CARE HOME ADULTS 18-65
38 Church Street Pinchbeck Spalding Lincs PE11 3UB Lead Inspector
Vanessa Gent Unannounced Inspection 12th January 2006 09:30 38 Church Street DS0000032997.V276829.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 38 Church Street DS0000032997.V276829.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. 38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service 38 Church Street Address Pinchbeck Spalding Lincs PE11 3UB 01775 711103 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) pinchbeck@btconnect.com www.sense.org.uk Sense East Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (0) registration, with number of places 38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 25/08/05 Brief Description of the Service: The home is one of a number of homes in the county operated by SENSE East. The property is owned by a housing association which has maintenance responsibilities. It is a two-storey house, located in a residential area of the village of Pinchbeck, which has a number of shops, pub, a church and other amenities, with the nearby town of Spalding providing a wider range of facilities. The home is registered to provide personal care for up to six residents between eighteen and sixty-five years of age who have a sensory impairment and/or a physical disability, and any associated conditions. The ground floor accommodates three residents in single rooms, all of which are ensuite. There is a communal lounge cum dining room. The upper storey contains three self-contained flats, each with a bedroom, lounge/kitchen and bathroom and its own front door. Access to the upper floor is by a wide staircase, with a stair lift. Outside, a secure, well-kept garden is available for residents to sit in. At the front of the house, there is a small car parking area for staff and visitors. Two minibuses are kept at the home to provide transport for all residents, one having being able to accommodate a wheelchair. 38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The main method of inspection used is called case-tracking which involves selecting a proportion of residents and tracking the care they receive through the checking of records, discussion with them, the care staff, any relatives available and observation of care practices. Four of the staff, including the deputy and acting managers were spoken with. The records and care plans of two residents were examined to ensure the health, safety and welfare of the residents is safeguarded and that residents are allowed dignity, autonomy and choice. What the service does well: What has improved since the last inspection?
Alterations, refurbishment and re-decoration of both communal and private areas of the home have taken place since August 2005. Residents’ bedrooms are decorated in colours and furnishings chosen by the residents themselves and attractively arranged to their own tastes. The laundry and manager’s office have been altered and are now, according to the manager and staff, better placed and sized to fit their purposes. 38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 6 A financial check was done in December 2005 by the owners of the home and their recommendations were put into place by the acting manager without delay, to safeguard the residents’ monies. 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. 38 Church Street DS0000032997.V276829.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 38 Church Street DS0000032997.V276829.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): 2 The home’s admission procedures safeguard the residents living in the home and any new residents admitted. EVIDENCE: New admissions do not occur often as the present residents are long-term and the home is small. However, should a new person be admitted to the home, the home has a policy whereby a pre-admission assessment would be undertaken by a representative of the home’s owners but the present acting manager or her deputy would also visit the prospective resident to ensure that the home can meet their needs and that the resident would be able to live comfortably with the residents already living in the home. 38 Church Street DS0000032997.V276829.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, 7, 9 The home safeguards the residents whilst allowing them freedom to take risks and make decisions about how they want to conduct their lives. EVIDENCE: The care plans are well-completed and comprehensive. They demonstrate, and examination of the accommodate and staff confirm, that the residents occupying the upper floor flats live as independently as possible, being allowed to take risks but also being helped to make their own decisions by discussion and support from the staff, to keep them safe. Compliment letters, received from relatives, confirm that they are aware of the contents of the care plans; they know what care the residents are receiving and they “have nothing but praise and gratitude” and “continue to be delighted with the resident’s care and progress”. 38 Church Street DS0000032997.V276829.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, 15, 17 Whilst encouraging independence and individuality, the staff ensure that the residents are assisted to maintain a healthy, active lifestyle and close family contact. EVIDENCE: Some of the residents attend a Day Centre and go out into the community, to help them develop their skills both socially and emotionally. The care plans and compliment comments seen show that family and friends are encouraged to visit and keep in close touch with their loved ones. A minibus with special equipment to hold a resident who is wheelchair bound has been purchased and adapted to enable a resident to stay with her parent. A care staff member goes with the resident to also stay at the family home to help the parent with the resident’s care, in order to maintain the family ties and contact. The menus for the ground floor residents are seasonal. Records of food intake are recorded in detail to ensure that the residents are taking an adequate and nutritious diet.
38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 11 The residents living independently upstairs are encouraged to buy, cook and eat a nutritious diet, although they make their choices and wishes themselves as to what they should and do eat. 38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Safe medication practices are in place that protect the residents from the risk of harm. EVIDENCE: The medication practices, seen as efficient and conscientious at the previous inspection, have improved still further and ensure that the residents are protected from harm or injury. 38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home has procedures in place that protect the residents and maintain a caring, happy atmosphere, free from abuse or harm. EVIDENCE: The Complaints policy is displayed publicly although no complaints have been received in the past twelve months. Relatives’ questionnaires are given out and completed regularly. Many complimentary comments have been received which state how pleased and happy all the relatives are with the care, devotion and support given by the manager and staff at the home and how well the residents are thriving. 38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The home is maintained in good order to safeguard the residents. EVIDENCE: The home has continued to have a ‘facelift’ internally, which has enabled the residents to imprint their personalities on the colours and styles of their living accommodation and has improved some communal areas. The next project in plans for the forthcoming year is to upgrade the upstairs flats and get the residents to choose their own colour schemes and furnishings. Hygiene systems are in place, in the laundry facilities and ensuite bathrooms, as confirmed in the maintenance records, to prevent the spread of infection and keep the residents safe. The home was clean and tidy. The residents in the upstairs flats are encouraged to keep their own accommodation clean and tidy. 38 Church Street DS0000032997.V276829.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): 34, 36 The recruitment and supervision procedures and practices are robust and protect the residents from the risk of harm. EVIDENCE: A new staff member had been recruited two days prior to the inspection. Her records showed, and she confirmed, that the correct procedures have been followed leading to her employment at the home and the manager has ensured that she will be supernumery until her induction has been sufficiently completed for her to work competently and confidently. Staff supervision is now conducted on a regular basis, the records for the staff files examined showed that the meetings are minuted and signed by both parties. 38 Church Street DS0000032997.V276829.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): 39, 42 The home is operated in a positive manner by a manager and staff team, with company support, that enables the staff to maintain a well run and safe home environment which incorporates the residents’ wishes and choices. EVIDENCE: Although the acting manager has only been in post for a short while, staff say they feel supported and are enthusiastic to work towards further improvements and quality care. The views of residents and relatives are obtained regularly to ensure that the residents’ wishes and opinions are taken into consideration in the running of the home. Documentation and records demonstrate that the home safeguards the interests and welfare of the residents at all times, such as in maintenance, care plans, policies and procedures, staff training and supervisions. 38 Church Street DS0000032997.V276829.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 4 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 3 12 X 13 X 14 X 15 4 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 4 X X X 3 X X 3 X 38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 19 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 38 Church Street DS0000032997.V276829.R01.S.doc Version 5.1 Page 20 - 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!
