Inspection on 13/12/05 for 523 - 525 Marfleet Lane

This inspection was carried out on 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

523 - 525 Marfleet Lane 02/10/08

523 - 525 Marfleet Lane 05/10/06

523 - 525 Marfleet Lane 04/07/05

523 - 525 Marfleet Lane 17/03/05

523 - 525 Marfleet Lane 17/11/04

523 - 525 Marfleet Lane 04/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Marfleet Lane 523 525 523 525 Marfleet Lane Hull East Yorkshire HU9 4EP Lead Inspector Christina Bettison Unannounced Inspection 09:30 13 December 2005 th Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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 Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Marfleet Lane 523 525 Address 523 525 Marfleet Lane Hull East Yorkshire HU9 4EP 01482 796093 01482 329337 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) Avocet Trust George Harker Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2005 Brief Description of the Service: The service at 523-525 Marfleet Lane is managed by Avocet Trust who rent the premises from Sanctuary Housing. It is one of a small number of similar services that Avocet provides. Avocet Trust is a registered charity. 523-525 Marfleet Lane consists of two units registered to provide personal care and accommodation for up to 7 adults of either gender with a learning disability. The home is purpose built, designed to meet the needs of the service users who live there and is situated to the east of the city centre. The accommodation consists of seven single rooms (four in one unit and three in the other) and each unit has its own kitchen, laundry, and bathing facilities. All accommodation is on the ground floor with wheelchair access. There are gardens to the rear of each unit and some parking space to the front of the home. The home is on a main bus route into the city centre and close by are shops, pubs, GP surgeries and leisure / recreational facilities. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours and was an unannounced inspection. None of the service users or staff were at home on the day of inspection. A tour of the premises took place and the manager was spoken to. Staff files were examined. This report should be read in conjunction with the previous inspection report as the majority of national minimum standards were assessed at the previous inspection. What the service does well: What has improved since the last inspection? The houses have been redecorated in specific areas and the garden in 525 has been tidied up providing a pleasant area in which service users can enjoy. A training audit has been developed so that the manager can identify the staff training needs and develop a training plan. The policy/procedure has been developed for the use of restrictive physical interventions so that staff have clear guidance on how to respond to incidents and safely meet service users needs. Recruitment practices have improved so that service users are protected from harm. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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 Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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): EVIDENCE: There had been no new service users (who would have had their needs assessed) come to stay at Marfleet Lane since the previous inspection; therefore none of these standards were assessed. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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): EVIDENCE: NMS 6,7,9, and 10 were assessed and met at the previous inspection therefore none of these standards were assessed at this inspection. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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): 12, 17 Service users are enabled to be part of the local community by the provision of an ordinary housing located in a residential area and access to a range of community activities. Service users are provided with a healthy eating menu that takes into consideration their needs, likes and dislikes. EVIDENCE: NMS 13,14,15,and 16 were assessed and met at the previous inspection; therefore they were not assessed at this inspection. The manager informed the inspector that none of the service users would be able to have a job however they all participate in community activities. Service users have attended a variety of adult education and college classes in the past however it was felt inappropriate currently and service users did not appear to want to attend. Some service users attend the local authority day services and Avocets five senses day service. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 Page 11 All service users participated in a range of leisure activities in the community and within the home e.g. swimming, shopping, games. The inspector was informed that none of the service users follow any particular religion or attend any services. The menu in the home followed a healthy eating plan and consisted of gammon, fish, mince, chicken with a variety of vegetables and fresh fruit. One of the service users has difficulty in swallowing and has recently attended the hospital for investigations. Their diet had been amended to cater for their current needs. Another of the service users is fed by the use of a Percutaneous Endoscopic Gastrostomy but can on occasions eat small amounts of liquidised food. The manager reported that the staff have recently purchased a smoothy maker so that they can make her smoothies out of fresh fruit. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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): 19,20 The service users physical and emotional needs are met, by the provision of a wide range of healthcare professionals and outside agencies. EVIDENCE: NMS 18 was assessed and met at the previous inspection therefore was not assessed at this inspection. The home has policies and procedures for the administration of medication and staff have commenced the training. The staff have submitted module 3 for marking however it has not been returned yet, therefore it remains an outstanding requirement from the previous inspection. One of the service users is fed by the use of a Percutaneous Endoscopic Gastrostomy; this had been agreed by the GP, family members and district nurse who retains overall responsibility. The staff had all received training, however Avocet must ensure that their Policies and Procedures support this practice and staff have clear unambiguous guidance, this remains an outstanding requirement from the previous inspection. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 Page 13 Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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 the following standard(s): 23 The staff team are not fully aware of the Protection of Vulnerable Adults policies and procedures and their responsibility within these therefore strategies are not in place to ensure that service users are protected from abuse, neglect and harm EVIDENCE: NMS 22 was assessed and met at the previous inspection; therefore it was not assessed at this inspection. The manager informed the inspector that staff had not yet received training in the Protection Of Vulnerable Adults Policies and Procedures and their responsibilities within this, therefore this remains an outstanding requirement. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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 the following standard(s): 24,30 Decorating had been undertaken in the houses to provide a homely, comfortable and safe environment in which service users can enjoy. EVIDENCE: NMS 25,26,27,28,and 29 were assessed and met at the previous inspection therefore they were not assessed at this inspection. 525 Marfleet Lane The lounge and the hallway had been decorated on this house. The sensory environment/room is currently being used as a store room this needs to be returned to its former use as the inspector was informed that some of the service users like to use it. 523 Marfleet Lane The lounge had been decorated in this house and new curtains purchased. The bathrooms in both houses appear clinical and institutional and require updating. One of the gardens has been tidied up however the other still Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 Page 16 requires some attention to provide a pleasant environment outside in which service users can enjoy. The inspector was informed that Avocet have recently employed a handy person/gardener to undertake decorating and gardening who will be commencing employment in January 2006. The inspector was informed that Avocet are considering the purchase of a dishwasher for each kitchen to ensure good hygiene practices/infection control and assist the staff team in prioritising service users over domestic chores. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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 Service users are cared for by a staff group, which is sufficient in numbers to meet their needs, however the lack of training both mandatory and service specific leads to the staff team not being adequately supported and thereby there is potential for service users needs not to be met. EVIDENCE: NMS 31,33, and 36 were assessed and met at the previous inspection; therefore they were not assessed at this inspection. A sample of staff recruitment records were examined, including staff appointed since the previous inspection. Recruitment and record keeping has improved greatly since the previous inspection all staff had an up to date CRB disclosure and two written references obtained. All of the ID required by schedule 2 was in place. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 Page 18 6 staff have got NVQ level 2 or above however out of a staff group of 26 this does not meet the target of 50 , therefore this remains an outstanding requirement from the previous inspection. The manager reported that within Avocet Trust there is a Human Resources section responsible for organising training. Since the previous inspection the manager has completed a training audit, however from examination of records and discussion with the manager it was apparent that although staff were up to date with the majority of mandatory training this did not include infection control and staff had not fully completed the appropriate medication training. New staff are supposed to complete Learning Disability Award Framework – accredited training to meet the Sector Skills Council targets for staff induction. New staff were not doing so and staff had still not received updated training in the protection of vulnerable adults. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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): 37,40,42 Marfleet lane now has a manager thereby providing the service users with a stable and consistent staff group and lead person to develop the service. Service users live in a safe environment however all staff need to be up to date with mandatory training to ensure that the health, safety and welfare of service users is promoted. EVIDENCE: NMS 39,41and 43 were assessed and met at the previous inspection therefore were not assessed at this inspection. A new manager has been appointed to the home and started on 24/10/05. She has previous experience of managing a care home for older people, however does not have any experience of working with this service user group. Therefore the manager must undertake the LDAF induction and foundation standards. The manager has got D32/D33 NVQ assessors award and the Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 Page 20 Registered Managers Award however has not completed the NVQ level 4 which she must also undertake. The manager needs to be registered with the CSCI. All maintenance has been attended to and all certificates seen were in date, however all staff need to be up to date with all mandatory training. Policies and procedures were examined as part of the previous inspection since then some have been updated, one of these being the use of physical interventions. The quality assurance manager is making steady progress in reviewing and amending the policies and procedures in line with changes in legislation and best practice guidance and the timescale for completion has been agreed at 31/1/06. Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 x 3 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Marfleet Lane 523 525 Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x 2 x 2 x DS0000000915.V255613.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 YA19 Regulation 13 Requirement The registered person must ensure that the policies and procedures give clear guidance in relation to consent, staff involvement role, training and record keeping when service users have a Percutaneous Endoscopic Gastrostomy in situ. (Timescale of 30/9/05 not met) The registered person must ensure that all staff receive training in the administration of medication and this must include a competency check. (Timescale of 30/9/05 not met) The registered person must ensure that all staff recieve training in the protection of vulnerable adults. (timescale of 30/10/05 not met) The registered person must ensure that at least 50 of staff are qualified to NVQ level 2. (Timescale of 1/12/05 not met) The registered person must ensure that all staff are up to date with mandatory training and this must include Infection control. (Timescale of 30/9/05 not met) DS0000000915.V255613.R01.S.doc Timescale for action 28/02/06 2 YA20 13 31/01/06 3 YA23 13 (6) 31/03/06 4 YA32 18 31/03/06 5 YA35 18 31/03/06 Marfleet Lane 523 525 Version 5.0 Page 23 6 YA35 18 7 YA35 18 8 YA35 18 9 10 YA37 YA37 18 18 11 YA40 24 The registered person must ensure that a training plan is developed for the staff team. (Timescale of 30/9/05 not met) The registered person must ensure that all new staff receive induction training that meets LDAF standards. (Timescale of 30/9/05 not met) The registered person must ensure that all staff have an individual training profile. (Timecale of 31/10/05 not met) The registered person must ensure that the manager is registered with the CSCI. The registered person must ensure that the manager undertakes LDAF induction and foundation training, POVA for managers and the NVQ level 4 in care. The registered person must ensure that Avocets policies and procedures are updated and amended in line with legislation and best practice guidance. 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/01/06 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 Marfleet Lane 523 525 DS0000000915.V255613.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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