Inspection on 11/05/05 for 32a Broadgate Lane

This inspection was carried out on 11th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

32a Broadgate Lane 04/07/07

32a Broadgate Lane 20/07/06

32a Broadgate Lane 07/02/06

32a Broadgate Lane 09/03/05

32a Broadgate Lane 18/05/04

Similar services:

Applegarth

Thornham Grove

Hunter`s Lodge

Conifer Lodge

Manor Court

92 Black Prince Avenue

Agnes House

The Manor House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 32a Broadgate Lane Deeping St James Peterborough Cambridgeshire PE6 8NW Lead Inspector Julie Western Unannounced 11 May 2005 09.30 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. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 32a Broadgate Address Deeping St James Peterborough PE6 8NW 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) 01778 380522 n/a n/a Sense East Rebecca Eva Clarke Care Home 6 Category(ies) of Sensory Impairment (SI) - 6 registration, with number of places 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: All six service users must have a learning disability and either a physical disability or sensory impairment. Date of last inspection 09/03/05 Brief Description of the Service: 32a Broadgate Lane is a purpose-built, single storey specialist care home for six adults with sensory, learning and physical disabilities. On the day of the inspection the home was fully occupied. The home is situated in a residential area in the village of Deeping St. James in South Lincolnshire and is 8 miles equidistant from Peterborough, Bourne, Stamford and Spalding. There is a garden to the rear of the property, with sensory areas and pathways for wheelchairs, and space for car parking to the front. The building is owned and partly maintained by South Kesteven District Council. The service users in the home are very dependent and some of them have lived in the home since it opened in 1996. The home is one of a number of homes in the Deepings area, which is managed by SENSE East. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4 hours and was unannounced. The Manager of the home was present throughout the inspection and attended a review meeting of one of the residents during the inspection. A partial tour of the building took place and care records were inspected. The main method of inspection used was called ‘case tracking’; this involved selecting four residents and tracking the care they received through the checking of their records, discussion with them, the care staff and observation of practices. Some policies and procedures were examined and records concerning the safety of the home were also seen. Two members of staff were spoken with and two visitors and a social worker attending the review meeting were also interviewed. One service user was observed communicating with his carer. What the service does well: What has improved since the last inspection? The relatives said that the home had improved a great deal since the arrival of the new Manager and that her style of communication was open and honest, giving them confidence that the needs of their resident were being met. Relatives are now invited to all reviews. Two of the care plans have been reviewed and are more concise. Policies and procedures are in the process of being updated. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 6 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. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 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 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 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, 2,3,4 The home clearly sets out what it intends to provide for its residents and the procedures support staff in enabling a smooth transition into the home on admission. Residents have an opportunity to visit the home before moving in on a permanent basis. EVIDENCE: 32a Broadgate has a statement of purpose and there was a copy of the service user guide in each resident’s room. The Manager described the most recent admission to the home and care plans showed that there had been many transition meetings to enable effective planning and co-ordinating of the process. An admissions officer based at headquarters managed all admissions to the home. All present residents had come either from an education setting or transfer from another SENSE home and therefore a great deal of information from other agencies was available. Some discussion was held about the ability of the present residents to understand the guides and the Manager said the home was currently working on how to make the information accessible to them as only one of them could understand pictures and none could understand the written word. Care plans had individual risk assessments tailored to each resident. Relatives spoken with said they were very happy with the information given them and felt that the guide was useful for them. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 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) 6,7,8,9 The care plans are in enough depth and detail to allow staff to care for the individual needs of residents safely. Every effort is made to enable residents to be involved in the daily routines in the home. EVIDENCE: Care plans seen had comprehensive assessments, including risk assessments and achievement forms, which clearly detailed goals identified or attained. They were reviewed formally every six months and revised accordingly. Each resident also had a Daily Log, which accompanied residents everywhere they went; these contained essential and up to date information. The Manager had reviewed two of the care plans and was in the process of reviewing the other four to make them easier to read. During the inspection a review took place for one of the residents; this involved the Social Worker and two relatives. All said that the staff members were good at communicating the resident’s needs to them and involving them where the resident could not make informed choices. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 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) 11,12,13,14,17 There is a wide range of activities for residents to participate in and the catering arrangements reflect residents’ choices and preferences. EVIDENCE: Staff spoken with said that the one resident who was able to make an informed choice, had chosen to go to a night club with two carers. There was a weekly activities sheet and each resident had an individual programme of activities. These ranged from visiting the local pub to walks around the village or the local woods and beauty spots. The staff rota showed that extra staff members were available at weekends when these activities took place. Three residents could access media such as television, radio and music. During the week one resident went to the main SENSE resource centre and five went to the Peterborough Resource Centre, where they undertook various tasks and activities. The relatives said that all six residents were going to a SCOPE bungalow in Skegness on a holiday arranged by the home. Menus were seen and were varied and balanced, with a use of fresh fruit and vegetables. The relatives said the food was very good and compared it favourably with the food served at a previous home. Each resident’s likes and dislikes were recorded in care plans. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 11 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) 18,20,21 The health needs of residents are met, with good communication between the home and health care services. Residents are treated with respect for their wishes when dying. The medication arrangements ensure that prescribed medication is safely administered and monitored. EVIDENCE: Each resident had a Health Log, which recorded visits to the local dentists, GP’s and hospital appointments. They also recorded weight records and medication records. Medication administration records were comprehensive and the latest pharmacy visit was seen; any issues from this had been addressed. No resident was currently able to self-medicate. Homely remedies were used according to the policy. The Boots system of medication was used for all resident and staff members said they received regular training on medication. There were policies referring to death and dying and one resident had instructions to follow in the event of his death; these were in his care plan. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 12 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 There are robust procedures for managing complaints or allegations of abuse and staff members are clear on the action to take in the event of this occurring, ensuring that residents are safe. EVIDENCE: The organisation has developed a comprehensive policy and procedure in relation to adult abuse, which includes reference to ‘raising concerns at work’. The home has a policy, which is linked to the Local Authority Adult Protection procedures. The relatives were aware of how to make a complaint either to the home directly or about the home to Headquarters or to other agencies. The Manager said that all staff received training on adult abuse within the home’s induction modules and staff spoken with confirmed this. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 13 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) 24,25,26,27,28,29,30 The home offers a comfortable and homely place for residents to live, but some work is needed to bring the communal areas up to the standard of the residents’ rooms; in particular, the kitchen area and bathrooms. There is a variety of equipment to aid disabled residents and cleanliness and hygiene are to a good standard. EVIDENCE: The home has an open plan lounge/dining area/kitchen area and a quiet room which doubles as a sensory room. The upgrading to the kitchen area has been outstanding for the last three inspection reports but is due to commence this month. The corridors have recently been redecorated but clear Perspex wall coverings designed to protect the walls from wheelchair marks give an institutional feel to the home and are scuffed and marked with previous paint on the inside. Chair covers in the lounge are worn. The standard of decoration in residents’ rooms is generally good, with two of the rooms having been recently decorated. Three rooms have hospital beds. Rooms are well personalised, one having a door bell which activated a sensory machine to alert the resident to callers. All doors have locks. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 14 The baths are not suitable for the needs of the current residents, being of a Victorian roll-top design and too high for residents to get in and out of comfortably and safely. Only one current resident is able to use the bath, the remaining five having showers. The home has two showers with shower trolleys. The premises are generally clean and safe, with all dangerous cleaning substances kept locked away. The laundry has one industrial washer with a sluice programme and one industrial dryer. There is equipment throughout the home to meet the physical needs of residents, including bed rails and hoists. There are raised signs on the walls to assist residents with a sensory impairment to identify rooms. There is a ‘quiet room’, which is used as a sensory room. The gardens are tidy and the Manager has plans to include a sensory garden with a roped walkway. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 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) 31,32,33,34,36 There are sufficient staff numbers on duty to meet the needs of residents, with additional staff available for when there are activities needing more assistance. There is a good training programme, which enables the staff to carry out their role effectively. EVIDENCE: The staff rota showed that there were adequate staff numbers on duty. There was one less staff member on duty at weekends, as on resident went home every weekend, but additional carers were available if there was an activity requiring more staff. An on-call member of senior management was always available. Staff members spoken with said they had undergone a thorough recruitment procedure including application forms, interviews, processing of references, CRB checks and an induction programme. The staff group is stable, with one 28-hour vacancy for a support carer. One staff member has NVQ at Level 2 and six staff members are currently working towards this qualification. One staff member said her recent training had included diabetes and management of gastronomy tubes. The Manager said that all staff undertook an examination on Sign Supported English six months after commencing employment. Staff training was either in-house or externally with SENSE at the Deeping Community Centre. Training records showed that most statutory training was 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 16 on a rolling basis, with medication training being the last to be undergone. The minutes of the most recent staff meeting, which was held on 26/4/05, were on the office notice board, along with the programme of meetings for the whole year and the agenda for the next meeting. Staff members confirmed that they had supervision every two months and the Manager had supervision with the Regional Manager. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 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 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) 37,38,39,40,42 The home is well run, with good leadership and guidance for staff. Some work is still needed to ensure that the record keeping is kept up to date. The health, safety and welfare of residents are promoted by the use of clear policies and procedures. EVIDENCE: The registered Manager has a Post Graduate Diploma in Art Therapy and has twelve years’ experience in a hospital setting with residents with learning disabilities. She is currently working towards the NVQ Registered Manager’s Award in Management. Staff commented that they found her to be very supportive. The Manager acknowledged that obtaining views from residents who were deaf blind, or with other learning difficulties, was very hard and the organisation was currently looking at how residents’ could be involved in the development of their homes. Recently relatives have been invited to reviews and their views 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 18 have been sought. The relatives spoken with said that they thought this was a very good idea. The annual Audit Action Plan dated June 2004 was very comprehensive. The home has a set of policies and procedures which the Manager and deputy Manager are currently updating by downloading from the organisation’s website. The home’s maintenance, fire, servicing and environmental health records were up to date, along with policies on Health and Safety, COSHH and water temperatures. The hydrotherapy pool has been closed and, it is thought, will be removed from the home for reasons of upkeep and safety. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 N/A Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 2 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 32a Broadgate Lane Score 3 x 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x 3 x C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 20 1,2 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 YA24 Regulation 23 Requirement The registered person must make the following repairs;upgrading of the kitchen area and renwal of worn covers to chairs and sofas in the living area. THIS REQUIREMENT HAS BEEN OUTSTANDING FOR THE LAST 3 INSPECTIONS. AN EMAIL FROM HEADQUARTERS SHOWED THAT THE KITCHEN WAS BEING UPGRADED THIS MONTH. The registered person must ensure that staff members records contain an up to date photograph. RECORDS SHOWED THAT THIS REQUIREMENT WAS BEING ACTIONED. The registered person must ensure that the baths are suitable and safe for the needs of the current residents The registered person must review the suitablility of the perspex wall covers in the corridors. Timescale for action 7th July 2005 2. YA41 19 7th July 2005 3. YA27 23[2][j] 7th July 2005 7th July 2005 4. YA28 23[2][a] 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 21 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 YA8 Good Practice Recommendations It is a recommendation that the home continues to look at ways of consulting and obtaining the views of residents with sensory disabilities and of providing a service user guide which is meaningful. 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unity House, The Point Weaver Road Lincoln LN6 3QN 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 32a Broadgate Lane C53 C04 S2311 32a Broadgate Lane V225720 110505 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!