Inspection on 07/02/06 for 32a Broadgate Lane

This inspection was carried out on 7th February 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 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 2 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 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 16th January 2006 09:30 32a Broadgate Lane DS0000002311.V278399.R01.S.doc Version 5.1 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.V278399.R01.S.doc Version 5.1 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.V278399.R01.S.doc Version 5.1 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.V278399.R01.S.doc Version 5.1 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. 11th May 2005 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.V278399.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours and was unannounced. 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 three 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, in the absence of the Manager, the Team Leader was present throughout the inspection. What the service does well: What has improved since the last inspection? Improvements to the environment have included the redecoration of all the bedrooms, including new carpets, the refurbishment of the kitchen with new cupboards and worktops, the replacement of two sofas and matching covers provided for the armchairs. In the garden, a rope trail has been installed. All the care plans have now been reviewed. Policies and procedures have now been updated. 32a Broadgate Lane DS0000002311.V278399.R01.S.doc Version 5.1 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 DS0000002311.V278399.R01.S.doc Version 5.1 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.V278399.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 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. The Team Leader said the home was still working on how to make the information accessible to residents as only one of them could understand pictures and none could understand the written word. 32a Broadgate Lane DS0000002311.V278399.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6-9 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. 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.V278399.R01.S.doc Version 5.1 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 the following standard(s): 11-17 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, chose to go to a night club occasionally, with two carers. She will also be flying to Portugal in the summer with two carers. The other five residents will holiday 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. On the day of the inspection five residents were taken shopping in Peterborough, accompanied by four carers. 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 Peterborough Resource Centre, where they undertook various tasks and activities. Menus were seen 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.V278399.R01.S.doc Version 5.1 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 the following standard(s): 18-21 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. 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 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; these were in his care plan. 32a Broadgate Lane DS0000002311.V278399.R01.S.doc Version 5.1 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 the following 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: 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.V278399.R01.S.doc Version 5.1 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 the following standard(s): 24-30 The home offers a comfortable and homely place for residents to live, but the bathrooms need to be brought up to standard as the roll-top baths are not suitable for these residents. There is a variety of equipment to aid disabled residents and cleanliness and hygiene are to a high 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 completed and the chair covers and two sofas have been replaced. The varnish on the dining tables has worn badly and the kitchen walls need repainting. The clear Perspex wall coverings in the corridors have been cleaned and all bedrooms have been redecorated and re-carpeted to a high standard. 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. Bedroom doors do not have locks. 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 32a Broadgate Lane DS0000002311.V278399.R01.S.doc Version 5.1 Page 14 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. The Jacuzzi has been taken out of the home and the room is currently being turned into a new sensory room. 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.V278399.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected. EVIDENCE: Although these standards were not fully inspected, 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. 32a Broadgate Lane DS0000002311.V278399.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 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 Team Leader said that the organisation was currently looking at how residents could be involved in the development of their homes. The home’s policies and procedures have been updated by downloading from the organisation’s website and are now consistent with those of the other SENSE homes in the area. 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. 32a Broadgate Lane DS0000002311.V278399.R01.S.doc Version 5.1 Page 17 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 3 4 3 5 N/A 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 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 X X X 3 X 32a Broadgate Lane DS0000002311.V278399.R01.S.doc Version 5.1 Page 18 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 YA24 Regulation 23 Requirement Timescale for action 04/04/06 2.. YA27 23[2][j] The registered person must arrange for the following repairs • the walls in the lounge need repainting • The varnish on the dining tables is worn The registered person must 04/04/06 ensure that the baths are suitable and safe for the needs of the current residents. THIS REQUIREMENT IS OUTSTANDING FROM THE PREVIOUS INSPECTION RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA8 YA42 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. The shelves in the office are dangerous as they are too high for staff to reach easily; a risk assessment should be conducted on these. DS0000002311.V278399.R01.S.doc Version 5.1 Page 19 32a Broadgate Lane 32a Broadgate Lane DS0000002311.V278399.R01.S.doc Version 5.1 Page 20 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. 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