Inspection on 13/09/05 for 7 Dove Lane

This inspection was carried out on 13th September 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

7 Dove Lane 16/03/09

7 Dove Lane 20/08/07

7 Dove Lane 07/02/06

7 Dove Lane 02/03/05

7 Dove Lane 12/08/04

7 Dove Lane 20/02/04

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Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

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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 7 Dove Lane Harrold Bedfordshire MK43 7DF Lead Inspector Ansuya Chudasama Announced Inspection 13th September 2005 10:00 7 Dove Lane DS0000014894.V251698.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 7 Dove Lane DS0000014894.V251698.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. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 7 Dove Lane Address Harrold Bedfordshire MK43 7DF 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) 01234 720019 www.aldwyck.co.uk Aldwyck Housing Association Mr A Neate Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2005 Brief Description of the Service: 7 Dove Lane is a residential home for adults with profound learning and physical disabilities. The detached bungalow was registered in 1993 and is located in the village of Harold. The home is owned and managed by Aldwyck Housing Association. The home has six single bedrooms and these were a good size for ambulant service users. However further extension was planned to meet the needs of wheelchair users. The home has a lounge, dining room, kitchen, and laundry as well as bathroom and shower room, both including toilet facilities. Staff were provided with an office/sleeping-in-room, which had an en-suite facility. The home has its own vehicle with facilities for wheelchair access. The village has shops, pub, and church, which were all used by the service users. They also used the facilities in the nearby towns. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced inspection took place over 5 hours. The manager, deputy manager, senior support worker and support workers were present at the inspection. The inspection comprised of a tour of the bedrooms, bathing facilities and the communal areas of the home, care tracking in relation to two service users and conversations with most of the service users, staff and the manager. What the service does well: The home was clean and very homely. The manager was very experienced and ran the home to a high standard. The staff described the manager as being a “good boss” and always available. The staff team worked hard to meet service users needs. One staff stated that this was the best home they had worked at. It was also stated that all the staff worked well as a team and with the service user group. This was observed on the day of the inspection. The staff had excellent understanding of the needs of the service users. The staff were observed treating service users with dignity. The home had a core staff group that had worked at the home for some time and provide continuity to service users. Staff stated that the training provided by the organisation was excellent. Service users body language and facial expressions showed that they were happy and they were observed to relate to staff in a positive and relaxed manner. The meals provided are healthy, varied and catered to meet the needs of service users. The home provides a variety of activities both in doors and in the community to suit all service users needs. The local people in the village are very supportive to the home and know them well. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 6 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. 7 Dove Lane DS0000014894.V251698.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 7 Dove Lane DS0000014894.V251698.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): The homes statement of purpose and service user’ guide provided prospective service users and their families information of the services the home provides, enabling an informed decision about admission to the home. EVIDENCE: The home had a statement of purpose and a service users’ guide. The documents gave detailed information about the services and facilities that were provided by the home. The manager was in the process of producing the service users guide’ in a format suitable to meet the needs of the service user group. The service users in the home had been admitted on the basis of a full assessments being undertaken by the home. Relevant information was also obtained from the funding authority to give the home more information about the service users. Prospective service users and their families had visited the home on an introductory basis prior to their admission. The home did not admit any emergency admissions. All admissions to the home were planned and the home had not admitted any new service users for a number of years. The staff training programme and discussion with staff showed that they had the skills to meet the assessed needs of the service users. The service users’ files inspected had contracts with the home. It is good practice to have the contract signed by the service user or their representative to further promote their rights. 7 Dove Lane DS0000014894.V251698.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): There was clear and consistent care planning systems in place to provide the staff with the information they needed to meet the needs of the service users to a high standard. EVIDENCE: The care plans for two service users were examined in detailed. The plans were found to be very comprehensive, containing detailed information about what care would be provided and the service user’s preferences for the way in which the care would be given. The plans covered information on personal, social and healthcare needs. The staff spoken to had been involved in implementing the care plans. The plans were being reviewed on a six monthly and yearly basis. The staff stated that the plans were also discussed with service users’ families. The staff spoken to stated that they promoted service users rights by giving them choices at meal times and with activities. This practice was observed through out the whole inspection. The staff were also observed talking to service users in a polite and encouraging manner. They also had very good understanding of the service users non-verbal communication behaviours. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 10 Service users’ families and other professionals involved in their care also promoted their rights. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 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 the following standard(s): Service users have opportunities for personal development to enrich their social and educational opportunities. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The staff were observed talking to service users in a kind and positive manner when giving them their breakfast and lunch. They informed the service users of what was available for breakfast and lunch. One service user was shown a variety of spreads to choose from. The staff spoken to were able to give detailed information about the service users likes and dislikes for food. This information was also recorded in their care plans. The staff encouraged some service users to feed themselves. Service users who were unable to feed themselves were observed being feed by staff in a sensitive manner. The meals provided by the home were nutritious and included a good variety of different foods that the service users enjoyed. The home provided stimulating activities to maintain and develop service users skills. Some of the activities included, cooking, visiting garden centres, pubs, 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 12 cafes, fetes, shops, theatre, clubs, and swimming pools. Service users also attended art and craft sessions, aromatherapy and reflexology. They also went horse riding and went for walks in the village. Service users also went on holidays with the home in twos and three members of staff accompanied them. The photographs of the holidays were displayed around the home. On the day of the inspection, most of the service users were encouraged by staff to get involved with the inspection process. The inspector sat with the staff and service users in the dinning room for the majority of the time, observing and asking questions. The service users facial and body language observed was very positive and relaxed. Records were kept on daily activities undertaken by service users. The homes community experience coordinator monitored the activities. This information was also presented on a monthly basis to the stakeholders meetings. The home had very good relationships with the people who lived in the community. All the service users in the home had contact with their families. The home also had good relationships with service users’ families. The families were invited to the home’s social events and service users’ review meetings. Recently one service user had a 40th birthday party and all the families and friends were invited to the function. The home had routines, but these were flexible and centred around meeting the needs of the service users. Service users had unrestricted access to all parts of the communal areas. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 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 the following standard(s): The knowledge of staff, safe systems for administering medication and detailed care planning meant that the personal and health needs of service users are met. EVIDENCE: The two care plans inspected had detailed information on how service users personal care needs were being met by the staff. The service user’s preferred routines were made very clear in the plan. The staff spoken to were aware of the service users needs. The plans also had information on how service users medical needs were being met by the staff. The staff spoken to were able to give detailed information about the two service users medical needs that were case tracked. They had also undertaken appropriate training to help them understand and meet service users medical needs. Detailed appointments were recorded for health appointments attended. The staff were observed giving service users their medication and this was given in a satisfactory manner. The staff spoken to were able to give detailed information about the medication the service users took that were case tracked. They had also completed the accredited training in administering medication and other courses on safe handling of medication. The home had a new medication cupboard with an alarm fitted for security. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 14 The staff had received training on ageing, illness and death. This was also discussed with families. Information on service users wishes concerning burial arrangements was discussed and completed by families. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 15 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): The staff have good knowledge and understanding of adult protection issues, which protect service users from abuse EVIDENCE: The home had a policy on adult protection. The inspector spoke to a number of staff, and they were all aware of the adult protection procedures and had covered this in their NVQ training. The staff also gave many examples of how they would know if a service user was unhappy or if some thing was wrong. It was stated that they understood the service users behaviours and characteristics well. This was observed on the day of the inspection. Many examples were given by the staff to tell when a service user was happy, and the behaviours displayed when they were unhappy. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 16 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): The premises were clean and homely as to allow all those living at the home to enjoy a comfortable environment. All service users had single rooms but the room sizes did not meet all service users needs. The home had adapted bathing facilities but there were not enough in numbers to meet the needs of the service users. EVIDENCE: 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 17 The home was well maintained and very homely. Service users rooms seen were individualised and decorated to a high standard. All service users had single rooms. However, service users who were wheelchair users had rooms that did not met the standard. Some of the rooms had hoist ceilings and low special beds. Some service users had sensory equipment installed in their rooms. The home had adapted bathing and shower facilities with tracking hoists to meet service users needs. A balsam spa bath mat was also fitted for regular sessions. The bathing facilities were attractively decorated. However when the two bathing /toilets were occupied, other service users had to use the commode. The home needed more toilets. The plans to increase the size of the bedrooms with en-suite facilities were seen at the last inspection. The manager stated that the plans were going to be discussed at the board of Aldwycke Housing Association and then at the Joint Commissioning Team and Housing Corporation. The home had a large lounge and separate dining area. The garden was large and beautiful and had a summerhouse with a swing. This was owned by one of the service user in the home. Another swing was also available in the garden. A water feature was also available. The home also held barbeques in the summer months. The home had overhead track hoists as well as mobile hoists and a hi-lo bath. The bathing facilities had been adapted to meet the needs of service users. The occupational therapist and other specialist services had been accessed by the home to provide the adaptations 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 18 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): The home provided very good training so that the people living at the home had their needs met by competent and suitable staff. EVIDENCE: The staff spoken to had done induction training, the Learning Disability Award Framework (LADAF) training and all the statutory training as stated in the standard. All the staff stated that the training offered by the organisation was excellent. The home had over 60 per cent of the staff with NVQ level 2 or above. The staff received supervision once a month but it was stated that they were able to speak to the manager any time with any concerns. The staff received annual appraisals and staff meetings were held regularly. The staff also stated that they worked well as a team and they were very supportive towards each other. It was stated that the standard of care received by the service users was very good but the staff try and meet the goals of service users but this did not always happen due to staff shortage and sickness. The home had eleven staff and two full time vacancy for full time staff. It was stated that relief staff and agency staff covered the hours. The manager has worked hard to fill the vacancy hours. The inspector was informed that the service users needs had increased. The number of staff needed had increased from 13 staff to fifteen staff to meet the needs of the service users. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 19 The staff recruitment files inspected had all the information stated in the standard. One staff file for a new member of staff was not available. However the manager stated that he had seen all the information on this staff. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 20 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): The home has an experienced and committed manager who ensures strong leadership, and safe working practices so that service users health, welfare and safety are safeguarded. EVIDENCE: The manager had completed the Registered Manager’s Award. The manager was a registered nurse in learning disabilities. He had the diploma in management studies, D32/33 assessors award and Further Education Teaching Certificate. The manager had over 23 years experience of working with the service users group. Observation showed that the home was well managed by the manager. The staff spoken to stated that they received “excellent support from management”. The training records showed that all staff had received the statutory training as stated in the standard. Health and safety checks were carried out on a weekly and monthly basis. The fire drills were carried out six monthly and when new staff started employment at the home. The fire alarm testing was carried out on a weekly basis and emergency lighting was checked on a monthly basis. It was stated that all staff took responsibility for the 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 21 health and safety of the home. Risk assessments were available for service users and the building. 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 22 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 3 3 3 3 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 4 2 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7 Dove Lane Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 4 X X X 3 X DS0000014894.V251698.R01.S.doc Version 5.0 Page 23 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 YA24 Regulation 16 Requirement The registered persons must ensure that single rooms accommodating wheelchair users have at least 12sqm floor space. The registered persons must provide more toilets to meet the needs of the service users. 2 YA34 17 The registered person must ensure that all staff files are available for inspection. 31/11/05 Timescale for action 30/04/06 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 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 7 Dove Lane DS0000014894.V251698.R01.S.doc Version 5.0 Page 25 - 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. 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