Inspection on 23/02/06 for 56 Monks Dyke Road

This inspection was carried out on 23rd February 2006.

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 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

56 Monks Dyke Road 20/09/06

56 Monks Dyke Road 02/06/05

56 Monks Dyke Road 13/01/05

56 Monks Dyke Road 07/04/04

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 56 Monks Dyke Road Louth Lincolnshire LN11 0NY Lead Inspector Alison Marshall Unannounced Inspection 23rd February 2006 10:00 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 56 Monks Dyke Road Address Louth Lincolnshire LN11 0NY 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) 01507 610877 www.sense.org.uk Sense East Mrs Fiona Kennedy Care Home 7 Category(ies) of Learning disability (7), Sensory impairment (7) registration, with number of places 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to admit a maximum of 7 service users in the categories Learning Disability (LD) or Sensory Impairment (SI). Date of last inspection Brief Description of the Service: 56 Monks Dyke Road is one of a number of care homes within the county operated by SENSE East and is located in a residential area in the market town of Louth. The building is owned by a housing association which has maintenance responsibilities. It was originally a family home. It provides personal care and support in single rooms for up to seven service users over the age of eighteen. Three bedrooms have ensuite facilities. The home has a safe, enclosed garden at the rear of the property and car parking spaces at the front and rear of the house. Transport is provided through the use of a minibus and staff cars. The stated aim of the home is to provide a safe and supportive environment for the people it cares for. The objectives are to provide a warm and homely place, to respect each individuals privacy and dignity, to support service users and their families to be as independent as possible, to provide staff with training and to check on how well the service is doing through monitoring and reviewing it regularly. 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Thursday evening morning, from 3:00 pm to 6:30 pm. The previous inspection in June 2005 had covered all of the key standards. This inspection focused on spending time with service users and staff and observing the evening routines and following up on the requirements made at the last inspection. What the service does well: What has improved since the last inspection? 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. 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 6 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 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 7 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): These standards were assessed at the previous inspection. EVIDENCE: 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 8 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 and 7 Service user individual needs were promoted and documented appropriately. EVIDENCE: The previous inspection had identified that improvements were needed to the care planning process to ensure that service users’ needs were clearly identified along with the means by which they would be met. The manager explained that this was being addressed regionally through the organisation and that a new process and format was being developed. Each service user had a daily log. This contained a weeks worth of daily log sheets, eating guidelines, communication guidelines, and behaviour guidelines and risk assessments. From the records and discussion with staff it was apparent that service users were encouraged to make as many decisions for themselves as possible. 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 9 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 and 17 Service users had busy and varied lifestyles with opportunities to engage in a range of educational, vocational and leisure activities. EVIDENCE: Six service users attended the Sense workshop at Louth. Of these, five had a home day every week to do their personal shopping, clean and tidy their room and for individual trips. One service user did voluntary work at a stable for one day a week. One service user remained at home all week as the workshop was not appropriate: staff worked with him during the day at home. There were set activities most nights, for example, baking or crafts. A member of staff took responsibility for each night to plan and arrange the activity. The home had access to two vehicles to allow service users to access the community. Family members were encouraged to visit at any reasonable time. Service users were supported to maintain contact through visits, telephone calls and letters. Staff provided appropriate guidance and support to service users with 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 10 regards to personal relationships to ensure they had sufficient information on which to make safe choices. The home had a four-week rolling menu. This had been drawn up by a member of staff based on service user known likes and dislikes. Advice had been sought from the dietician regarding healthy eating. Staff prepared meals with service user support. On the evening a winter vegetable casserole with dumplings was being prepared – it smelt and looked very good. Staff said that the meals were always freshly prepared and that they ate with the service users. 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 11 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 Staff responded appropriately to ensure that the welfare of service users was promoted. EVIDENCE: Staff noticed that one service user returned from the workshop with a large bump on his forehead. Staff took appropriate steps to gather more information about how this had occurred. As the service user was not able to say how he was feeling and given that the bump was large and to the head the staff took him to the local A&E to be checked out. This process was managed calmly and efficiently. The medication standard was not inspected. However, the senior on duty explained that following the last inspection the home was monitoring and recording the temperature of the room in which medication was stored and taking action to ensure the room did not become too warm. 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 12 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): These standards were assessed at the previous inspection. EVIDENCE: 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 13 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, 25, 26, 27, 28 and 30 Service users lived in a homely and comfortable environment. EVIDENCE: The home was bright, modern, comfortable and decorated to high standard. The furniture and fittings were all domestic in nature and in good condition. There was plenty of communal space including a sensory room. Service users had their own bedrooms which were individually decorated and personalised with belongings. One service user damaged her environment and as a result there were no curtains at her bedroom window. Staff explained that they had had tried a range of other coverings, including blinds, but she was not able to tolerate anything at the window. The service user would sometimes remove her clothing and the agreed strategy was to ask her to go to her room until she redressed. Although the room was not directly overlooked the home may want to consider frosting on the bedroom windows to ensure her privacy at all times. Three of the bedrooms had ensuite. There were sufficient bathrooms and toilets for the service users. 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 14 A previous inspection had required that the home have an industrial washing machine with sluice facility. This had now been provided. The inspection in June 2005 had identified that not all the fire exits had ramps to allow safe exit by service users in wheelchairs. The manager said that an occupational therapist had carried out an assessment on the home and the findings had been sent to Sense and would be addressed through the estates manager. 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed at the previous inspection. EVIDENCE: Whilst inspecting the building and fittings it was noted that the filing cabinet containing staff supervision notes was unlocked. 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed at the previous inspection. EVIDENCE: 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 4 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 4 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X X X X X X X X 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 18 YES 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 YA6 Regulation 15(1)(2) Requirement Care plans must express clearly how the service users needs are to be met, must be reviewed monthly and must show evidence of the service users involvement. This is outstanding. Fire exits must provide a safe and efficient means of escape for all service users. This is outstanding. Timescale for action 01/06/06 2. YA24andYA42 23(2)(4) 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA26 YA36 Good Practice Recommendations The registered person should consider the use of frosting on one service user’s bedroom window. The registered person should ensure that the filing cabinet containing staff supervision files is locked at all times. 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 56 Monks Dyke Road DS0000002678.V282817.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!