Inspection on 25/08/05 for 38 Church Street

This inspection was carried out on 25th August 2005.

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 23/08/06

38 Church Street 12/01/06

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 Lincolnshire PE11 3UB Lead Inspector Vanessa Gent Unannounced 25 August 2005 @ 10.00 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 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 Stationary 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 C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 38 Church Street Address 38 Church Street Pinchbeck Spalding PE11 3UB 01775 711103 01773 711103 stellaarcher@sense.org.uk Sense East Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) YA 6 Category(ies) of Learning Disability - 6 registration, with number of places 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16/03/05 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 and other amenities, with the nearby town of Spalding providing a wider range of facilities. The ground floor accommodates three service users in single rooms, one of which is ensuite. There is also a communal toilet and a bathroom, as well as the staff sleep-in room, office, kitchen, laundry, lounge and dining room. The upper storey contains three flats, each with a bedroom, lounge/kitchen and bathroom and its own front door. Access to upstairs is by stairs with a stair lift. Outside, a secure, well-kept garden is available for service users to sit in. At the front of the house, there is a small car parking area for staff and visitors. The home is registered to provide personal care for up to six service users between the ages of eighteen and sixty-five years of age who have a sensory impairment and/or a physical disability, and any associated conditions. Two minibuses are kept at the home to provide transport for all service users. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 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 service users and tracking the care they receive through the checking of records, discussion with them, the care staff and observation of care practices. Two service users’ care plans were examined. Three of the six residents were communicated with as well as speaking with the acting manager and deputy manager. Two of the four staff on duty were interviewed and their records examined. What the service does well: What has improved since the last inspection? What they could do better: No requirements were set at this inspection. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 Page 6 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 C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 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 standard(s) 3, 5 The acting manager and staff communicate well with the service users to provide them with a happy and safe environment, appropriate to their needs and wishes. EVIDENCE: Staff have all learned to ‘sign’ to help them communicate effectively with the service users who have hearing and speech disabilities. This was put to good effect with staff and service users having a good rapport: laughing and ‘chatting’ easily. Specialist equipment is in use around the home, with assessments and risk assessments for each item clearly described in the care plans to ensure the home can meet the needs of the service users it admits. The terms and conditions contract is kept in the service user’s personal records; it is clearly written and shows a highlighted picture plan of the room in relation to the house and the number of the room occupied. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8 Service users are encouraged and supported to make their wishes known and participate fully in all aspects of life at the home. EVIDENCE: The care plans are comprehensive documents – well-completed, clear and concise, showing a good overview of the lives of the service users in the home. There is evidence of involvement in the annual reviews and of a relative in the care of a service user although signatures of the service user or representative were not seen. A service user, spoken with through signing interpretation, communicated that she knew about her care plans. The service user indicated that full choice and participation is encouraged by staff, as seen by the choosing of colours and furniture for the re-decoration and refurbishment of the home to commence immediately following the inspection, and the assessments for individual specialist equipment in the care plans. Service users who are able, shop for their own food and personal items in the village, with the assistance of staff. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 16 Service users are given as much independence, choice and encouragement to participate in activities as their disabilities allow, with staff support and the aid of appropriate equipment. EVIDENCE: Clear recording in the care plans show that independence, choice and participation is encouraged in all aspects of the service users’ lives at the home and within the community. An adapted vehicle has been ordered and paid for by Sense East to take a wheelchair to enable service users with restricted mobility to go on outings and not feel isolated. Service users spoken with indicated that they are happy with the staff support provided and can do what they want within their limitations. Care plans show that risk assessments and consultation with healthcare professionals are in place to provide appropriate specialist equipment to ensure that the service users are able to participate in activities such as education, leisure, holiday and community facilities. The service users’ daily routines and needs are described and risk assessed in detail, covering every aspect from getting up till bedtime, to enable staff to 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 Page 11 cater for their needs appropriately. There was evidence in the care plans of involvement in community activities. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 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 standard(s) 18, 19, 20 Service users are well-supported in their personal, health and emotional welfare by staff who are, in turn, supported by healthcare professionals and the acting manager to ensure the service users’ needs are met. EVIDENCE: The care plans and case-tracking show clearly that service users are wellsupported in all aspects of their personal and healthcare needs. Contact with healthcare professionals is evident. One consultant physician wrote “I have always been very impressed with the high quality of staff that you have looking after (the service user).” The consultation and involvement of specialist therapists is documented, including the diabetic nurse, speech and language, physio and behaviour therapists, as well as dentist, optician and chiropodist. The practice of medication administration is excellent, with the service user being supported to assist in the process as much as possible. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 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 standard(s) 23 Measures are in place to protect the service users from harm or abuse and they are relaxed and comfortable with the staff. EVIDENCE: All staff are booked on a course for the awareness and prevention of adult abuse. New staff confirm that this subject is also covered in the comprehensive induction given. Staff meetings and staff supervisions are held monthly and documented and staff say that the acting manager supports them and they can talk to her about any concerns. The inspector was unable to fully communicate with the service users about their feelings but they laughed a good deal, seemed at ease in the presence of staff and the acting manager and their expressions were cheerful when ‘chatting’ in ‘sign’ to staff, laughing and responding enthusiastically. One service user has regular visits from her family who liaise frequently with staff, as recorded in the care plans, to ensure that staff carry out appropriate procedures to maintain the service user’s health and welfare and protect her. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 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 standard(s) 26, 29 The service users’ accommodation is personalised, adapted and equipped to suit their needs and tastes. EVIDENCE: All service users living downstairs have single rooms, one is ensuite; the service users living in the flats upstairs have keys to their front doors and live independently with support from staff. A stair lift is fitted for easy access to the upper floor, should this become necessary for any service user. Bedrooms are personalised and adapted to suit the individual needs and wishes of the service users. Further adaptations to one room have become necessary, following assessments of the service user and will be incorporated into the room during the alterations and refurbishment of the home, to enable the service user to achieve as much independence as possible. Specialist equipment is in use for all service users in the ground floor rooms. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 35, 36 Staff are well-trained, supervised and supported to meet the needs of the service users and promote their health, safety and welfare. EVIDENCE: Staff interviewed said that the induction process is thorough and ‘worthwhile’. Induction training sessions are provided by the company; one staff said it “dealt with all subjects” and gave her the chance to “meet staff from the other homes so get different ideas”. Staff say that training is encouraged. Staff training includes mandatory training, drug administration, diabetes care, adult abuse awareness, signing and coping with challenging behaviour. Staff meetings are held and one-to-one supervisions take place for all staff monthly. Staff say they feel well-supported by the management, and which, they feel, has an positive impact on the quality of care for the service users. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 41, 42 Good leadership, quality monitoring, a high standard of record-keeping and the health and safety measures and procedures in place in the home promote the welfare and well-being of the service users. EVIDENCE: Staff spoken with say that the acting manager is open and friendly, someone with whom they can talk things over and take their concerns to. They feel supported by the acting manager and the company, and by the training and supervision they receive, which reflects positively on their ability to provide quality care to the service users. Service users’ views are taken into account in the running of the home through individual discussions with service users and communication with their families or representatives. Quality monitoring takes place monthly by the responsible individual and regular audits are completed by the acting manager. A business/action plan of the forthcoming alterations and for future improvements was available to view. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 Page 17 Record-keeping for the maintenance of the home and to ensure the health and safety of the service users is excellent, clear and easy to read and understand. The remainder of the radiators that do not comply with health and safety regulations, will be covered in the refurbishment of the home to ensure the safety of the service users. 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x 3 x 3 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 4 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x 3 x x 3 x Standard No 11 12 13 14 15 16 17 x 3 4 3 x 4 x Standard No 31 32 33 34 35 36 Score x 3 x x 3 4 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 38 Church Street Score 4 4 4 x Standard No 37 38 39 40 41 42 43 Score x 4 3 x 3 3 x C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 Page 19 No 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 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. 1. Refer to Standard Good Practice Recommendations 38 Church Street C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Unity House, The Point Weaver 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 C53 C04 S32997 38 Church Street V245713 250805 Stage 4.doc Version 1.40 Page 21 - 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!