Inspection on 28/02/07 for 3 Storer Close

This inspection was carried out on 28th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Storer Close 12/02/09

3 Storer Close 05/07/06

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 Storer Close 3 Storer Close Sileby Loughborough LE12 7UD Lead Inspector Ruth Wood Key Unannounced Inspection 28th February 2007 10:30 3 Storer Close DS0000062844.V331429.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 Storer Close DS0000062844.V331429.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 Storer Close DS0000062844.V331429.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 Storer Close Address 3 Storer Close Sileby Loughborough LE12 7UD 01509 815285 01509 815285 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 Sharon Bryan Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places 3 Storer Close DS0000062844.V331429.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Categories No person to be admitted to the home in categories LD or LD(E) when 5 persons in total of these categories/combined categories are already accommodated in the home 5th July 2006 Date of last inspection Brief Description of the Service: 3 Storer Close is situated in a residential area of Sileby, adjacent to the doctor‘s surgery. The home is one of two bungalows owned and operated by Heritage Care, and provides residential accommodation for up to five people with learning disabilities under or over the age of 65. The home is close to the local train station and bus service between Leicester and Loughborough. Sileby offers a good range of facilities including a library, public houses and a variety of shops. The purpose built bungalow has a large lounge/dining area, four bedrooms (one being a double) kitchen and separate utility room. Toilet and bathing facilities, suitable for people with additional physical needs are also provided. There is a large enclosed garden and patio area, fully accessible to all residents being on one level. The home has a no-smoking policy. All current residents are funded through contract with Leicester City and Leicestershire County Councils; there are no privately funded service users. 3 Storer Close DS0000062844.V331429.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a weekday between 10.30am and 1.10pm. All three residents were at home and the inspector had the opportunity to observe interaction between them and the two support workers on duty. One resident’s support plan and assessment documentation was examined and discussion was held with the support workers as to how they met that person’s needs. The inspector was able to communicate with one of the residents about their activities, using a combination of speech, sign and gesture. Fire, health and safety and medication records were also inspected. The inspector would like to thank both support workers and the three residents for making her welcome and helping with the inspection. What the service does well: What has improved since the last inspection? What they could do better: Residents are actively involved on a day-to-day basis in making choices about their lives. However a more formal system of finding out what they, their families and other people connected with the service (such as doctors or social workers) think about the service still needs to be established. The information 3 Storer Close DS0000062844.V331429.R01.S.doc Version 5.2 Page 6 gained from finding out these people’s views should then be used to review the quality of care and support provided. A report of this review should be made available to residents, their representatives and the Commission. 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 Storer Close DS0000062844.V331429.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 Storer Close DS0000062844.V331429.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 Quality in this outcome area is, good Comprehensive assessments ensure that residents’ needs and aspirations can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ assessments and support plans are kept in their bedrooms. One resident’s assessment was examined in detail and information checked with the support workers on duty. From discussion and observation the document appeared to be an accurate reflection of their needs and covered all aspects of care and support, as well as giving details of the resident’s goals and aspirations. A social worker’s comprehensive assessment was also in place. Each resident has a personalised service user’s guide which includes photographs of their room and uses pictures and simple language to covey information about the service. 3 Storer Close DS0000062844.V331429.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 Residents 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: One resident’s support plan was examined and the information checked through discussion with support workers and observation of the resident. At the beginning of the plan there was an outline of the resident’s routine written from their perspective. This offered support staff a very detailed account of how the person would like their needs met. Appropriate risk assessments were in place detailing how staff should response to any behaviour, which may be interpreted as challenging and how to avoid situations where such behaviour was likely to occur. Details of how the resident preferred to communicate appeared in the plan and this information corresponded with the methods of communication observed between the staff and the resident. Residents are involved in day-to-day decisions such as what activities to participate in and the kind of food to eat. Staff were observed giving opportunities for this kind of choice to all three residents. Residents are supported in managing their finances and records were seen detailing expenditure, which included receipts for items purchased. 3 Storer Close DS0000062844.V331429.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 Residents have opportunities to engage in leisure and community activities, are given support in maintaining links with family and friends and enjoy good, nutritious food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All three residents are now near or past retirement age and their lifestyle reflects this. Two attend a formal day care centre in Loughborough for one day per week and one of the residents said that they enjoyed this. Good use is made of the local facilities in Sileby. One resident visits the library each week; residents also visit shops and pubs with staff support and usually go out for lunch, once or twice per week. During the inspection two of the residents went into the village to do some shopping each supported by one member of staff. Residents’ leisure interests are clearly outlined in their support plan and of particular note was the information relating to family and friends and how contact is maintained in this area. One resident is accompanied to visit their family (who live some distance away) at least three times per year. This 3 Storer Close DS0000062844.V331429.R01.S.doc Version 5.2 Page 11 sometimes involves overnight stays and a high level of staff support. Social events are organised regularly in the home to celebrate residents’ birthdays and major festivals and family and friends are invited to these events. Daily routines are very personalised with residents being able to get up and go to bed when they choose; details of each residents’ personal preference is contained within their support plan. During the inspection one of the residents was asked for their input in selecting vegetables for dinner – when told what the main course was going to be they said “ I like that”. Menu records showed that a good variety of food is served with plenty of fresh produce and vegetables. Residents are involved in shopping for food and are therefore able to exercise choice at this level also. 3 Storer Close DS0000062844.V331429.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 Residents receive appropriate personal support and their health and medication needs are well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ personal care needs are very well detailed in their support plans including such information as the kind of garment people like to wear at certain times and how they like their hair washing. Information is also given as to the gender of staff that residents prefer to receive support from. Health care needs are also clearly detailed with health care appointments listed and information (such as optical prescriptions) showing that they have regular access to dental, optical and chiropody services. All residents have an annual health review by the learning disability services medical team and documentation in the file showed that residents’ medication is reviewed by their GP every 6 months. Specialist services (such as continence nurses) are accessed where appropriate. Medication is stored appropriately and medication records appeared accurate. Staff demonstrated a good understanding of the medication that residents take and said that they had received training on how to administer medication. A system is in place to assess the competency of new staff in this area. 3 Storer Close DS0000062844.V331429.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): 22,23 Quality in this outcome area is good Staff understand and respond appropriately to how residents express their views and effective systems are in place to protect them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a personal copy of the complaints procedure, written in simple language with pictures to assist understanding. There have been no complaints about the service since the previous inspection. Residents were observed to interact well with the two staff members on duty. Staff were able to explain to the inspector how residents let people know what they want. Staff said that they had received training in adult protection. They were able to discuss aspects of this with the inspector including the types of abuse that residents may be subjected to and their responsibilities to inform someone senior to them if they suspected that such incidents were taking place. Training schedules confirmed that staff had received training relating to the protection of vulnerable adults on 14th February 2007 and that training dealing with appropriate responses to behaviour which may challenge had taken place on 16th February. 3 Storer Close DS0000062844.V331429.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 Residents live in a clean, comfortable and homely 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 were clean, tidy and well maintained. Each bedroom has been decorated and furnished following consultation with the resident and they have been actively involved in picking colour schemes and furniture. Residents were also involved in choosing the décor of the communal rooms. The majority of staff have undertaken training in infection control; staff showed the inspector training documentation that they had completed. There were ample supplies of protective clothing in the home for staff when assisting residents with personal care needs. 3 Storer Close DS0000062844.V331429.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, 33, 34, 35 Quality in this outcome area is good Residents are supported and protected by well-trained staff This judgement has been made using available evidence including a visit to this service. EVIDENCE: Documentation relating to recruitment was not available for inspection as the registered manager was not on duty and recruitment records are held centrally. At the previous inspection on 4th July 2006 the manager told the inspector that all required recruitment checks are completed before staff commence work and a record of Criminal Records Bureau checks was seen. There are two staff on duty at all times and one member of staff sleeps in at the home. A formal on-call system is in place should additional staff be needed and staff members on duty said that as the majority of staff live locally there were always people available should additional help be needed. Training plans were displayed in the office and a wide range of relevant training has been made available to staff. Training received so far this year includes, dementia care for people with learning disabilities, managing epilepsy and managing challenging behaviour. Staff said that training opportunities were good; both staff on duty had also obtained their National Vocational Qualification in care at level 2 and five out of the nine staff members hold this qualification. 3 Storer Close DS0000062844.V331429.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 residents’ welfare in these areas is promoted however improvements to quality assurance are required to ensure residents’ 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 holds a National Vocational Qualification in care at level 3 and is currently undertaking a level 4 qualification together with the registered manager’s award. At the previous inspection a requirement was made that a formal quality assurance system be implemented to ensure that residents’ views inform the way the service is delivered. There was no evidence available to suggest this had been implemented, although there is on-going consultation with residents about many aspects of daily life (see Standard 7). This requirement therefore remains outstanding. 3 Storer Close DS0000062844.V331429.R01.S.doc Version 5.2 Page 17 All documents relating to fire safety, health and safety and maintenance of the environment were available for inspection and demonstrated that there is good practice in this area with regular fire tests & drills taking place and gas and electrical systems being regularly serviced. Training schedules and discussion with staff demonstrated that they had received training in First Aid, Food Hygiene, Health and Safety, Moving and Handling and Infection Control. 3 Storer Close DS0000062844.V331429.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 3 2 3 3 X 4 X 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 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 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 Storer Close DS0000062844.V331429.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 YA39 Regulation 24 Requirement 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 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 3 Storer Close DS0000062844.V331429.R01.S.doc Version 5.2 Page 20 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. Extracts may not be used or reproduced without the express permission of CSCI 3 Storer Close DS0000062844.V331429.R01.S.doc Version 5.2 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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