Inspection on 29/11/05 for 8 Brantwood Road

This inspection was carried out on 29th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 Brantwood Road 24/10/08

8 Brantwood Road 18/10/06

8 Brantwood Road 13/04/05

8 Brantwood Road 20/01/05

8 Brantwood Road 02/08/04

8 Brantwood Road 17/02/04

8 Brantwood Road 08/07/03

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 8 Brantwood Road Luton LU1 1JJ Lead Inspector Pursotamraj Hirekar Unannounced Inspection 29th November 2005 16:30 8 Brantwood Road DS0000014993.V267364.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 8 Brantwood Road DS0000014993.V267364.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. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 8 Brantwood Road Address Luton LU1 1JJ 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 480642 Advance Support Ltd Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th March 2003 Brief Description of the Service: Advance Housing and Support Ltd is a charitable organisation providing services within the community to meet the needs of people who have either a learning disability or a mental health problem. 8 Brantwood Road is a semidetached house and is located near the town centre of Luton and overlooks the park. The home provides accommodation for five service users with mental health needs. All the service users have single rooms. The first floor has four bedrooms, a bathroom and utility room. The downstairs has one bedroom, a lounge and kitchen/diner, a toilet, separate smoking room and an office. There is also a small garden at the rear of the house. At the front of the building is a small driveway. The accommodation is not suitable for service users with mobility problems. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection that was undertaken by Ansuya Chudasama and Pursotamraj Hirekar on 29/11/05 between 16.30 and 18.40 hours. The staff member on duty was present throughout. The methods of inspection-included study of service users care plans, arrangement of their care, communal lounge, dining and smoking facility. Conversation took place with three service users, staff member on duty. Records relevant to the operation of the home were also studied. 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. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 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 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 The service users were aware of the home prior to their admission and their needs have been appropriately assessed. EVIDENCE: The service user whose situation was case tracked had all the necessary information prior to making a choice of the home. The needs and aspiration of the service user were systematically assessed. The service user had signed the terms and conditions with the home. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7&9 Care plans were adequately prepared and meet the changing needs of the service users. EVIDENCE: The service users whose situation was case tracked had care plans prepared in consultation with the service users. The care plan covered daily living skills, independent living, outdoors activity, cooking skills, manage money, personal needs, medication and the physical and mental health. Service user was encouraged to take part in the routine activities of the home including providing support to promote independent lifestyles. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 Page 9 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): 12,13,15,16 & 17 The various activities provided by the home help service users to improve their quality of life. EVIDENCE: The home was providing appropriate opportunities and support to service users to help them achieve skills that lead to a better quality of life. The various opportunities and activities the service users engage in include attending college, learning carpentry skills, participating in cooking meals at the home, watching television, reading and going to the gym once a week. The Service users spoken to, enjoy college activities and feel happy about the skills they have learnt. The service user case tracked was in regular touch with the family members and spends weekends with them. The service users enjoy their meals and help support in cooking. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 Page 10 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): 19 Service users’ health needs and emotional needs were appropriately met. EVIDENCE: The service user health care needs were appropriately met with regular appointments with the psychiatrist. The nurse administered injections as prescribed in the treatment plan. The service user expressed happiness with the positive outcomes of the treatment. The service user was feeling much better, appeared happy and looked more confident and the weight record also showed improvements. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 Page 11 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 Non-adherence to complaints policy and procedure puts the service users at risk of harm. EVIDENCE: There were no complaints recorded in the complaints register. However, the service user whose situation was case tracked had made two complaints to the staff member on duty about the mice eating chocolates and making sounds in the bed. The second complaint was about non-availability of hot water in the home for two days. None of these complaints were recorded in the complaints register and the service user felt that their grievances were not listened to and not acted on time. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 Page 12 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): 24, 30 The poor environmental risk assessment concerns and follow-up action of the home puts the service users at the risk of harm. EVIDENCE: The home was providing facilities including bedrooms, bathrooms, kitchen, dining space, community lounge, separate smoking room and toilets with sufficient privacy that meet their individual service users needs. However, there is poor maintenance of the environment standards. The service users have complained about the mice eating chocolates, making sounds in the bed and moving freely in the kitchen. Unable to bear the problem of mice, one service user had stayed at their father’s place for 6 days. The problem continued for over 9 days. At the time of this inspection, the inspectors’ have seen the mice moving in the kitchen from one corner to the other. The staff member on duty informed inspectors that the environmental health department of the home have been informed about the problem. The service user also, complained about the non-availability of hot water in the home for two days. The staff member on duty informed the inspectors’ that the engineer is expected to attend any time now. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 Page 13 At the time of inspection one service user burnt a finger while taking a hot pan from the oven. The inspectors’ found that the hand gloves used by the service user had holes and were not safe to hold hot objects. The home must undertake an environmental risk assessment immediately and implement actions suggested. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 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, 34 & 35 The inadequate staff recruitment and retention practices of the home do not provide quality services to the service users EVIDENCE: The staff member on duty is a casual staff and a student of mental health. The staff received training in health and safety, fire drill, food and hygiene, first aid and medication. The manager of the home imparted most of this training. There were no records provided on this inspection about the staff training and various pre-employment checks as required by the legislation. The staff review meetings are irregular. On this inspection one record of a staff meeting was found dated 13.09.05 and the next meeting was scheduled for 11.10.05. There was no evidence of this meeting and any other staff meeting that were held after 13.09.05. The staff member on duty was not aware of staff meetings. However, staff member on duty said that the manager supervises the work including medication to service users. The service users’ spoken to were not happy with the frequent changes of staff, which hampered the continuity of quality service. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 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): 37, 39, 42 The home does not have a full time manager to run the home professionally which compromises with the needs of the service users. EVIDENCE: The home does not have a fulltime-registered manager. The current manager is responsible for 8 Brantwood and 95 Ashburnham road and not able to cope with the demands of both the homes. The records of service users including, complaint register, risk assessments, and care plans were not updated. The staff supervision records are incomplete. The service users complaints not recorded and their concerns not acted upon in time. Staff turnover, absence of continuity of quality service to the service users’ were issues that do not match with the core values and principles of the home and also does not meet the needs and aspirations of the service users’. 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 Page 16 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 X X X Standard No 22 23 Score 1 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 1 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 1 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 Standard No 37 38 39 40 41 42 43 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 8 Brantwood Road Score X 3 X X 1 X 1 X X 1 X DS0000014993.V267364.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 YA23 Regulation 13 (6) 21 22(3) Requirement The home must have robust procedures for responding to neglect and to ensure the safety and protection of service users The registered provider must ensure that all complaints made to the organisation are fully investigated. (Previous time scales 31.07.05 not met) The home must provide sufficient and suitable kitchen equipment for preparation of food The home must ensure that the home is clean, provided with hot and cold water and undertake consultation with authority responsible for environmental health and implement outcomes of environmental risk assessments The CSCI must be informed of the action taken to restore the hot water, interim arrangements for the provision of hot water and the date when the supply is/was restored The CSCI must be informed of the action taken to remove the infestation of vermin, the action DS0000014993.V267364.R01.S.doc Timescale for action 15/12/05 2. YA22 15/12/05 3. YA24 16 (2) (g) 15/12/05 4. YA30 23 (2) (d) (j) (5) 15/12/05 5 YA30 37 15/12/05 6 YA30 37 15/12/05 8 Brantwood Road Version 5.0 Page 18 7. YA34 18 (1) 8. YA37 Schedule 4 (12)(b) 24 (1) 9. YA39 10. YA42 12(3) 13 (4) taken on the advice of the environmental health officer and the date when the problem has been resolved. The home must ensure continuity of quality care to service users to meet their needs. (Previous time scales 30.02.05 and 31.07.05 not met) The home must ensure to prevent any incidents that is detrimental to the health or welfare of service users The home must ensure to regularly review at appropriate intervals to improve care. (Previous time scales of 01.09.05 not met) The home must take into account the wishes and feelings of service users and keep all parts of the home free from hazards for the safety of service users. (Previous time scales of 28.03.05 and 31.07.05 not met) 31/12/05 15/12/05 15/12/05 15/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA22 YA32 YA35 Good Practice Recommendations The registered person should up date the complaints policy The home should always ensure competent and qualified staff are employed to sustain quality care The home should ensure that the staff employed are trained appropriately and their skills are regularly updated 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 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 8 Brantwood Road DS0000014993.V267364.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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