Inspection on 16/02/07 for 75-77 Wickstead Avenue

This inspection was carried out on 16th February 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

75-77 Wickstead Avenue 27/02/09

75-77 Wickstead Avenue 25/01/06

75-77 Wickstead Avenue 08/08/05

75-77 Wickstead Avenue 14/03/05

75-77 Wickstead Avenue 27/09/04

75-77 Wickstead Avenue 05/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 75-77, Wickstead Avenue Luton Bedfordshire LU4 9DW Lead Inspector Mr Paul Worthy Unannounced Inspection 16th February 2007 12:00 75-77, Wickstead Avenue DS0000014986.V330347.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 75-77, Wickstead Avenue DS0000014986.V330347.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. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 75-77, Wickstead Avenue Address Luton Bedfordshire LU4 9DW 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) 01582 504217 F/P 01582 504217 www.mencap.org.uk Royal Mencap Society Mrs Anita Meaton Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: Five adults with learning disabilities live at the home. Mencap is the registered provider, while Aldwyck Housing Association owns the building. On the first floor there are five single bedrooms, two bathrooms and toilets and a sleep-in room for one member of staff. On the ground floor there are two lounges, an office, laundry facility, dining area and kitchen, and a large conservatory. There is a well-maintained garden to the rear of the house. Two adjoining semi-detached houses had been converted into one property, which is not distinguishable from the other houses in the residential area of Luton where it is located. Shops and some local services are all within walking distance. Public transport into Luton town centre runs near the home. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 12.00 p.m. It took place over 7 hours. The inspector met two of the people living at the home and spoke to three staff. Records were also seen. The pre-inspection information sent by the manager was also taken into account. The inspector would like to thank everyone at the home for their help. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs and aspirations of those considering moving to the home would be assessed to ensure that they could be met in ways that they chose, and this assessment would then be kept up to date if the person moved to live at the home. EVIDENCE: There had been no recent moves to the home but Mencap had good policies and procedures relating to people considering moving to the home. Initial assessment documents were seen as well as the updating information that was produced to ensure that the current needs of the service users were being addressed. Talking to staff showed that they were very aware of service users current needs and that where doubt arose because of changing needs appropriate professional advice was sought. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good service user plans, which ensured that the needs of those living at the home would be met in ways that took account of their wishes and supported them to be as independent as possible. EVIDENCE: There was comprehensive and up to date assessment and planning information on the personal files of those living at the home. This included risk assessments to ensure that independence and autonomy was supported in safe ways. Staff spoken to were very aware where the service users were at risk and needed extra support. There was ongoing work to ensure the involvement of those living at the home in planning for their own lives through the use of person centred planning. This included the use of photography to provide a record of peoples’ lives and help in communication. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 9 The key workers monthly reports provided an ongoing updating of the assessment and planning information. There were arrangements in place to ensure that those living at the home were involved in the decisions associated with the home’s group living environment. Staff were seen throughout the day to involve those living at the home in decisions about what they wanted to do. Staff also referred to the changing needs of those living at the home and the way other professionals were involved in monitoring those changes. The main working file for each service user was intended to be owned by them and included a user-friendly plan, which was written in the first person. These gave a clear and comprehensive picture of the needs of the service user and how they were being met. There was referencing to other sources of information such as risk assessments and guidelines for helping service users with special needs. The files were, however, very full and difficult to navigate. They contained documents in user-friendly format relating to planning and also to building up both a past and ongoing life storybook. There were plans to review these folders and rationalise them to make them more manageable as working tools. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those living at the home were provided with the support they needed so that they were able to maintain appropriate and fulfilling life styles in and outside the home. EVIDENCE: All those living at the home were being supported to be involved in a wide range of activities. A weekly list of activities was seen. It was drawn up by a staff member each week with those living at the home. It included the regular activities such as going to a day centre or college and the activities for times that are not pre-booked. The activities provided the opportunity for individual development as well as leisure activities. One service user expressed disappointment that a college cookery course had been cancelled because of 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 11 financial cutbacks. The leisure activities included holidays. All thee service users had regular contact with the local community. The service users plans indicated that good contact with relatives and friends was being supported and this was borne out talking to staff and a service user. Staff indicated how supportive to the home relatives were. The home was seen to be operating in a way that created a group living situation. This included all those living at the home being gently encouraged to participate in domestic activities while supported by staff. It was seen that this helped those living there to maintain as much independence as possible and develop independent living skills. There were arrangements for involving those living at the home in decisions relating to their daily lives, including meals. Appropriate arrangements for meals, including staff supporting those living at the home to eat in a healthy way were seen to be in place. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 12 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff were providing appropriate care and support to those living at the home to ensure that they maintained as much independence and good health as possible. EVIDENCE: There was seen to be good assessment and planning information relating to care, support and health needs. The personal support and care provided was seen to be appropriate to individual needs. There was awareness on the part of staff of the changing care and health needs of some of the service users and there was an appropriate involving of other professionals to help in the assessing these changing health needs. The service users plans provided information relating to the type of personal care that was needed. The assessment and planning information about the medical needs of those living at the home was seen to be up to date and to cover routine, emergency and ongoing medical care. Appropriate arrangements for managing medication were seen to be in place. This included excellent medication profiles for each service user. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 13 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were effective arrangements for identifying and responding to the concerns and complaints of those living at the home to so that they felt listened to and safe. EVIDENCE: Mencap has good formal policies and procedures relating to the making of complaints. The excellent relationships that staff had with those living at the home were seen throughout the day of the inspection and the way their views were listened to and encouraged. This provided a context in which any concerns or requests that the service users had would be picked up on. Service users confirmed that they knew how to make complaints and felt they would be listened to. There had been no complaints since the last inspection. Appropriate procedures were in place to ensure that incidents of abuse or possible abuse would be dealt with. A recent incident provided evidence that this was effectively implemented and the appropriate authorities involved including CSCI. This provided further evidence that service users were listened to and supported when they expressed concerns. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 14 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation was well maintained and furnished so that it provided those living there with a homely and comfortable environment. EVIDENCE: The accommodation was on a comfortable domestic scale and those living there were seen to be very much at home and able to move around as they wished. The service users were seen to be relaxed in the home and treat it as their home. Talking to staff provided evidence that there was ongoing monitoring to ensure that the environment continued to meet their changing physical needs. It was observed that the home was being kept clean and fresh and that there were appropriate arrangements in place to ensure hygiene and infection control. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff were appropriately trained and organised to ensure that all the needs of those living at the home would be met. EVIDENCE: There was a staff rota that reflected the staffing on the day of the inspection. Acceptable staffing levels were being maintained when service users were at home. The staff confirmed that there were enough staff to meet the needs of those living at the home and ensure that normally they could undertake their planned activities. There was also an ongoing programme of NVQ training. There were records of the training undertaken by staff. Talking to the staff and observing their interaction with those living at the home provided evidence that there was a good knowledge of the service users and their needs. This enabled them to 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 16 support the service users to live as independently and fully as possible. There was supportive ongoing interaction with the service users throughout the day. There was an awareness where specialist knowledge was needed to work with particular service users and courses had been organised for staff to cover such areas. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed so as to ensure that the needs of those living at the home were met in ways that reflected their wishes. EVIDENCE: The home was seen to be operating in an open, positive and inclusive way, which emphasised that it belonged to those living there. There were day-today arrangements to ensure that those living at the home were involved in decision-making. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 18 Mencap was seen to have introduced an excellent system for monitoring and reviewing the quality of the service being provided to those living at the home. It included a policy and procedure that detailed a continuous improvement programme. It also included a diagram of the process. The latter made clear how person centred planning arrangements lay at the heart of the process. The process will include a managers monthly report. The monthly visits on behalf of Mencap (regulation 26 visits) now cover a far wider area in a systematic way and constitute a part of the overall process. Staff understood that the manager had either completed an annual development plan or was in the process of doing so. Mencap had very comprehensive health and safety policies and procedures. There were good systems seen to be in place for monitoring health and safety issues, including risk assessments, which were both general and specific to individual service users. 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 19 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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 20 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. Standard Regulation 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. Refer to Standard Good Practice Recommendations 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 21 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 75-77, Wickstead Avenue DS0000014986.V330347.R01.S.doc Version 5.2 Page 22 - 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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