Inspection on 20/07/06 for 32a Broadgate Lane

This inspection was carried out on 20th July 2006.

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 3 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 07/02/06

32a Broadgate Lane 11/05/05

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 PE6 8NW Lead Inspector Julie Western Unannounced Inspection 20th July 2006 09:00 32a Broadgate Lane DS0000002311.V304062.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 32a Broadgate Lane DS0000002311.V304062.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. 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 32a Broadgate Lane Address Deeping St James Peterborough PE6 8NW 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) 01778 380522 www.sense.org.uk Sense East Rebecca Eva Clarke Care Home 6 Category(ies) of Sensory impairment (6) registration, with number of places 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Condition of Registration All six service users must have a learning disability and either a physical disability or sensory impairment. 7th February 2006 Date of last inspection 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 DS0000002311.V304062.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took into account any previous information held by CSCI including the homes previous inspection reports, their service history, the homes pre-inspection questionnaire and residents questionnaires sent to the home by the Commission prior to this inspection. The site inspection consisted of case tracking a sample of two residents’ records and assessing their care. Some policies and procedures were examined and some records concerning the safety of the home were also seen. Two residents and three care staff were present, one of these being the deputy manager. What the service does well: 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. 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 6 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 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 7 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): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the service. 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. 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. Although none of the current residents can interpret the written word, the Deputy Manager said that the one resident who can interpret pictures now has a video describing the home and its facilities. 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 8 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): Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the service. 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 very 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; relatives and social workers were part of the review. Each resident also had a Daily Log, which accompanied residents everywhere they went; these contained essential and up to date information. The Deputy Manager said that all care plans had now been reviewed. The home had a key worker system with two designated carers for each resident. Staff members were observed communicating the resident’s needs to them and involving them where the resident could not make informed choices. 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 9 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 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the service. There is a wide range of activities for residents to participate in and the catering arrangements reflect residents’ choices and preferences. EVIDENCE: Care plans showed that the one resident who was able to make an informed choice recently flew to Portugal for a holiday with her father, accompanied by two carers. The other five residents have just returned from holidaying in Suffolk. There was a weekly activities sheet and each resident had an individual programme of activities. These ranged from visiting the local pub for lunch to walks around the village or the local woods and beauty spots. The staff rota showed that extra staff members were available for such activities to take 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 Bourne Resource Centre, where they undertook various tasks and activities. Menus have recently been revised and were varied and balanced, with a use of fresh fruit and vegetables. Each resident’s likes and dislikes were recorded in care plans. 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. 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. 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. On the day of the inspection one resident was attending the dietician accompanied by two carers. Medication administration records were comprehensive and the latest pharmacy visit was 2/2/06; 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. The district nurse visited one resident twice daily for insulin injections; she was also available for consultation should any issues occur with the other residents. There were policies referring to death and dying and one resident had instructions to follow in the event of his death according to his religion; these were in his care plan. 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. 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: Records showed that there had been no complaints in the last 12 months. 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 Team Leader said that all staff received training on adult abuse within the home’s induction modules; in addition staff were currently sending in a questionnaire consisting of a test on adult protection procedures as part of their appraisals; staff members confirmed this. 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. The home offers a generally comfortable and homely place for residents to live, but some areas need upgrading and the refurbishment needs completing. There is a variety of equipment to aid disabled residents and the home is clean and hygienic. EVIDENCE: The home has an open plan lounge/dining area/kitchen area. Several issues identified at the previous inspection are in the process of being addressed, including the replacement of the roll-top baths and the provision of a sensory room and a quiet room. The varnish on the dining tables is still worn. All bedrooms have new blinds. 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 since bedroom doors do not have locks. 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 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 13 residents, including bed rails and hoists and there are raised signs on the walls to assist residents with a sensory impairment to identify rooms. The gardens are tidy and well tended; there is a new rope trail for residents to walk around the garden safely. 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Staff numbers are in sufficient quantity for them to be able to care for the residents. Staff members are suitably trained, qualified and competent; they undergo an induction programme before commencing their duties. EVIDENCE: The staff rota showed that there were enough staff numbers according to the staffing matrix and shifts were staggered to accommodate the needs of residents; staff confirmed that there were enough staff members on duty to complete their tasks. The most recent staff member to be interviewed said she had given two references, which were followed up, had a CRB check and had undertaken a three-day induction programme before commencing work. Staff records seen verified this. Regular quizzes were also devised for staff members, the most recent being the inspection process and fire safety. Training records showed that one carer had achieved the National Vocational Qualification at Level 2, with a further four members working towards it and the Manager and Deputy Manager were due to complete the Registered Manager’s Award. The training plan showed that recent training included moving and handling and first aid updates. The home has monthly house meetings and team leader meetings. 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The home is well run, with good leadership and guidance for staff. Record keeping is now up to date and the health, safety and welfare of residents are promoted by the use of clear policies and procedures. EVIDENCE: The registered Manager, who was not present on the day of the inspection, 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 Deputy Manager said that all policies and procedures have been revised and are now in the quiet room for all staff to have access to. The home’s policies and procedures are consistent with those of the other SENSE homes in the area. 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 16 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 X 2 4 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 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 3 X X 3 X 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 17 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 YA27 Regulation 23[2](j) Requirement The registered person must ensure that the baths are suitable and safe for the needs of the current residents. THIS REQUIREMENT IS OUTSTANDING FROM THE PREVIOUS TWO INSPECTIONS. The Deputy Manager said that new baths are currently being chosen and should be in the home within the timescale for action The registered person must ensure that the garden and grounds are well maintained. The registered person must renovate or replace the lounge carpet. Timescale for action 18/09/06 2 3 YA24 YA28 23[1](b) 23[2](b) 18/09/06 18/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 32a Broadgate Lane DS0000002311.V304062.R01.S.doc Version 5.2 Page 18 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby 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 DS0000002311.V304062.R01.S.doc Version 5.2 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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