CARE HOME ADULTS 18-65
67-71 Lansdowne Road 67-71 lansdowne Road Leicester Aylestone LE2 8AS Lead Inspector
Steve Hunnybun Unannounced 5th May 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. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service 67-71 Lansdowne Road Address 67-71 Lansdowne Road Aylestone Leicester LE2 8AS 0116 283 4025 0116 283 4025 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) Lansdowne Road Limited Ms Lesley Wakefield Care Home 28 Category(ies) of LD - Learning disability (28) registration, with number of places 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 4th November 2004 Brief Description of the Service: 67-71 Lansdowne Road is registered to provide care for twenty-eight adults with learning disabilities. The home is divided into four self-contained units for service users with differing levels of need and ability. There is a large outdoor area to the rear of the property.The home is situated close to Aylestone Road and is approximately one mile from the city centre. A regular bus service to and from the centre can be accessed close to the home. A number of shops, parks and a leisure centre are located nearby. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over four hours and was the first statutory unannounced inspection this year. Four files were examined, a tour of the building was undertaken and the inspector spoke with residents, the registered manager and staff. What the service does well: What has improved since the last inspection?
Most of the environmental issues addressed at the last two inspections have been met or are part of a programme of redecoration; this includes several areas of refurbishment and redecoration and the fitting of radiator covers. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 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. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 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 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 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 Residents’ needs are assessed accurately and with their input. EVIDENCE: All files tracked contained comprehensive assessments of residents needs. This included community care assessments and those generated at the home. In conversation with staff and residents it was clear that these assessments reflected residents needs accurately. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 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) 6,7,9 Residents’ needs are reflected in their care plans but they need to be in a consistent format and need to be cross-referenced to risk assessments. Residents are able to make decisions and choices regarding their lives. Residents are able to take risks but need more individual assessments that are cross-referenced to care plans. EVIDENCE: All files tracked contained care plans. These were comprehensive in themselves but each file contained several on different formats, some of which were generic and were repeated in more than one file. Two care plans contained references that the inspector felt needed exploring with staff. One related to the resident’s eating habits and was found elsewhere in the file. The other was a reference to the residents sexuality which the inspector felt implied that she is vulnerable. The inspector could not find a risk assessment or any other reference to this in the file. Upon discussing this with staff it was apparent that the resident is not vulnerable but this was not clear from the file. Residents are enabled to make choices about their lives. This was evident from the files and in conversation with a resident who stated that he has been able to make choices about his room and about where he lives within the home.
67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 Page 10 There is a regular residents meeting at which issues such as menu plans are discussed. All files contained risk assessments, however these were all the same, using a generic format. While there is nothing wrong with this in itself, it is clear from examples such as the one quoted above that individual assessments are needed. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16,17 Residents are offered a range of activities and are enabled to be part of the local community. Residents are encouraged to maintain personal relationships. Residents’ rights and responsibilities are recognised. Residents are given healthy food and enjoy their meals. EVIDENCE: All files tracked contained a wealth of information about residents’ activities. Examples included music groups, library, indoor games and leisure centres. A resident who spoke with the inspector is recovering from a broken hip and is unable to go to the day centre. He stated that he is able to pursue various hobbies such as letter writing, stamp collecting and reading. Residents are enabled to access local community facilities such as pubs, parks and shops. Residents are registered to vote and several had used a postal vote in the general election, which took place on the day of the inspection. Residents are enabled to maintain contact with family and friends. This was evident when looking in files as they contained contact lists. A resident who spoke with the inspector stated that he is able to visit his mother who is currently in hospital.
67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 Page 12 Residents’ risk assessments include one relating to their freedom to leave. This clearly balances the risk of residents leaving the home alone against their right to do so. In conversation with the inspector a resident stated that he is able to move round the building freely. Files indicated that residents are able to contribute to menu planning through residents meetings. A resident stated that the food is ‘very good’. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Residents’ personal and healthcare needs are met. Residents are supported to take their medication by suitably trained staff. Medication is stored and recorded appropriately. EVIDENCE: Residents’ personal and healthcare needs are assessed and the home is proactive in meeting these. A resident who spoke with the inspector stated that he was supported during his recent hospital stay and with any care he has needed since. Residents’ files contained records of their healthcare needs including doctor’s appointments. No residents administer their own medication. The inspector had sight of medication records that had been completed appropriately. Staff are only able to give medication when they have attended appropriate training. Residents on PRN (as required) medication have a PRN procedure on file that clearly sets out the criteria for giving. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 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 enabled to complain and feel that heir views will be listened to. Residents are protected from abuse and feel safe. EVIDENCE: Residents have recently been enabled to access an advocacy service. This gave rise to a number of complaints about various aspects of the service. The registered manager stated that these issued have been resolved and that she felt the process was a positive one. In conversation with the inspector a resident stated that he feels able to complain and knows who to talk to should he need to. The home has a robust procedure regarding adult protection and also uses the Multi-Agency Vulnerable Adult Protection document No Secrets. The copy in the home has been updated to include recent updates. All staff have attended training regarding adult protection and this is also included within the NVQ. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 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) 24,30 The home is fit for its purpose and a lot of work has been completed since the last two inspections to address environmental issues. EVIDENCE: There was a decorator present in the home on the day of the inspection. He toured that building and obtained information to enable him to quote to decorate all bedrooms that need doing and a number of communal areas. A number of areas of improvement were identified at the last two inspections and most of these have been carried out or are part of the redecoration programme mentioned above. Radiator covers have been fitted throughout the home. The following areas still need to be completed, o An area of rendering near the back door of house A needs replacing. o The kitchen and hall in number 71 need refurbishing. The home was clean and tidy on the day of the inspection. A resident who spoke with the inspector stated that he likes the house and is happy to live there. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 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) 34,35 The recruitment procedure ensures that suitable staff are employed and that residents are protected. Staff are appropriately trained and this better enables them to meet residents needs. EVIDENCE: The home has a robust recruitment procedure. All recruitment administration is handled centrally, application forms are collected, references are requested and verified and Criminal Records Bureau checks are requested. The registered manager then takes part in the interview. Staff all have comprehensive training programmes all are registered for NVQ, one member of staff was discussing a unit with the registered manager on the day of the inspection. An external assessor was present and able to discuss NVQ issues with staff and the registered manager. Training also includes a range of health and safety courses, adult protection, medication and equal opportunities. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 Page 17 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) 42 The home is proactive in ensuring health and safety is maintained. EVIDENCE: The home has a comprehensive health and safety procedure that includes a range of training including fire, food hygiene, infection control and the Control of Substances Hazardous to Health. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 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 3 x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 3 x 2 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
67-71 Lansdowne Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 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 none 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. 2. 3. Refer to Standard 6 9 24 Good Practice Recommendations It is recommended that each resident has one care plan using a consistent format. It is recommended that all residents have individualised risk asesments and that they are cross-referenced to care plans. It is recommended the outstanding environmental issues identified are complete as soon as possible. 67-71 Lansdowne Road C51 S6412 67-71 Lansdowne Road V225086 050505.doc Version 1.30 Page 20 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park, Enderby Leicester, LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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