Inspection on 24/08/05 for 44 Blyford Road

This inspection was carried out on 24th August 2005.

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 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

44 Blyford Road 10/09/07

44 Blyford Road 20/09/06

44 Blyford Road 25/01/06

44 Blyford Road 21/02/05

44 Blyford Road 04/08/04

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Paradise Lodge

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

CARE HOME ADULTS 18-65 44 Blyford Road 44 Blyford Road Lowestoft Suffolk NR32 4ST Lead Inspector John Goodship Announced 24 August 2005 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. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 44 Blyford Road Address 44 Blyford Road Lowestoft Suffolk NR32 4ST 01502 531007 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) Royal Mencap Service Mrs Karen Smith Care Home 6 Category(ies) of LD Learning Disability (6) registration, with number PD Physical Disability (2) of places LD(E) Learning Disability over 65 years (2) 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 14/03/05 Brief Description of the Service: The bungalow is situated in north Lowestoft in a pleasant residential area. There are some shops close by. It was purpose built for 6 people with learning disabilities. The home was extended and refurbished in 2003 to offer more spacious accommodation for two individuals with physical disabilities, widening all the doors in the existing building, and lowering all light switches and plug sockets to wheelchair height. A third person with physical disabilities was admitted in March 2004. The building is owned by Orbit Housing Association. The service is provided by Mencap. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, the first in the current inspection year. The visit took place from 11.00am to 5.00pm.n The manager was present, and some residents arrived from their day services in the afternoon. Two sets of relatives spoke to the inspector during the visit. All of them commented that they were very happy with the care given to their relatives. Two issues of uncertainty about policy have been described in the report, under Lifestyle, and Concerns. What the service does well: What has improved since the last inspection? What they could do better: It is essential that all staff identification documents are kept in their personal files. Staff should receive annual refresher training in moving and handling. New staff should receive their initial training in this topic from a qualified trainer. The wishes of the residents concerning terminal illness and death should be recorded. The home should develop a continence policy to ensure best practice is followed. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 6 There should be clarification of the home’s policy regarding the funding of residents’ holidays. 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. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 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 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 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) 2,3,4,5 Residents will only be admitted to the home if they and the home staff believe their needs can be met. Admission procedures ensure this decision is made in an informed way by both parties. EVIDENCE: A recent service review, which had led to agreement by the County Council to fund an extra post at night to provide a waking member of staff, as well as the sleep-in, had been successful in meeting the increasing dependency needs of residents. The home was well equipped with specialist aids for bathing, moving, stimulation and relaxation. No new resident had been admitted since March 2004. All pre-admission assessments and information had been obtained. The contract was with the funding authority, but each service user had a set of Mencap terms and conditions. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 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) 7,8,9,10 Residents can expect that the home is run according to their wishes, with the development of independence as a primary goal. EVIDENCE: A discussion with some relatives showed that the confidentiality of information about residents is maintained by the home’s staff. Residents were encouraged to be involved in the running of the home as much as they wished to be, for instance helping with shopping and housework. Nationally, it is understood that Mencap involves service users as much as possible with the development of policies, procedures and services. Residents’ meetings took place on a regular basis. Individuals were continually supported by staff to make decisions. Residents were involved in all assessment processes. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 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) 11,12,13,14,15,16,17. Residents are given many opportunities to choose how to spend their time, as a group, and individually. Residents are encouraged to play an active part in the running of the home according to their wishes and abilities. EVIDENCE: All residents attended regular day services during the week according to their needs. They took part in a variety of leisure activities - inside the home, such as listening to their own tapes, watching television as a group or in their own room, helping with cooking and gardening; outside the home, such as swimming, going to shows, going to football matches (one resident is a keen supporter of Norwich City), shopping and bowling. Some also participate in activities organised by SCOPE, Club 85 and the local Gateway Club. One resident was described as needing encouragement to go out, but then enjoyed doing so. One resident was able to walk to the shop at the end of the road on their own, and was assisted to attend car boot sales. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 11 Two parents described the range of activities their relative took part in. They occasionally went home for a week-end, and the parents took them on holiday once a year. The home had some difficulty supporting holidays for all residents. The amount allowed by Mencap was £300 per resident. Therefore choice was limited unless several residents went away together. One resident had chosen to go abroad with another resident and had to pay the additional cost of the package, including the cost of support from 2 staff. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 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) 18,19,20,21 Residents can expect their needs to be identified, monitored and appropriate action taken. EVIDENCE: It was seen that staff provided sensitive and flexible personal support to residents. The home had a good service from health professionals. This included the continence adviser. The home did not have a continence policy, however. Medication procedures were audited regularly. A sample of the Medication Administration Record (MAR) charts showed that all administrations had been signed for, and there were no gaps. A sample stock check took place and was reconciled with the number administered. Bottles in use had been dated when first opened. Training in the safe administration of drugs followed the Mencap workbook course, with assessment by the manager. Special training was given in the administration of rectal diazepam. Although the manager and the relatives were aware some residents’ wishes regarding funeral arrangements, there was no record of this in residents’ files. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 13 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 14 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) 22,23. Residents are helped to understand how they are protected and how to raise issues of concern. EVIDENCE: The residents benefit from the visits of a lay visitor who acts as a friend and if necessary an advocate for any resident who wishes to have some help. There was evidence that this person had been checked as for other staff. There was an Induction manual for the post, and copies of visit reports were available. A discussion with 2 relatives about the control of the finances of a resident clarified responsibilities within the policy of confidentiality. At present the manager is the appointee for 4 residents. The manager offered to help the relatives take over the appointeeship for their relative if they wished. The bank book and cash for one resident was checked and found to balance with the receipts and withdrawals. The complaints procedure, and the reporting of incidents of abuse, were explained by use of pictographs and symbols. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 15 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) 24,25,26,27,28,29,30. Residents live in a purpose-built home with the appropriate facilities and specialist equipment and furniture for their needs. EVIDENCE: There had been no change to environmental standards since the last inspection, when they were all met. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 16 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) 32,33,34,35,36 Residents are protected by the home’s recruitment and training practices, which produce staff who are competent to meet the needs of all residents. EVIDENCE: There were no identification documents in the files of 2 staff members, although all had Enhanced Disclosure certificates. Two care staff had completed National Vocational Qualifications (NVQ) Level 2, and 2 more were waiting to be signed off. Therefore 6 staff would have completed Level 2 by the end of 2005, out of a staff complement of 15. As there were no staff booked to start training, the home will not be able to achieve the target of 50 of staff qualified by the end of 2005. Mandatory training programmes were up-to-date, organised through the Mencap training co-ordinator. However Mencap policy required Moving and Handling refresher sessions to be held every 3 years, whereas good practice would recommend every year. This training during the induction programme was not given by a qualified trainer in moving and handling. Two volunteers had been recruited with the same protection checks as other staff. One helped with the gardening, and was able to drive residents to appointments, and the other occasionally took out an older resident. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 17 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 18 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) 37,38,39,40,41,42,43. Residents can expect the home to be run according to the national policies and procedures of Mencap. There are two policies and procedures which need clarifying: continence policy and holiday funding. EVIDENCE: The manager was registered with the Commission and was experienced in the care of this client group. She had completed her NVQ Level 4 and had got the Registered Managers Award. The home follows the comprehensive Mencap quality assurance system, samples of which showed the complimentary comments of residents, families and external professionals. Monthly visit reports were up-to-date. The home follows the Mencap policies and procedures. However there was no policy for continence, although the appropriate action was being taken to promote continence. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 19 There was some misunderstanding by one relative of the financial arrangements for resident holidays. The home’s budget reduced residents’ choice of how they took their holidays. The information in the service users’ guide states that “Holidays…are not covered by the service charge. Service users will normally be expected to pay in full or contribute towards the cost of any such events that they participate in. The contribution…is also dependent upon any contractual arrangements with the funding agency.” It is not clear what costs are included, nor how the policy complies with National Minimum Standard 14.4. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 20 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 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 2 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 44 Blyford Road Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 3 3 I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 21 NONE 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 21 Regulation 12(3) Requirement The registered person must ascertain and take into account the wishes of residents, or if appropriate their families, regarding arrangements when they die. The registered person must ensure that the identification documents specified in this regulation are kept in the home. The registered person must ensure that staff training in mov ing and handling is given by appropriately trained persons. Timescale for action Immediate and ongoing. 2. 34 19 Immediate and ongoing. Immediate and ongoing. 3. 35 13 4. 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 14 19 Good Practice Recommendations The registered person should ensure that the homes policy on the funding of holidays is clear and understood by residents and relatives. The registered person should ensure that the home has a policy on the promotion of continence, and the treatment of incontinence. I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 22 44 Blyford Road 3. 32 The registered person should produce a strategy for achieving the target, set by this national minimum standard, of 50 of care staff trained to NVQ Level 2. 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 5th Floor St Vincent House Cutler Street Ipswich IP1 1UQ 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 44 Blyford Road I54 - I04 S24338 44 Blyford Road V232123 050824 Stage 4.doc Version 1.40 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!