Inspection on 07/02/06 for 7 Dove Lane

This inspection was carried out on 7th 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 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 13/09/05

7 Dove Lane 02/03/05

7 Dove Lane 12/08/04

7 Dove Lane 20/02/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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 Unannounced Inspection 7th February 2006 16:10 7 Dove Lane DS0000014894.V283181.R02.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 7 Dove Lane DS0000014894.V283181.R02.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. 7 Dove Lane DS0000014894.V283181.R02.S.doc Version 5.1 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.V283181.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 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.V283181.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place under two hours. The inspection was comprised of a tour of the lounge, kitchen and dinning room areas, talking to staff and service users. Some of the standards not inspected at the last inspection were looked at this inspection. This report should be read in conjunction with the last inspection report undertaken on the 16/8/2005 The inspector would like to thank the staff and service users who helped with the inspection What the service does well: What has improved since the last inspection? The staff and service users were looking forward to having an extension and some parts of the home being refurbished. 7 Dove Lane DS0000014894.V283181.R02.S.doc Version 5.1 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. 7 Dove Lane DS0000014894.V283181.R02.S.doc Version 5.1 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.V283181.R02.S.doc Version 5.1 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): 0 None of the standards were assessed on this occasion but these were all assessed and met at the last inspection. EVIDENCE: 7 Dove Lane DS0000014894.V283181.R02.S.doc Version 5.1 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): 10 Staff respect service users information given to them in accordance with the homes policies and procedures and therefore this ensured that service users confidentiality was maintained. EVIDENCE: The staff at the home had done training on confidentiality and they worked with the homes policies and procedures. Service users files were kept secured in the office. 7 Dove Lane DS0000014894.V283181.R02.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15,17 Service users engage in appropriate activities in the home and in the community. EVIDENCE: The inspector was informed that the home had two members of staff who monitored service users activities in the home and in the community. The service users were offered choices at meal times and for choosing their clothes. A service user confirmed this by shaking their head. One service user had their families visit them twice a week. However the staff kept in touch with other service users families by telephone. All families are also invited to Christmas parties and some also help out with this. 7 Dove Lane DS0000014894.V283181.R02.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): 0 None of the standards were assessed on this occasion but these were all assessed and met at the last inspection. EVIDENCE: 7 Dove Lane DS0000014894.V283181.R02.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): 22,23 The homes policies and procedures ensure service users are protected and safe guarded from abuse EVIDENCE: The inspector asked one of the service users, if they knew how to inform the staff when they felt unhappy. The service user was not able to use verbal communication, however the person used body language and verbal noises to inform staff when they were not happy. The staff spoken to understood the needs of the service user. Examples of behaviours used by the service user to tell them how the person was feeling were given. The service user spoken to confirmed this by nodding their head. All staff had training on adult protection. However refresher training was requested. The complaints policy was updated and available in the service user guide. The home had not received any complaints or POVA investigations. 7 Dove Lane DS0000014894.V283181.R02.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): 0 None of the standards were assessed on this occasion. The inspector was informed that some parts of the home were being refurbished and they were still waiting for the date of when the extension was to commence. EVIDENCE: 7 Dove Lane DS0000014894.V283181.R02.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,36. The staff team on duty were competent and experienced to meet the needs of the service users in the home. EVIDENCE: The home had two fulltime and one part time vacancy for support workers. Agency and permanent staff were used to cover the hours. The deputy manager of the home was helping out at another sister home. The home had low sickness levels in year 2005 and in January 2006. The staff spoken to stated that they had supervision. Positive Comments were received from staff about working in the home. For example, service users ”are our family” and they had a “brilliant manager and deputy”. The home was described as a “ lovely home”. The staff spoken to had attended many training courses and had completed NVQ level 3. The staff were observed talking to service users in a sensitive and kind manner. 7 Dove Lane DS0000014894.V283181.R02.S.doc Version 5.1 Page 15 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): 38, 39 Some monitoring of the home was taking place but there was not a formal overview of this process of quality assurance. 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. These were Regulation 26 visits, which were undertaken on a monthly basis. It was also stated that a service users satisfaction questionnaire was undertaken. However there was no evidence to state when this had been carried out or where the analysis was kept. The inspector was informed that the home wrote reports on day care services undertaken by service users. These reports were discussed at their quarterly stakeholders meetings. However all the information needed consolidating into one formal quality monitoring process. 7 Dove Lane DS0000014894.V283181.R02.S.doc Version 5.1 Page 16 The staff on duty were not able to find an annual development plan. The paper work in the office needed to be better organised and staff needed to be informed where certain information was kept. The inspector was informed that the office was too small to accommodate all the records and it was stated that the extension was going to create more space for storing paperwork. 7 Dove Lane DS0000014894.V283181.R02.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 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X 3 2 X X X X 7 Dove Lane DS0000014894.V283181.R02.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 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. The registered person must ensure that all staff files are available for inspection. Standard not inspected on this occasion. Timescale for action 30/04/06 2. YA34 17 30/05/06 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.V283181.R02.S.doc Version 5.1 Page 19 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.V283181.R02.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. 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