Inspection on 19/04/05 for 3 Goodes Avenue

This inspection was carried out on 19th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

3 Goodes Avenue 14/08/07

3 Goodes Avenue 20/07/06

3 Goodes Avenue 13/10/05

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 Martin Hefferman Unannounced 19 April 2005 09.40 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. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service 3 Goodes Avenue Address Syston Leicester LE7 2JH 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) 0116 2608925 0116 2608925 Heritage Care Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration Date of last inspection 30/11/04 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 C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over the course of four hours twenty minutes. The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they receive through review of their records, discussion with them (where appropriate), the care staff and observation of care practices. The majority of service users at the home have no verbal communication. Two service users and the relatives of a third were spoken to during the course of this inspection. What the service does well: What has improved since the last inspection? What they could do better: Heritage Care have developed a more accessible version of the Service User Guide, which has the potential to be a useful document for current and prospective service users. The document needs to be completed to fully realise that potential. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 Page 6 Care plans must be kept under review to ensure that they reflect any changes in service users’ needs. The introduction of person-centred planning will, when implemented, increase the participation of service users in the development and review of their care plans. Staff records must be kept at the home to enable the Commission to verify that recruitment practices protect service users. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 2 A more accessible version of the Service User Guide has the potential to be a useful document for current and prospective service users. It needs to be completed to fully realise that potential. Regular reviews ensure that service users’ needs continue to be met. EVIDENCE: The home has produced a Statement of Purpose and a Service User Guide. A more accessible version of the Guide was available at the time of the inspection. This document has yet to be fully completed. The home has a settled and stable service user group. The most recent admission took place in May 2001. Social workers undertake regular reviews of service users’ placements at the home. Records of recent reviews indicate that service users’ needs continue to be met. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 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 standard(s) 6 & 9 Individual plans were clear and comprehensive, with the exception of one identified shortfall. Failure to keep each plan under review could result in the plan not being updated to reflect any changes in need. Service users are supported to take risks as part of a more independent lifestyle. EVIDENCE: The individual plans that were inspected set out service users’ needs in respect of their health and social care. The home has produced care plans on a number of specific issues such as how to reduce the incidence of self-harming behaviours and night-time support. Two of the plans that were inspected had been reviewed during January 2005; the third did not appear to have been reviewed since June 2004. The acting manager stated that person-centred plans had yet to be completed for the service users at the home due to staff changes and the need for new staff to attend training. Two of the service users who were chosen for the purposes of case tracking go horse riding. Staff members have received training to enable them to support service users when they undertake this activity. On the day of the inspection, service users were encouraged to participate in a range of domestic tasks. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 15 & 17 Service users are encouraged to take part in appropriate activities and to maintain contact with their families. They appear to enjoy their meals and to receive a varied and nutritious diet. EVIDENCE: Two of the service users who were chosen for the purposes of case tracking attend daytime activities at local colleges. The third attends a day centre once a week. He showed the inspector the flowers and vegetables he is growing in the home’s greenhouse with the support of the gardener. The relatives of a service user stated that they feel welcome to visit the home at any time. They reported that they always phone in advance as their son is often out. They stated that when for a period they were unable to visit the home due to illness, staff members had brought their son over to see them. Records indicate that other service users are in regular contact with their families. Service users were consulted about the midday meal and actively involved in its preparation. One service user stated that he enjoys the food provided by 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 Page 11 the home. Individual plans contain details of service users’ likes & dislikes, dietary requirements and any assistance or equipment needed. Records indicate that service users receive a varied and nutritious diet. The home was reminded that it must keep a record of all of the meals provided to service users. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 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 standard(s) 18, 19 & 20 Service users’ personal and healthcare needs are fully met by the home. They are protected by the home’s practices regarding the handling of medication. EVIDENCE: The individual plans that were inspected detail the personal support service users require and any preferences that have been identified regarding their care. For a number of service users, this information is based upon knowledge built up over time. The plans also set out details of any healthcare needs that have been identified and of any action that is felt to be necessary as a result. The staff members who were on duty at the time of the inspection were implementing measures outlined in a care plan relating to self-harming behaviours. A staff member stated that the implementation of the measures had led to a noticeable reduction in the behaviour. Records of the receipt, administration and disposal of medication met relevant requirements. The acting manager stated that a new member of staff had attended a course on medication (for which a certificate was available) and would observe and be observed administering medication before being assessed as competent. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 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 standard(s) 22 & 23 Arrangements for dealing with complaints and responding to allegations of abuse support the protection of service users’ rights. The proposed involvement of an independent advocate will further strengthen those arrangements. EVIDENCE: Heritage Care have produced a procedure for dealing with complaints internally. A more accessible version of the home’s Service User Guide includes information about the other agencies service users may contact if they wish to complain. The acting manager stated that she hoped that a worker from a local advocacy service would undertake some work with service users in the future. Heritage Care have also produced policies and procedures on issues such as responding to allegations of abuse and confidential reporting (whistle blowing). Staff members have received training on the protection of vulnerable adults and on how to deal with physical and verbal aggression. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 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 standard(s) 24, 28 & 30 The work that was underway at the time of the inspection should lead to an improvement in the standard of accommodation provided for service users. EVIDENCE: Since the date of the last inspection, work has started to address a number of issues relating to the premises, which had been the subject of lengthy negotiations between the landlord and the previous registered provider. One service user was keen to show the inspector his room, which had recently been redecorated in his favourite colours. Work on other areas was ongoing at the time of the inspection. The areas of the home that were inspected were reasonably clean (given the circumstances in which the inspection took place) and free from offensive odours. Service users have access to a large lounge, dining room, kitchen and conservatory. The staff ‘sleep-in’ room has been adapted to provide a snoozelum facility. The home plans to convert its garage into a single room with en-suite facilities. There is a well-maintained garden to the rear of the property. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 & 35 Staff members are well trained and are deployed in sufficient numbers to meet service users’ needs. Staff records must be kept at the home to enable the Commission to verify that recruitment practices protect service users. EVIDENCE: The rota for the week in which the inspection took place indicates that staffing levels comply with guidance published by the Residential Forum. The records for a recently recruited member of staff contained a Criminal Records Bureau disclosure but no references. The acting manager stated that these documents are held at a local office. Records indicate that staff members have received training on a wide range of subjects including advocacy, crisis & risk management, dual diagnosis, equal opportunities, person-centred planning, record keeping and team building in addition to the training provided on topics mentioned under Standards 9, 20, 23 and 42. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 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 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) 42 Service users are protected by the home’s current working practices. EVIDENCE: Records indicate that staff members have received training on fire safety, first aid, food hygiene, health & safety, infection control and moving & handling. The acting manager stated that a number of staff members are due to update their first aid qualifications. Progress regarding this issue will be checked at the next inspection. Fire tests and drills have been completed at the required frequency. Since the date of the last inspection, the home has checked that restrictors have been fitted to all windows that it feels may pose a risk and that they are in full working order. It has also taken action to minimise the risks associated with hazardous substances. The acting manager agreed to update the insurance certificate on display in the office and to forward a copy of the home’s gas safety certificate as soon as it is received. She is in the process of applying to be registered as the manager of the home. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 x 3 Standard No 11 12 13 3 Goodes Avenue x 3 x Standard No 31 32 33 34 35 Score x x 3 2 3 Version 1.20 Page 18 C51 S31787 3 Goodes Avenue V221405 190405.doc 14 15 16 17 x 3 x 3 36 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 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. 2. Standard 6 34 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 1 Good Practice Recommendations It is recommended that the home complete a more accessible version of its Service User Guide. 3 Goodes Avenue C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 Page 20 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire 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 C51 S31787 3 Goodes Avenue V221405 190405.doc Version 1.20 Page 21 - 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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