completion of October 31, 2005. There are records in the home of the manager and senior personnel of Westhouse pursuing this issue with the landlord, Impact Housing Association, who have agreed to it. An appointed contractor has been to the home to estimate the job and new units have been chosen, but as yet the home has received no confirmation from Impact H.A. as to when the work will be undertaken. The paintwork in the bathroom of Number 4 has been renewed. The fire extinguisher in the hallway of No. 4 presents a hazard in its present position and detracts from the homeliness of the house, and should be moved. Both the house and bungalow are kept very clean and hygienic with no offensive odours. There are, however, some defects which should be attended to. The ventilation system in the upstairs toilet in No. 4 is not working, and some of the joints between the skirting and the floor in some of the bathrooms need to be filled. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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): 32,35 The staff team is stable, their training needs are being met and they are becoming well qualified. EVIDENCE: The new staff team has come together and settled well. Relatives commented positively about the staff team. The team is currently operating at 143 hours per week below its full establishment until April 2006 when a new member of staff will start work. These ‘vacant’ hours are covered by bank staff and existing staff doing extra time. Seven of the staff team (excluding the manager) have achieved NVQ level 2 or above. Four members of staff are currently undertaking this qualification, one member of staff is still on probation and another is due to start work in the home in April 2006. Staff’s training needs are identified in their individual supervision sessions. The staff are very receptive to new training opportunities and Westhouse do all they can to arrange for training needs to be met. The manager is to consider developing a simple management tool which records what training has been undertaken by the team, and identifies what their outstanding needs are and when they will be met. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 18 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): 37,39,42 The home is well run and the first Annual Service Plan has been developed. The health and safety of the service users are ensured by the staff and the home’s systems. EVIDENCE: The actions taken by the senior management of Westhouse to renew and stabilise the staff team have worked well. The new manager since November 2005, Fiona Dixon, achieved her Registered Managers Award in April 2005 and is now registered with CSCI. She and the new Senior Support worker have developed a good working relationship. The manager has focused on ensuring that basic standards of care and support are in place, and the staff work together as a team. One way of doing this has been to roster all staff to work in No. 3and No. 4 so that cliques to do not develop. She has also delegated certain responsibilities regarding the internal environment to individual staff members so as to encourage ownership amongst the team. The manager has produced an Annual Development or Service Plan with a mixture of general and specific goals. This is meant to gradually improve all aspects of the home and its service over and above its basic core duties and responsibilities. The manager is consider how to develop this plan in future 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 19 years so its goals are more specific and easier to assess and that some of them are clearly based upon the views of the service users and or their representatives. Westhouse has been undertaking its own periodic environmental risk assessments. Staff make daily and weekly checks on a range of issues such as water temperatures, emergency equipment and fire drills which either the manager or the senior support worker monitors. On entering the building a support worker points out emergency exits to new visitors. The home has records of all of the checks and maintenance schedules of the various contractors who are responsible for various pieces of equipment or services. The manager is waiting upon Impact H.A. to undertake checks regarding legionella and asbestos in the home. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 X X 3 X 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 21 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. Standard YA5 Regulation 5 Requirement The home must have contracts of residency signed by all the service users (or their representatives). This requirement has only been partially met from the last inspection (Timescale 31/08/05). The home must develop a process which clearly links assessments to care plans, actions and reviews. The registered person must ensure that the staff receive accredited training in the administration of medication. The provider and the landlord must arrange for the kitchen units in the bungalow to be replaced. (Unmet requirement with a timescale of 31/10/05). Timescale for action 30/04/06 2. YA6 13,14 30/09/06 3 YA20 18 31/07/06 4. YA24 16,23 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 22 No. 1. 2 3 4. 5 Refer to Standard YA6 YA9 YA19 YA24 YA30 Good Practice Recommendations The manager should attempt to coordinate all of the reviews on each service user so that a whole picture of needs and plans is developed. The manager should ensure that all actions to increase the service users’ independence are clearly linked into the care plans. The manager should consider developing health action plans for all of the service users. The registered person should move the fire extinguisher in the hallway of No. 4. The registered person should ensure that the ventilation system in the upstairs toilet in No. 4 is working, and that all of the joints between the skirting and the floor in the bathrooms are filled. The manager should develop a training management tool. The manager should develop the Annual Service plan so its goals are more specific and easier to assess and that some of them are clearly based upon the views of the service users and or their representatives. 6 7 YA35 YA39 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 3/4 Glebe Lane DS0000022557.V280078.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!