Inspection on 14/08/07 for 3 Goodes Avenue

This inspection was carried out on 14th August 2007.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Goodes Avenue 20/07/06

3 Goodes Avenue 13/10/05

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 Ruth Wood Key Unannounced Inspection 14th August 2007 01:15 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 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.V346943.R01.S.doc Version 5.2 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.V346943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 Goodes Avenue Address Syston Leicester Leicestershire LE7 2JH 0116 2608925 F/P 0116 2608925 ditta.stokes@heritagecare.co.uk www.heritagecare.co.uk Heritage Care 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) Mrs Ditta Stokes Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration Date of last inspection 20th July 2006 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, and is approximately a 15-minute bus journey from the centre of Leicester. 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. A service user’s guide to the service is available in a variety of formats and copies of the latest inspection report are available on request from the manager. Current fees at the home are £765.45 per week 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit took place on a weekday between 1:15pm and 4:15pm. All four service users were at home although one went out to visit friends (with staff support) before the visit finished. This gave the inspector the opportunity to observe how the service users and the three staff on duty interacted with each other. Two service users’ support plans and assessments were looked at and the inspector spoke to the staff about how they met people’s needs. Staff also spoke about the training they had completed and the kind of leisure activities that service users took part in. Fire, health and safety and medication records were also inspected. Because none of the service users use formal means of communication the inspector was unable to ask them directly how they felt about living in the home. However throughout the visit they looked relaxed and comfortable and responded positively to staff. Before the inspection visit, the owners of the home, Heritage Care, had sent the Commission detailed information about the home and this information was used to inform the inspection visit and this report. What the service does well: Staff display a very good understanding of people’s needs and how to meet them; this information is also reflected in detailed, well-written support plans, which include each service user’s ideal daily routine. Interaction between service users and staff is warm and friendly and staff appear to have a very good understanding of service users’ different ways of communicating. Good staffing levels enable people’s individual needs to be met and a high priority is placed on supporting service users with their vocational and leisure interests as well as maintaining contact with family and friends. All service users have the opportunity to go on at least one holiday per year as well as day trips and regular outings to the pub and cinema. Holidays and outings are tailored to the individual’s interests, such as an upcoming trip to London for one service user to see a musical. Service users are well supported to access a variety of health care practitioners in addition to their General Practitioner such as physio and speech therapists. This shows that staff seek to gain appropriate input to meet each service user’s individual health care needs. Staff receive regular and appropriate training, which ensures that their skills and knowledge are kept up to date. For example staff are to receive training in the implications of the new Mental Capacity Act in September 2007. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 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.V346943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is good Good assessment procedures ensure that service users’ needs are effectively met. Information about the home is accessible to service users enabling them to make informed decisions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user has an accessible/personalised version of the service user guide, which includes photographs of parts of the home and staff. The guide is also available in audio format and Braille. While the statement of purpose appears accurate in other respects it incorrectly states that waking night staff are on duty in the home. This requires amendment as only sleep- in- staff are on duty at night. Contracts of residency between the home and service users had been signed by their relatives acting as the service users’ representatives. The most recently admitted service user came to live at Goodes Avenue from another home in the Heritage Care group. Full assessment documents from the home and the local authority are in place and a staff member stated that the service user visited the home on a number of occasions before they moved in; this was also documented. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good Service users are involved in day to day decisions, are supported to take reasonable risks and support plans accurately reflect their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users’ support plans contain very detailed information about likes and dislikes, communication needs, health and personal care needs and how all these should be met. These are regularly reviewed (most recently in April 2007) and the information written appears to accurately reflect service users’ observed needs. Detailed risk assessments, appropriate to individuals are in place; these cover such areas as facilitating social activities. Staff display a good understanding of people’s needs and personalities and were observed to support service users to make choices as to the kind of activities they pursued during the afternoon of the inspection. Service users receive support to manage their finances; two service users’ financial records were examined together with balance of monies held and these were accurate. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good Service users have access to appropriate vocational and recreational activities, are well supported to maintain their relationships and enjoy a good, well balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A high priority is placed on supporting service users with their vocational and leisure interests as well as maintaining contact with family and friends. Service users attend a wide range of college courses such as art, music and personal presentation. They have the opportunity to go on holiday with staff support at least once per year; past destinations have included Spain as well as those closer to home such as Great Yarmouth. A service user who enjoys musical theatre is planning a short break in London with staff support later this year, to see a show. One service user chooses to attend church every Sunday supported by a member of staff. During the inspection a service user was going to visit friends supported by two members of staff. After the inspection a relative told the inspector that 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 11 staff support their child to visit them as ill health now prevents them from visiting Goodes Avenue. A letter from the Leicestershire Nutrition and Dietetic Service demonstrates that advice had been sort on how to provide a healthy and balanced diet for all the service users, including one with specific dietary needs. Menu records demonstrate that food served is nutritionally well balanced. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good Service users’ personal care and health needs are well met and medication is appropriatley managed and administered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users’ support plans contain detailed information as to how personal care needs should be met and staff displayed a good knowledge of people’s needs. All health care appointments are clearly recorded as are any conversations held with medical practitioners about a person’s health; this is good practice. Assessments from occupational, speech and physiotherapists are in place together with documentary evidence of optical, chiropody and dental appointments. Medication records were completed accurately and recording systems are in place for the receipt and return of medication to the pharmacy. Staff said that they had received training in administering medication and this was also stated on the information returned by the registered person; training records were not available during the inspection to confirm this as the registered manager was on leave. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good Service users are effectively protected by the home’s procedures and practice relating to complaints and adult abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three staff on duty at the time of the inspection said that they had recently received training in the protection of vulnerable adults and displayed a good understanding of their own and the organisation’s responsibilities in this area. The service has received no complaints since the previous inspection. The Complaints Procedure is available in an accessible format, which includes pictures and symbols to aid service users’ understanding. As they do not use formal means of communication service users’ support plans contain information as to how they show if they are unhappy with anything; this is good practice. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good Service users live in a homely, comfortable and clean environment, which meets their needs well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All areas of the home appeared fresh and clean with gloves and aprons in place in bathrooms for staff use when assisting service users with personal care. Staff on duty said that they had received training in infection control and this was detailed as an agenda item for a forthcoming staff meeting. Service users’ bedrooms are individually decorated and personalised with a range of photographs and ornaments. Communal areas are spacious and comfortably furnished and service users are able to move around easily. The garden has a large paved area as well as grass and mature trees. Some vegetables are grown in the greenhouse – service users are involved in this – and there is a range of garden furniture for use when the weather permits. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35, 36 Quality in this outcome area is good Service users are effectively supported and protected by well trained staff This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff recruitment and training files were not available during the inspection as the registered manager was on annual leave. Recruitment practices were found to be satisfactory at the home at the previous inspection. Staff said that the organisation offered very good training opportunities; forthcoming training includes information about people’s responsibilities under the new Mental Capacity Act. All staff on duty (3) had obtained or were involved in training to achieve National Vocational Qualifications in care. Staff also said that they had regular one to one meetings with the registered manager. This confirms information submitted by Heritage Care prior to the inspection visit. The rota showed that there are always at least two people on duty during the day and one staff member sleeps in at night; a duty manager is always on call. The rota is arranged in such a way to prevent staff from working excessive hours and any relief staff used are also employed by Heritage Care and are generally known by the service users. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good Good health and safety practice ensures service users’ welfare in these areas is promoted however improvements to quality assurance are required to ensure their views fully inform the way the service is delivered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has nearly completed the Registered Manager’s Award and a National Vocational Qualification in Care at Level 4. Observation of staff interaction with service users and reading of support plans indicates that efforts are made to obtain service users’ opinions concerning day to day issues in the home such as what to eat and leisure activities. Clear guidance is also given as to how individual service users may express their dissatisfaction with a situation to enable staff to react appropriately. A formal quality assurance system in which service users’ views are formally sought is yet to be implemented, although information received from Heritage Care prior to the inspection visit suggests that this has now been formulated. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 17 Discussion with staff and information received in the AQAA indicates that staff have received training in food hygiene, fire safety, and infection control. Documentation demonstrates that fire systems and equipment are regularly serviced and records show that fire systems are regularly tested and that fire drills involving service users have taken place. The fire risk assessment (Completed in July 2005 and seen at the previous inspection) could not be located on the day of the inspection visit. Later conversation with the registered manager confirmed that this was readily available and staff would be reminded as to its location. Documents showed that portable electrical appliances had been tested and the gas central heating system was undergoing service on the day of the inspection visit. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 18 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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 19 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 YA1 Regulation 4 Requirement The statement of purpose must be reviewed to ensure that it accurately reflects the staffing levels currently provided in the home. A copy of the updated statement must be forwarded to the Commission. The registered person shall: Establish and maintain a system for reviewing at appropriate intervals and improving the quality of care at the home. Supply to the Commission a report of the review and make a copy available for service users The review must include consultation with service users and their representatives. Timescale for action 30/09/07 2 YA39 24 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 20 No. Refer to Standard Good Practice Recommendations 3 Goodes Avenue DS0000031787.V346943.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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