Inspection on 13/10/05 for 3 Goodes Avenue

This inspection was carried out on 13th October 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Goodes Avenue 14/08/07

3 Goodes Avenue 20/07/06

3 Goodes Avenue 19/04/05

3 Goodes Avenue 30/11/04

3 Goodes Avenue 22/06/04

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 3 Goodes Avenue Syston Leicester Leicestershire LE7 2JH Lead Inspector Paula Dutton Unannounced Inspection 13th October 2005 09:30 3 Goodes Avenue DS0000031787.V255390.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 3 Goodes Avenue DS0000031787.V255390.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. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 3 Goodes Avenue Address Syston Leicester Leicestershire LE7 2JH 0116 2608925 0116 2608925 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) www.heritagecare.co.uk Heritage Care Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration Date of last inspection 19th of April 2005 Brief Description of the Service: 3 Goodes Avenue is registered to provide care for five people with learning disabilities. The home is situated in a residential area close to the centre of Syston. There are three single bedrooms on the first floor and a double room downstairs. Shared facilities include a large lounge, dining room, conservatory and kitchen. There is a well-maintained garden to the rear of the property. The home has its own vehicle. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day. The manager was available for most of the inspection. The area manager (John Goree) and chief executive (Kim Foo) were visiting the premises. All five service users were available at the home for all or some of the inspection. The services provided to four service users were examined for positive outcomes. This was measured by discussion with service users, staff and the manager. The inspector observed the interactions between service users and staff. Individual records were viewed including core information, risk assessments, medication records and daily notes. Service users showed the inspector their bedrooms. Two staff files were viewed. What the service does well: Overall this is a well managed and operated service. Some comments were made by service users: • • • ‘it’s alright’ ‘I can sleep in bed all day’ ‘I like my room’ A relative/visitor stated ‘I feel that….is cared for extremely well and we are well informed by staff at the home’. What has improved since the last inspection? What they could do better: There were no shortfalls identified during this inspection and therefore no statutory requirements were issued. There were no recommendations made. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 6 Some discussion took place about delivery of medication training, the use of Person Centred Plans as care plans and the guarding of one radiator in a service user’s bedroom as the weather becomes cooler. 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 Goodes Avenue DS0000031787.V255390.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 3 Goodes Avenue DS0000031787.V255390.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, Service users have access to information to enable them to make informed choices and decisions about the services provided by the home. EVIDENCE: Information is made available to service users on an ongoing basis about the services provided by the home. There were no new admissions to the home in the last five years. However the manager described current individually led work undertaken by service users and their keyworkers to form their own Service Users’ Guide according to their communication needs. This illustrates the commitment from the manager and the staff team to ensuring service users can access information effectively and can become empowered in making decisions about how they wish to live. This is good practice. Four service users’ files showed each service user had been assessed by an outside professional such as a social worker. Evidence was seen of assessment and care plan reviews by social workers. 3 Goodes Avenue DS0000031787.V255390.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, 7, 8, 9, 10 Services are provided so that service users maintain their independence. EVIDENCE: Four service users’ record files were viewed. Each file contained individually maintained records which were stored securely. Evidence indicated the home had gained assessments undertaken by outside professionals such as social workers. Records contained evidence of care plan reviewing completing by the staff at the home through monthly evaluation. Reviews held with social workers had occurred to ensure service users’ needs were consistently being met. All evidence indicated the home closely monitors service users for changes in needs and takes action to meet those identified needs. Records contained individual core information records to accompany the assessments/reviews completed by outside professionals such as social workers. The core information record showed the service users’ opinions as to how they wanted their care needs to be met. This information was supported by photographic prompts. The manager stated this information could be made available on tape for a service user to refer to at any time. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 10 3 Goodes Avenue DS0000031787.V255390.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, 13, 14, 15, 16, 17 Service users are able to lead purposeful lives and exercise their rights through opportunities and choices. EVIDENCE: Discussion with staff and service users established a range of social and leisure activities are undertaken by service users. Staff had a good understanding of service users’ abilities and preferences. On the day of inspection two service users had been on a horse riding lesson followed by lunch at a village pub. Staff had received training in how to assist a service user to ride a horse. Staff stated visitors and relatives are made very welcome when arriving at the home. One service user told the inspector about how frequently family members visited the home and how the staff were assisting him to plan a large social event held at the home. This is very good practice. Discussion with the staff on duty found there is a varied and nutritional choice of foods available to service users. Service users stated they enjoyed the food offered. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 12 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 Service users’ personal care needs are supported effectively and sensitively. EVIDENCE: Each service users’ record file held information about how they wanted their care needs to be met. This included a core information sheet and risk assessments. The core information was composed by the service user with the assistance of care staff. Risk assessments highlighted high risk areas and contained instruction to staff as to how to reduce the identified risks. Observation found staff communicated effectively and sensitively with service users. Staff showed respect and a flexible approach to working to with service users so that their personal care needs were met. Medication is securely stored and those items requiring storage at a low temperature were securely kept in a lockable box in the fridge. Appropriate levels of stock were available for service users and records of administering medications were all signed and dated showing medication as given. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 13 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, 23 Service users can express their opinions freely thus ensuring their rights are protected. EVIDENCE: Observation at the time of inspection found all service users were able to express themselves freely and each person was able to move around the premises freely. Service users were observed to make statements of opinion and state their choices to staff members. Observation found staff interacted effectively with service users and clearly had an established understanding of each service users’ communication needs. Discussion took place with the manager about ensuring staff had access to makaton training. The manager stated makaton training could be provided particularly for those staff who were keyworkers to people who used makaton to communicate. The home does have a complaints and compliments policy and procedure which includes details of how to make a complaint. Staff have access to the Department of Health’s Guidance document entitled ‘NO SECRETS: The Mistreatment of Vulnerable Adults’. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 14 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, 27, 28, 29, 30 The environment is well maintained so that service users can live comfortably with independence, privacy and dignity. EVIDENCE: A tour of the premises found all areas of the home to be clean, tidy and homely in appearance. Soft furnishings and home entertainment equipment contributed to creating a comfortable relaxed environment. Evidence was seen of a range of video and musical interests belonging to service users. Four service users’ bedrooms were seen. Evidence was seen of personal property and items of interest. Service users had been able to choose materials and soft fittings to personalise their rooms. A discussion took place with the home about a radiator which was unguarded. The service user’s bed was placed against the radiator and posed a potential risk if the service user fell between the radiator and bed. The call bell alarm system was available but was not routinely used by this service user. A commitment was made by the home to address this issue as a priority. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 15 All bedrooms were clean. Staff were aware of the need for measures for the prevention of cross infection where necessary. Each service user has their own colour coded towels and flannels. This is good practice. A shared room was viewed with a service user. This service user expressed satisfaction with the shared room and was very clear about which areas of the room belonged to each service user. A partition wall mostly divided the two rooms and served to preserve service users’ privacy and dignity. A discussion took place with the manager about when the home needed to notify the Commission about any accidents, incidents of illness or infectious conditions (Regulation 37). 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 16 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, 33, 34, 35 A training programme offered to staff ensures service users have their needs met by competent staff. EVIDENCE: Staff are offered a structured programme of training opportunities commencing at the point of induction with a very comprehensive induction training schedule. Evidence was seen of the wide range of subjects addressed during induction. Staff stated they were offered the opportunity to complete LDAF or Learning Disabilities Award Framework training which contributes towards a National Vocational Qualification. The rota was viewed. This showed a recording of those staff on duty throughout a 24 hour period. At the time of inspection extra staff employed by Heritage Care were available in the premises. Staff files are stored securely and individually. Two staff files were viewed. Evidence confirmed the home undertakes recruitment checks including gaining two written references and a Criminal Record Bureau check. The home operates a formal and recorded system of supervision which addresses care practices and keyworker responsibilities. Evidence seen 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 17 indicated this is a planned activity between staff and line manager promoting an equal exchange of good practice ideas. This is good practice. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 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, 38, 40, 41 A well managed service ensures service users’ needs are identified, addressed and met. EVIDENCE: The manager was present for most of the inspection. Staff and service users were observed to easily approach the manager with queries and requests. The manager interacted effectively and sensitively with service users. The manager demonstrated a string commitment to the National Minimum Standards and achieving high standards of care in the home. The management of the home was informed by a range of policies and procedures which were well organised and easily accessible for all staff. Records were kept individually and were factual in their account of service users’ health and welfare. A discussion took place about how the manager expects the daily notes/charts to reflect the actual events/behaviours presented and experienced by service users. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 19 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 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 4 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3 Goodes Avenue Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 X X DS0000031787.V255390.R01.S.doc Version 5.0 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. 2. Standard YA6 YA34 Regulation 15 17 Requirement The registered person must ensure that individual plans are kept under review. The registered person must ensure that the records for any person employed at the home comply with the requirements of Regulation 17. The previous timescale of 28/02/05 was not met. Timescale for action 30/06/05 30/06/05 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 YA1 Good Practice Recommendations It is recommended that the home complete a more accessible version of its Service User Guide. 3 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Goodes Avenue DS0000031787.V255390.R01.S.doc Version 5.0 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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