Inspection on 23/08/06 for 38 Church Street

This inspection was carried out on 23rd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

38 Church Street 12/01/06

38 Church Street 25/08/05

38 Church Street 16/03/05

38 Church Street 09/06/04

38 Church Street 09/01/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 38 Church Street Pinchbeck Spalding Lincs PE11 3UB Lead Inspector Moya Dennis Key Unannounced Inspection 23rd August 2006 11:50 38 Church Street DS0000032997.V308028.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 38 Church Street DS0000032997.V308028.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. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 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.V308028.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: The home is one of a number in the county operated by SENSE East. The property is owned by a housing association, which has maintenance responsibilities. It is 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. Three residents live in single en suite rooms downstairs. There is a communal lounge and dining room. There are three self-contained flats upstairs, each with a bedroom, sitting room/kitchen and bathroom. There is a stair lift to the upper floor. The secure garden at the back is unkempt and not accessible to all residents at present. There are plans to landscape it; install raised beds and ramps to enable all residents to enjoy the garden. There is a small car parking area for staff and visitors at the front of the house. The home has two minibuses, one accommodating a wheelchair, to transport residents to local activities. 38 Church Street DS0000032997.V308028.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 undertaken using a review of all the information relating to the home and by visiting the premises. The inspection was unannounced, conducted by one inspector and took place over one and a half hours. The main method of inspection was case tracking, which is tracking the care received by selected residents. The care plans and records of two residents were examined and general care practices observed. The acting manager was present during the inspection, plus deputy manager and one care worker. Staff were very positive about working in the home and praised the teamwork and supportive atmosphere. Only two residents were present, one ill in bed and unable to take part in the inspection. No requirements or recommendations were made. What the service does well: What has improved since the last inspection? Residents’ rooms are being redecorated and they have chosen new furniture. The communal lounge has recently been decorated and new dining furniture is on order to replace the worn tables and chairs. The back garden is to be renovated and made accessible to all residents. The acting manager has further improved the personal documentation for residents. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 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. 38 Church Street DS0000032997.V308028.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 38 Church Street DS0000032997.V308028.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s admission procedures safeguard the residents living in the home as well as new residents. Applicants are encouraged to visit the home before moving there. Every resident is given a written statement of purpose. EVIDENCE: The present residents have been at the home for some time and new admissions are infrequent. Staff would visit any prospective resident to assess their physical and social care needs. No resident would be accepted as an unplanned or emergency admission. Relatives would be informed in writing that the home could meet all assessed needs. The home encourages prospective residents and their family and friends to visit the home and meet the other residents before deciding to move there. An individual contract is drawn up between Sense and the sponsoring authority. Copies are made available to residents or their supporters on request. Every resident is given a copy of the home’s statement of purpose and terms and conditions within the home. 38 Church Street DS0000032997.V308028.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9. Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Residents’ needs and personal goals are reflected in comprehensive care plans. They are supported to make decisions and consulted on all aspects of life at the home. They are able to take risks and live as independently as possible. EVIDENCE: The acting manager has improved the individual plans for each resident. These plans cover all aspects of personal, social and medical support needs. Some residents have limited communication skills and alternative communication methods are included in the plans. Staff are trained to use British Sign Language (BSL) and work to compile lists of words that residents are able to use. Families are fully involved in plans and attend monthly review meetings. The home does not hold residents’ meetings but residents are able to communicate their wishes and preferences on a day-to-day basis. Three residents are able to articulate their views; three are able to do so using signs, expression or gestures. During inspection staff explained how residents had 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 10 made individual choices. Relatives’ observations and comments about a resident’s care are recorded in daily logs or comment book. Any major changes would be reflected in the care plan. The acting manager confirmed that there is a good working relationship with families and they are able to influence key decisions in the home on behalf of residents. Feedback from families was not available for this inspection but past reports confirmed their satisfaction with the service offered. Residents take part in activities outside the home and are encouraged to live as independently as possible, including cooking their own meals. Risk assessments are completed as necessary. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 11 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): 11,12,13,14,15,17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff support residents to be independent and take part in appropriate activities in the local community. Families are encouraged to take part in any decision-making processes affecting residents. Residents enjoy a balanced diet. EVIDENCE: Residents are encouraged to develop new skills and improve existing ones. Examples may be basic literacy, assertiveness or social skills. Goals are agreed in care plans and progress is recorded. Some residents attend a day centre and take part in age, peer appropriate activities. Some residents prefer to go into the local area independently, shopping or sightseeing. Residents are encouraged to maintain their interest in activities they previously enjoyed and some have painted pictures for the home or plan to be involved in future building work. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 12 All residents enjoy some form of leisure activity outside of the home. Bowling, swimming, petting farms and hydrotherapy are popular choices and some residents enjoy the theatre, entertaining friends and karaoke. Residents spend time with their family during closure times at the home. Care staff accompany some residents; others are able to make the journey alone. Relatives and friends are welcome at the home and they are encouraged to be fully involved in daily routines, with the resident’s permission. They can choose to have visitors in their room, in private. Residents have the opportunity to make friends from other sources, away from the home. Staff receive training on sexual awareness, covering relationships and other issues likely to be met by young residents. During the inspection staff were seen interacting appropriately with the one service user present. Before entering a resident’s room, the manager assured the inspector that the resident had given her permission to show people round. Some residents are able to shop and cook their own meals. They are encouraged to discuss their choices to ensure they have a balanced diet. The home has a four-week menu, compiled by residents, reflecting their likes, dietary needs and any food intolerances. The menu was about to be changed at the time of inspection. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 13 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): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents have access to appropriate aids and equipment and their health needs monitored. Residents are encouraged to administer their own medication. Residents are supported to deal with the illness and death of other residents. EVIDENCE: Residents have access to hoists, slings and bath aids necessary for safe moving and handling practice. The equipment is kept within their room and care has been taken to minimise their visual impact. Staff receive full training as part of induction on using these aids. The health of residents is continually monitored to identify potential complications. Weight, dietary and fluid intake is recorded. Currently, only one resident is able to self medicate. This has been risk assessed and the resident provided with a lockable cabinet in which to store the medication. The resident maintains a medication chart, which they show to the manager, providing an effective monitoring process. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 14 Some residents have life limiting illnesses. Staff had discussed at a staff meeting on the day of inspection the impact the death of a resident could have on those less able to express their feeling. Recent developments prompted the manager to discuss these issues at a level residents felt comfortable with. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s complaint procedure is clear and protects the residents and all incidents are recorded. EVIDENCE: One complaint had been received since the last inspection. This related to the fabric of the building and was recorded appropriately, responded to and concluded within days. The home notified the commission of two incidents, both instances of human error, which were handled with appropriately. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home is safe, comfortable, well maintained and free from odour. EVIDENCE: The home is in a residential area and indistinguishable from those around it. Ramps give easy access to all, including wheelchair users. Further redecoration and refurbishment was taking place in the home. Several rooms were being repainted and furnished to residents’ tastes. The home was clean and there were no detectable odours. There were handwashing facilities in the laundry, kitchen and bathrooms, with no communal soap or towels. Discussions with staff identified that good working practices were integral to daily routine and further minimised the risk of infection 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 17 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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are supported by well-trained staff with knowledge of their specific needs and protected by the home’s recruitment policies. EVIDENCE: The inspector spoke to three members of staff during the inspection, including the acting manager. All had many years experience of caring for the particular client group and were able to explain, in detail, the needs of individual residents. One told the inspector of the need to understand that verbal aggression was another way of communicating need or frustration. Records of staff training are clear and it was easy to identify which members of staff had attended courses. Currently, three staff members have achieved National Vocational Qualification (NVQ) awards, one has almost completed and two others are about to start the course. The acting manager has recently completed the Registered Managers Award (RMA). Two new staff members had been recruited. Their records demonstrated that correct procedures were followed. All necessary checks had been completed and staff received thorough, documented induction. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 18 Staff training needs are identified and agreed during annual appraisals. Staff told the inspector that they had received mandatory training and more specialist courses, such as working with families, sexual awareness and BSL. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 19 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): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The acting manager provides strong leadership to the staff team. Residents are able to give feedback as part of daily routine. Close monitoring of working practices safeguard the health, safety and welfare of residents, staff and visitors to the home. EVIDENCE: The acting manager has been in post since October 2005. She has many years’ experience of working within care settings. She has recently completed the Registered Managers Award and will be applying to the Commission for Social Care Inspection, [CSCI] to become the registered manager. She has improved the written aims of the home and ensured that these are achieved and that policies and procedures are fully implemented. The acting manager has an ‘open door’ policy for staff, residents and visitors. Staff confirmed that this system worked well and any issues raised were 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 20 addressed as soon as possible. The outcomes were always fed back to the appropriate people. Although neither of the residents present during the inspection was able to give their views, the acting manager confirmed that families were asked, as advocates, for input about the running of the home. No formal residents meeting were held as the domestic nature of the home encouraged ongoing dialogue. The acting manager told the inspector that three residents routinely came to her to tell her about their day and she ensured that she spent an equal amount of her time with the three residents less able to articulate their wishes. Staff promote a total communication environment that encourages residents to develop communication skills. Staff told the inspector that they had been trained in the use of methods such as body language, sign language, hands-on signing and Braille. Individual care plans also identified how residents expressed likes and dislikes. Health and safety records evidenced that fire safety equipment is regularly tested. Staff received regular mandatory training, such as fire safety, manual handling and infection control. Ongoing maintenance programmes, thorough care plans, policies and procedures, staff training and regular supervision protected the interests and welfare of residents at all times. 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 21 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 3 5 3 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 3 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 4 4 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 4 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 4 3 X 3 X X 3 X 38 Church Street DS0000032997.V308028.R01.S.doc Version 5.2 Page 22 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. 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.V308028.R01.S.doc Version 5.2 Page 23 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.V308028.R01.S.doc Version 5.2 Page 24 - 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!