Inspection on 20/08/07 for 7 Dove Lane

This inspection was carried out on 20th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 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 07/02/06

7 Dove Lane 13/09/05

7 Dove Lane 02/03/05

7 Dove Lane 12/08/04

7 Dove Lane 20/02/04

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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 Alison Hilton Unannounced Inspection 20th August 2007 08:25 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 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.V349100.R01.S.doc Version 5.2 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.V349100.R01.S.doc Version 5.2 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 Alan.Neate@aldwyck.co.uk 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.V349100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2007 Brief Description of the Service: 7 Dove Lane is a residential home for six adults with profound learning and physical disabilities. The detached bungalow was registered in 1993 and is located in the village of Harrold, Bedfordshire. 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 the changing needs of the residents has meant that the room sizes are not wholly adequate with the use of wheelchairs. The home has a lounge, dining room, kitchen, and laundry as well as bathroom and shower room, both including toilet facilities. Staff are provided with an office/sleeping-in-room, which has an en-suite facility. The home has its own vehicle with wheelchair access. The village has shops, pub, and church, which were all used by the service users. They also use the facilities in the nearby towns of Bedford, Northampton and Milton Keynes, such as theatres and cinemas. The inspection reports are available in the office. The weekly charges are £1176. This figure does not include various items such as some social activities, vehicle diesel costs, hairdresser or toiletries. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place on Monday 20th August 2007 from 08:25hrs. There were six people living in the home at the time of the inspection. There were six staff on duty including the manager. The Annual Quality Assurance Assessment (AQAA) was completed prior to the inspection. Files relating to those living at Dove Lane and staff working there were seen, together with other documentation. Staff files were collected from the area office during the inspection. What the service does well: What has improved since the last inspection? The home has 3 more drivers since the last inspection, which means people who live in the home can be transported to events more frequently, providing more choice. New guidelines in relation to staff behaviour outside the home have been written. A risk assessment and plan (in relation to a resident who sometimes needs to be restrained) is now in place. There was evidence that on any occasion where any physical restraint is used, this is recorded with details of the circumstances and nature of the restraint. This meets the immediate requirements from the last inspection. The manager now ensures that Regulation 37 forms are completed and sent to the Commission. This meets the requirement from the last inspection. There is now consistency in the use of kilogrammes when weighing residents. Residents are now weighed monthly to ensure increases and decreases can be 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 Page 6 seen quickly. This meets the recommendations made at 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. The summary of this inspection report can be made available in other formats on request. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 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.V349100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 Quality in this outcome area is good. Assessments provide details of the needs and aspirations of people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have still been no new admissions to Dove Lane since the last inspection or for the previous five years, but there was evidence on files that the home has links with placing authorities and has their continued support throughout the placement. This suggests that appropriate assessments are completed prior to admission, and that a continuous process of review is completed. Contracts were seen on the files inspected as part of the inspection. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is excellent. The clarity of the care plans for each person living in the home means that staff can assist them to be as independent as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The information in the care plans seen during the inspection was excellent, being both clear and specific. Any specialist requirements were detailed and the input from other services acknowledged. There was evidence of reviews and any changes in care plans that had been made as a result of the review were detailed. There was information on file to show how staff could recognise how individual residents make choices, and this was demonstrated during the inspection and confirmed when the inspector spoke to staff. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 Page 10 A risk assessment in relation to restraint for one person living in the home had been completed after the last inspection. This meets the immediate requirement from the last inspection. There was also a record with details of the circumstances and nature of the restraint. This meets the immediate requirement from the last inspection. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is excellent. Residents have opportunities to take part in activities that develop and enrich their social and personal lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 3 more staff have completed courses allowing them to drive the vehicle used by the home. This increases the number of drivers to 8. This will provide more opportunities for those who live in the home to have outside activities. Details of the variety of activities were seen, and on the day of inspection all staff and people who live in the home went out. Some went to a local pub for lunch and others went to the local nature reserve to eat. It was evident that the service as a whole, and the residents individually are viewed as a positive part of the community and have a high presence in the village. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 Page 12 The staff were aware of the likes and dislikes of the residents and understood body language and other non-verbal communications. This was demonstrated during the inspection, some evidence seen on files and also as a result of talking to staff. The people who live in the home have three activities in the home and four activities outside the home each week, these can include walks, swimming, entertainers, horse riding and hand massages. The manager stated that residents go to concerts and shows in some of the nearby towns, as well as more local activities. Staff said that there were always at least four staff on duty so that residents could go out individually rather than everyone having to go out as a group. The staff rota seen confirmed this. The daily notes completed continue to be information led and do not give much indication or description of whether the resident has enjoyed an activity or not. Information contained in the AQAA (and in conversation with the manager) showed that he is considering how to record this information. Staff were seen to take steps to minimise risks, whilst allowing residents to maximise their independence as far as possible. On files for people who live in the home there was evidence of telephone contact and visits by relatives. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is excellent. Residents receive personal support in the way they prefer, and staff understand the non-verbal communications ensuring their needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were details on resident’s files of hospital visits, podiatry, and GP visits to meet their health needs. One person living in the home had had a planned hospital admission and there were details on file. The home has new scales that enable those who live in the home to be weighed in their wheelchairs. Records seen during the inspection showed that the home records weights consistently in kilograms. The recommendation made at the last inspection has been met. Residents are now weighed monthly to ensure increases and decreases can be seen quickly. The recommendation from the last inspection has been met. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 Page 14 Information in the AQAA indicated that staff had completed research into equipment that would improve the experience of personal care for 2 people living in the home. The equipment was purchased by the individuals involved. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good The home has a system for the protection of vulnerable adults, which ensures the safety of people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A risk assessment and plan (in relation to a resident who sometimes needs to be restrained) is now in place. There was evidence that on any occasion where any physical restraint is used, this is recorded with details of the circumstances and nature of the restraint. This meets the immediate requirements from the last inspection. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,29,30 Quality in this outcome area is good. The home is comfortable and safe for the residents who live there, with all the necessary equipment to ensure they can be assisted safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The surroundings at Dove Lane are homely and comfortable. Most areas are in good order and the bedrooms seen were personalised and had the necessary equipment for the individual. The manager stated that a new cooker had been purchased for the home. The manager stated that although there will continue to be minor refurbishment, because of the building of a new home in the garden of the current home, no major work will be undertaken. The new build is still under consultation with the appropriate authorities and neighbours. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 Page 17 There were no odours and the rooms were clean and bright. The garden is large but the manager said that the change in disability of the people living in the home meant it is not used very much. One person living in the home has a specially designed swing in the garden and he was using this during the inspection. Staff said they are trained to use the equipment necessary to ensure the safety of those living in the home. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is poor. Staff receive the training necessary to meet the needs of people living in the home. The process of recruitment does not protect the people living in the home the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff files are kept in the homes Head Office and arrangements were made that 4 files were collected by the deputy manager on the day of inspection. Two members of staff had commenced employment prior to any legal check i.e. POVA First or Criminal Record Bureau check being completed. One member of staff had started work 8 days before a current enhanced CRB came through and the other 12 days. The manager stated he thought staff could begin work as long as good references had been received and that they did not work on their own with any person living at the home. An immediate requirement was made. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 Page 19 Information provided in the AQAA, talking to the manager and staff, indicated that they received regular training. The manager stated that staff have to demonstrate their abilities and competency before the areas are signed off as completed. LDAF training is provided. The home currently has staff vacancies of 135 hrs, (3 and a half w/t equivalents), which are covered by regular agency staff. The manager is aware that the home would benefit from more permanent staff but recruitment continues to be difficult. The staff rota was seen and indicated that there were 4 staff on duty am and pm, one waking night and one sleep in. Recently one person living in the home had been in hospital and on discharge required care from 2 staff. The home ensured that there were two waking staff each night to provide the necessary level of care. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is good. The home is run in the best interests of the residents. The corporate quality assurance report does not reflect the individual homes method of change or improvement to enhance the lives of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The evidence on the day of the inspection showed that the home was being effectively managed on a day-to-day basis. There were systems in place to monitor the operation of the home such as Regulation 26 visits, which were undertaken on a monthly basis. The information provided in these showed that they were being used to improve the service at Dove Lane. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 Page 21 The home has regular staff meetings, the last being 24/5/07. The minutes were seen. The results of resident surveys have been published in a report and made available to all interested parties, however it includes all homes in the Aldwick group and does not provide information on how each individual home will make changes or improvements as a result of the surveys. A recommendation was made. Regulation 37 forms are now completed and sent to the Commission when an issue about the health and safety of service users is in question. This meets the requirement from the last inspection. Information in the AQAA showed that the management in the home uses a variety of web sites, circulars and other methods to ensure that staff have up to date information available to them. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 3 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 3 4 3 LIFESTYLES Standard No Score 11 X 12 4 13 4 14 3 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 3 3 2 X X 3 X 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 Page 23 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 YA34 Regulation 19 Requirement Adequate POVA First/CRB checks must be made on staff prior to the commencement of employment at the home to ensure the safety of people living there. Timescale for action 20/08/07 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. Refer to Standard YA39 Good Practice Recommendations The corporate quality assurance report needs to reflect the individual homes method of change or improvement to enhance the lives of residents. 7 Dove Lane DS0000014894.V349100.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V349100.R01.S.doc Version 5.2 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. 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