Inspection on 04/07/07 for 32a Broadgate Lane

This inspection was carried out on 4th July 2007.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

32a Broadgate Lane 20/07/06

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 Key Unannounced Inspection 4th July 2007 09:30 32a Broadgate Lane DS0000002311.V340377.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.V340377.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.V340377.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 rebecca.clarke@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Rebecca Eva Clarke Care Home 6 Category(ies) of Sensory impairment (6) registration, with number of places 32a Broadgate Lane DS0000002311.V340377.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. 20th July 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.V340377.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took into account any previous information held by CSCI including the home’s previous inspection reports, its service history, any preinspection questionnaires completed by the Manager and any residents’ questionnaires sent to the home by the Commission prior to the inspection. The site inspection was unannounced, took place over three hours and consisted of tracking a sample of residents’ care records and assessing the care given. Some policies and procedures were examined and some records concerning the safety of the home were also seen. Although the residents could not communicate verbally, they were observed interacting with staff and five care and ancillary staff members were spoken with. In the absence of the manager, the area manager was present for the inspection. At the time of the inspection the home confirmed that the weekly fees ranged from £1794 to £2051, depending on the assessed needs of the resident. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report is available in the manager’s office. What the service does well: What has improved since the last inspection? The sensory room has been completed and residents are able to use it for relaxing or stimulation. 32a Broadgate Lane DS0000002311.V340377.R01.S.doc Version 5.2 Page 6 A new Parker bath has been purchased and benefits both staff and residents, as it is easy to access. Closer liaison with the day centre has enabled better communication and ensures that there is a continuity of care for residents. 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. The summary of this inspection report can be made available in other formats on request. 32a Broadgate Lane DS0000002311.V340377.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 32a Broadgate Lane DS0000002311.V340377.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service and their families have good information about the home in order to make an informed decision about whether the home is right for them. EVIDENCE: The home has a statement of purpose and there was a copy of the service user’s guide in each resident’s room. Care plans showed that there had been many transition meetings to enable residents to move into the home with a minimum of disruption to them. An admissions co-ordinator based at headquarters managed all admissions to the home. All present residents had either come from an education setting or a transfer from another SENSE home and therefore a great deal of information was available from other agencies. Although none of the residents can interpret the written word, the one resident who can interpret pictures has a video describing the home and its facilities. 32a Broadgate Lane DS0000002311.V340377.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 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are involved in developing their own care plans and these give a clear picture of their needs. The staff group meets these needs with sensitivity and regard for residents’ privacy and dignity. EVIDENCE: Care plans had very comprehensive assessments of how the needs residents were to be met, including risk assessments and achievement forms, which clearly identified goals. They were reviewed formally every six months and revised accordingly; relatives and social workers were part of most reviews. Each resident also had a daily log; this accompanied the resident everywhere they went and contained essential and up to date information. The home had a key worker system with two designated carers for each resident. Staff members were observed communicating with residents sensitively and with regard for their dignity, allowing them choices wherever possible. 32a Broadgate Lane DS0000002311.V340377.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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this 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 residents had weekly activities sheets and each resident had an individual programme of activities. These ranged from visiting the local pub to walks around the village or to local places of interest. On the day of the inspection some residents were going swimming and others were going to the local resource centre run by SENSE. Three residents could access media such as television, radio and music. The home had a sensory room. Menus showed that residents had a choice of meals from a balanced and varied diet and residents’ likes and dislikes were recorded in care plans. On the day of the inspection a resident was seen clearly to show a dislike for bananas at breakfast time and this was skilfully and sensitively managed. 32a Broadgate Lane DS0000002311.V340377.R01.S.doc Version 5.2 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. 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 available evidence including a visit to this service. The health care needs of residents are met, with good communication between the home and health care services. EVIDENCE: Each resident had a health log, which recorded visits to the local GP’s, dentists and hospital. They included weight and medication records. Medication records were comprehensive and the Boots system of medication was used; the latest pharmacy visit was 6/6/07 and any issues from this had been addressed. The morning medication round was observed and was carried out by two carers. The area manager confirmed that all staff members had received medication training twice in the last year and medication training was also part of the induction process. The district nurse visited on resident twice daily for insulin injections; she was also available for consultation should any issues occur with the other residents. 32a Broadgate Lane DS0000002311.V340377.R01.S.doc Version 5.2 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. 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 available evidence including a visit to this service. The complaints procedure is clear and gives residents and their supporters the confidence that comments and complaints will be listened to. Residents are kept safe from harm by clear policies and procedures or allegations concerning safeguarding adults and staff members are clear on the action to take in the event of this happening. EVIDENCE: The area manager said that there had been no complaints since the last inspection. Staff members spoken with said they had received annual training in safeguarding adults and records confirmed that all staff received training on adult protection issues within the homes induction modules. In addition staff completed a test on adult protection procedures as part of their appraisals; staff members confirmed this. 32a Broadgate Lane DS0000002311.V340377.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers a generally comfortable and homely place for residents to live, but the lounge area shows signs of wear. There is a variety of equipment to aid residents with a disability. EVIDENCE: A tour of the building showed that it was in a good state of repair internally and externally. The area manager acknowledged that the lounge carpet and the chair covers were stained in places. The home has an open plan lounge/dining area. The kitchen and bathroom areas were clean and hygienic. The environmental health officer visited the home in May 2007 and awarded the home five stars in their system for food hygiene. Since the last inspection a new bath has been provided which staff said made bathing easier for staff and more enjoyable for residents. The area manager said that forthcoming plans for maintenance included the provision of a second new bath. There is 32a Broadgate Lane DS0000002311.V340377.R01.S.doc Version 5.2 Page 14 also a wet-room style shower. Residents’ rooms were well personalised and there was equipment throughout to meet the needs of residents, including bed rails, hoists and raised signs on the walls to assist residents, all of whom have a sensory impairment, to identify rooms. The front gardens were well tended but the rear gardens were overgrown in places and the lawn needed mowing. Although there is a path around the garden for residents to walk around it in safety, there are no special areas of interest for residents with sensory impairments to enjoy. 32a Broadgate Lane DS0000002311.V340377.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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this 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. EVIDENCE: The staff rotas showed that there were enough staff members to meet the needs of the residents. Staff members spoken with said they had enough time to complete their tasks and observations on the day showed that five members of staff were on duty at breakfast time, which was the busiest time of the day. The area manager said that the recruitment of new staff in the area was still difficult, but that there were no current vacancies. Two staff files were examined; they contained recruitment and induction procedures, including criminal records bureau and protection of vulnerable adults checks. Training records showed that six members of staff had achieved the NVQ, a nationally recognised qualification at level 2 with a further two working towards it. The deputy manager had achieved the NVQ at Level 4 in care management. Regular quizzes were devised for staff members to refresh 32a Broadgate Lane DS0000002311.V340377.R01.S.doc Version 5.2 Page 16 training issues such as fire training, moving and handling and safeguarding adults. The area manager said that additionally, several staff members had the nationally recognised CACPD, a specialist training in sensory impairment. The home has monthly staff meetings and team leader meetings. 32a Broadgate Lane DS0000002311.V340377.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, safety and welfare of the residents are promoted. The views of residents and their supporters are listened to. EVIDENCE: The registered manager, who was not present on the day of the inspection, has a Post graduate Diploma in Art Therapy and has thirteen years’ experience in a hospital setting with residents with learning disabilities. She has the Registered Manager’s Award in management, a nationally recognised qualification, and is working towards the RMA in care. Staff members said they had confidence in the manager and that she was approachable and accessible. Most of the staff had worked in the home for a long time and felt valued and supported. 32a Broadgate Lane DS0000002311.V340377.R01.S.doc Version 5.2 Page 18 The home has a set of policies and procedures consistent with those of the other SENSE homes in the area and these are well maintained. The home has a quality assurance system and takes part in a annual quality audit involving the funding authority and relatives/advocates of the residents. The results of the audit are then acted upon at local level. An annual development plan is completed by the manager and the staff group; this enables staff members to become involved in the plan. 32a Broadgate Lane DS0000002311.V340377.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 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 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 4 X 3 X X 3 X 32a Broadgate Lane DS0000002311.V340377.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? none 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 231(b) Requirement The registered person must ensure that the garden and grounds are well maintained. The registered person must attend to the following: 1] the stained lounge carpet. 2] the stained/worn chair covers Timescale for action 29/08/07 2. YA28 232(b) 29/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations Residents would benefit from raised beds in the garden, planted with flowers to stimulate the senses of smell and touch. 32a Broadgate Lane DS0000002311.V340377.R01.S.doc Version 5.2 Page 21 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 32a Broadgate Lane DS0000002311.V340377.R01.S.doc Version 5.2 Page 22 - 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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