Inspection on 01/02/06 for 83 Burgh Road

This inspection was carried out on 1st 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 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

83 Burgh Road 20/12/06

83 Burgh Road 29/09/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 83 Burgh Road 83 Burgh Road Skegness Lincolnshire PE25 2RW Lead Inspector Wendy Taylor Unannounced Inspection 09:00 1 February 2006 st 83 Burgh Road DS0000056745.V262157.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 83 Burgh Road DS0000056745.V262157.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. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 83 Burgh Road Address 83 Burgh Road Skegness Lincolnshire PE25 2RW 01476 562777 01476 562671 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) Thera Trust Ms Diane Quarton Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28 April 2005 Brief Description of the Service: 83 Burgh Road is a detached bungalow located on a main road leading to the Skegness sea front area. It is in easy reach of the town centre and sea front amenities, including shops, pubs, banks and leisure establishments. There are good local transport links. The bungalow is situated on a good sized plot, with ample parking and garden space. There are 3 single occupancy bedrooms. The gardens at the rear of the property are laid to lawn and accessible to all service users. There is a garage and a range of outbuildings leading off the parking area to the side of the property. The home is registered to provide a short break service for up to 3 adults with learning disabilities at any one time. Thera Trust maintains the home. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days in February 2006 so as to ensure that people who use the service were included in the inspection. General record keeping, policies and procedures were assessed along with individual files for people who use the service and the staff team. The inspector spent time talking to people who use the service and the staff members who were supporting them; and a tour of the home was carried out. Many of the key standards were assessed at the previous visit and no shortfalls were found, therefore they have not been looked at during this visit. There were no outstanding requirements or recommendations from the previous inspection and only one recommendation was made at this visit. What the service does well: What has improved since the last inspection? What they could do better: Although there are no requirements or recommendations made regarding care plans, the home is aware of the need to reinstate previous care plan formats as soon as possible to ensure that detailed and appropriate information is retained. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 6 It has also been recommended at this visit, that the home develop a more formal recording and monitoring system in regard to reviewing and auditing individual care files. 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. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,4 The home provides clear information about the service and people who use the service benefit from being able to spend time there prior to admission. EVIDENCE: The home now has a completed service user guide, which contains information required by Regulation 5 of the Care Homes Regulations 2001. Individual records contain evidence that all service users and relatives have been supplied with a service user guide. It also refers people to the service information file kept in the home, which gives further details about the home and what it provides. The home now provides evidence that service users and their relatives have the opportunity to visit the home prior to their first admission. This is recorded within daily records and maintained on individual files. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 The home provides comprehensive, person centred care plans and enables people who use the service to maintain their independence in a safe and supported manner. EVIDENCE: The home has recently transferred care plan information onto new formats that that are not appropriate to short break services. The manager said that the previous format will be reinstated as soon as possible, however plans relating to areas such as emotional health, behaviour, communication and 24 hour routines remain in place. People who use the service said that they could choose what they want to do and what they want to eat. They said that they could usually also choose what bedroom they wish to stay in. There are new formats in place for risk assessing and there was evidence in records that the manager had set goals for each named worker to complete transfer and updating of the information. Staff demonstrated that they were aware of their roles in this respect. Risk assessments include areas such as mobility and road safety. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 10 All individual care files now contain a photograph of the person who uses the service. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 People who use the service are encouraged to maintain and develop a range of social and leisure pursuits in a safe and supported manner. EVIDENCE: There is an activity file available in the home that contains information about local leisure and social facilities. Staff said that this is used to enable service users to make informed choices about what they want to do when they come to stay at the home. There is evidence in records that one member of staff has been appointed to monitor and update this file. Activities that people engage in are recorded in their individual daily records for example, swimming, meals out and cinema trips. There are policies and risk assessments in the home relating to the provision of activities in general and there are specific ones about horse riding and swimming. People who are currently staying at the home said that they like to watch TV and videos, do Karaoke and go for walks. They also said that they attend their usual day services during the week. In a recent Thera Trust news letter there was a report of an open day held at the house to celebrate their first anniversary of their opening. Various activities 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 12 were photographed and described, and they demonstrated an inclusive approach to the day. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. All standards were inspected at the last visit and no shortfalls were found. EVIDENCE: 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 14 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): These standards were assessed at the previous inspection and no shortfalls were found. There has been no complaints or adult protection issues raised since the last visit. EVIDENCE: 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 15 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): These standards were not assessed at this inspection. All standards were inspected at the last visit and no shortfalls were found. EVIDENCE: 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 16 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): 34,35,36 People who use the service benefit from being supported by a staff team who are well trained and supervised, and who have undergone a robust recruitment process. EVIDENCE: Staff files now contain an information sheet to demonstrate that Criminal Records Bureau checks, references, application forms and photographs etc have been obtained prior to employment, although the documents themselves are retained at Thera Trust head offices. There is a clear recruitment policy as well as one for training and development. Staff said that they receive a good training package that includes basic food hygiene, first aid, adult protection, autism and epilepsy. They said that they have access to NVQ Level 2 training and they feel that training equips them to meet the needs of the people who use the service. There is evidence on individual files that the registered manager is currently undertaking reassessments for all staff in the areas of medication and record keeping. Staff said that they have regular supervision sessions and an annual appraisal, and there was evidence in individual files to confirm this. They said that they are able to discuss training needs and performance issues at supervision. They demonstrated that they have a clear understanding of their roles within the 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 17 home and they were able to describe in detail the needs of the people who use the service. People who use the service said that they like all of the staff and they can ‘have a laugh’ with them. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 18 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): 37,39,41 People who use the service benefit from a quality assurance system, which ensures that they and their relatives are consulted and involved in the development of the service. Records are well maintained. EVIDENCE: There is a quality assurance policy and framework for the home. An independent quality assessor visits on a six monthly basis and provides a report of their findings. Two reports were seen at the visit and both were positive in their outcomes. They also demonstrate the involvement of all relevant parties. The registered manager and the deputy manager said that they meet with local placement officers on a six monthly basis to review placement plans and to ensure that compatibility of needs, wishes and any known friendships are taken into account. They also described how audits of individual files are being undertaken at present but no records are kept. Discussion took place about more formal processes and a recording system. The home has a record keeping policy in place. Daily records demonstrate that the home follows individual care plans and gives clear descriptions of any 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 19 behavioural issues, activities undertaken, food eaten and any referrals made. There are records kept for accidents/incidents such as slips or falls. A discussion took place regarding notifications to The Commission for Social Care Inspection (CSCI) under Regulation 37 of the Care Homes Regulations 2001, and the type of events that need to be reported. There is a new system for recording visits to the home by senior managers and CSCI receive copies of these reports. There is a policy regarding staff consultation and staff said that the manager is very approachable and she listens to individual views and ideas. They said that managers are always available for advice and support, and they have regular staff meetings at which they can air their views. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 20 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 X X 3 X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 83 Burgh Road Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X 3 X X DS0000056745.V262157.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No 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. 1 Refer to Standard YA41 Good Practice Recommendations It is recommended that the home develop more formal recording and monitoring systems for auditing individual care files. 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 83 Burgh Road DS0000056745.V262157.R01.S.doc Version 5.0 Page 23 - 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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