CARE HOME ADULTS 18-65
3 Goodes Avenue Syston Leicester Leicestershire LE7 2JH Lead Inspector
Keith Williamson Unannounced Inspection 20th July 2006 09:00 3 Goodes Avenue DS0000031787.V304267.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.V304267.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.V304267.R01.S.doc Version 5.2 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 Mrs Ditta Stokes Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of registration Date of last inspection 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 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. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. This inspection took place over one weekday, commencing at 9.30am took four and one half hours to complete, and was assisted by the care staff. An opportunity was taken to look around the home, view records, policies and care plans and to talk to the service users and staff. Four of the service users were seen during the inspection however few were able to give the inspector their impressions of the home. No questionnaires forwarded to the service users in the home, their relatives and other interested professionals, have yet been returned, and have therefore not been included as part of this report. There are no privately funded service users at the home, and the cost of each placement is set by contract at £765.45 per week. What the service does well:
Service users needs are assessed prior to moving into the home. Care plans contained information as to how the care needs of the service users was to be met. Care plans are negotiated with residents in the home and are now periodically reviewed. Decision-making and autonomy is promoted in care plans, and pointers are given to staff how to promote service user choice. Sensitive information is appropriately secured. Risk assessments are in place. Health care is well monitored, with residents having the choice of visiting the General Practitioner at the surgery, or being visited in the home. Service users personal development and social inclusion is recognised in the individual care plans seen on the day with service users participating in selfcare and practical life skills to varying degrees. Meals are varied and flexible, and specialist diets are catered for, one service user having a speech and language referral. Leisure trips are organised in advance, extra staffing is arranged in advance to assist at these times. Personal support is offered on a flexible basis, care plans reflect what abilities residents have. Medication is administered appropriately. The necessary complaints procedure and policies are in place. Staff spoken with has a good awareness of the policy content and how the procedure was operated. Detailed examination of the adult protection policy indicated that sufficient information is contained in the document for staff members’ guidance.
3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 6 The environment of the home is excellent, bedrooms are individually decorated and personalised with a range of photographs and ornaments. Staff showed a good awareness of cross contamination and service user protection issues. Staff are offered a structured programme of training opportunities commencing at the point of induction Service user and staff files are stored securely. Safe working practices were evident throughout the inspection, with evidence of a number of routine tests of fire safety equipment being made on a regular basis. 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. 3 Goodes Avenue DS0000031787.V304267.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.V304267.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. The admission process is detailed and effective resulting in accurate information for prospective residents and staff, however the non-availability and lack of signatures to certain documents could detract from the quality of care. EVIDENCE: The Statement of Purpose, which sets out the latest aims, objectives and philosophy of the home, about its services, facilities, and current staffing, was not available for inspection on this occasion. This shall be looked at on the next inspection of this service. The registered manager has yet to compile a more accessible version of its Service User Guide. Service users needs are assessed prior to moving into the home. The registered manager compiles information using the health and social service assessments, providing an information base from which care plans are then produced. All case tracked service users have a contract on file; these have yet to be completed detailing the specific bedroom allocated whilst in the home, and signed by a service user or their representative. 3 Goodes Avenue DS0000031787.V304267.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents are looked after well in respect of their health, medication and personal care needs, areas of risk are assessed appropriately. EVIDENCE: The care plans and records of two service users were viewed. Care plans contained information as to how the care needs of the service users was to be met. Care plans are negotiated with residents in the home; again the service user or a representative should sign these. Decision making and autonomy is promoted in care plans, and pointers are given to staff how to promote service user choice. Sensitive information is appropriately secured. Evidence is in place to suggest care plans and risk assessments are now periodically reviewed, this was a requirement in the last inspection report. Risk assessments are in place, which details how care is to be delivered, this promotes the health and welfare of both resident and care staff. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 10 Health care is well monitored, with residents having the choice of visiting the General Practitioner at the surgery, or being visited in the home. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 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, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Service users are supported in maintaining their relationships. EVIDENCE: Service users personal development is recognised in the individual care plans seen on the day with service users participating in self-care and practical life skills to varying degrees. Social inclusion is recognised within the plan for activities, with individual pastimes. Meals are varied and flexible, and specialist diets are catered for, one service user having a speech and language referral. Throughout the inspection process, staff were observed speaking with service users in a sensitive manner, with consideration being given to the promotion of their privacy and dignity. One service user had the option of a front door key, but declined the opportunity. Leisure trips are organised in advance, extra staffing is arranged in advance to assist at these times.
3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 12 The planned introduction of Person Centred Planning (pcp’s) could further enhance the care planning and lifestyle of service users in the home; the inspector would encourage the speedy completion of this process. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 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. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents’ health and personal care needs are met on an individual basis. EVIDENCE: Personal support is offered on a flexible basis, care plans reflect what abilities residents have, plans are reviewed and updated periodically. The monitoring of residents weights is undertaken regularly, and visits from medical staff and General Practitioners is recorded, though the current recording method could be updated and individualised. Medication is administered appropriately, the staff when spoken with, showed a good awareness of administration techniques. Medication is stored securely; the administration records (mar charts) were up to date and signed appropriately. Service users spoken with on the day were not aware of the content of their care plan. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Service users are protected by the policies and procedures regarding complaints and adult abuse, produced by the home. EVIDENCE: The home has the necessary complaints procedure and policies in place. Staff spoken with have a good awareness of the policy content and how the procedure was operated. The complaints literature has been reproduced in a format other than typewritten further formats could be explored. There have been no complaints recorded since the last inspection of this service. Detailed examination of the adult protection policy indicated that sufficient information is contained in the document for staff members’ guidance on how to prevent elder abuse in the home. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents live in a homely, comfortable and clean environment. EVIDENCE: The environment of the home is excellent, though it is not known if a plan of refurbishment in place. Bedrooms are individually decorated and personalised with a range of photographs and ornaments. During the inspection the appropriate use of safety equipment was observed. The outdoor area offers a large paved and grass area though the garden area has a range of mature trees and shading, patio and garden furniture, and greenhouse. Staff showed a good awareness of cross contamination and service user protection issues. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 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. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. The number of staff employed to work in the home is sufficient in meeting residents’ assessed care needs. The recruitment process is rigorous enough to ensure resident safety. EVIDENCE: Staff are offered a structured programme of training opportunities commencing at the point of induction with a very comprehensive induction training schedule. Though documentary evidence was not seen, staff indicated the wide range of subjects addressed during induction. Staff stated they were offered the opportunity to complete the Learning Disabilities Award Framework (LDAF) 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. Staff files are stored securely and individually; the appropriate recruitment and pre-employment checks are in place so ensuring service user safety in the home. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to the service. The management approach promotes effective care practice in the home for service users’ care and protection however improvements to Quality Assurance are required to safeguard service users’ interests. EVIDENCE: The registered provider must ensure that quality assurance is introduced into the home, by issuing unidentifiable questionnaires to service users, their relatives or representatives, and visiting professionals in an effort to enable the comments to be made honestly, and so ensure service users views underpin the review and development of the home. Safe working practices were evident throughout the inspection, with evidence of a number of routine tests of fire safety equipment being made on a regular basis. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 18 Fire records were examined; a current fire risk assessment is in place. A number of other tests are performed regularly to ensure service users’ safety in the home, evidence of visiting professionals assisting in this process was seen by the inspector on the day. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 19 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 X 5 2 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 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 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.V304267.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? Yes. 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 YA39 Regulation 24 Requirement The registered person must ensure that suitable and effective quality monitoring systems are set up in the home and involve service users their representatives and interested professionals visiting the home. Timescale for action 20/09/06 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. 2. 3. Refer to Standard YA1 YA1 YA5 Good Practice Recommendations It is recommended that the registered manager compiles a more accessible version of its Service User Guide. It is recommended that the registered manager updates and makes available to staff the Statement of Purpose. It is recommended that the registered manager arrange for the service user or a representative to sign the contract between the service user and registered person. 3 Goodes Avenue DS0000031787.V304267.R01.S.doc Version 5.2 Page 21 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
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