Inspection on 17/10/05 for 83 Tennyson Road

This inspection was carried out on 17th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

83 Tennyson Road 03/02/09

83 Tennyson Road 02/10/06

83 Tennyson Road 03/02/06

83 Tennyson Road 15/02/05

83 Tennyson Road 23/12/04

83 Tennyson Road 12/01/04

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 83 Tennyson Road Luton LU1 3RR Lead Inspector Ansuya Chudasama Unannounced Inspection 17th October 2005 12:20 83 Tennyson Road DS0000014975.V258695.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 Tennyson Road DS0000014975.V258695.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 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 83 Tennyson Road Address Luton LU1 3RR 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 480641 01582 480641 Advance Support Ltd Care Home 4 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (4) of places 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2005 Brief Description of the Service: 83 Tennyson Road is a semi-detached residential care home situated in Luton and provides care for four adults who have long term mental health needs. Advance Housing and Support Ltd manage the home. The accommodation consists of three single service users bedrooms, a bathroom and toilet and the office/sleeping in room on the first floor. The ground floor contains a lounge, a single bedroom and a kitchen/diner. The utility room is accessed via the kitchen back door. There is a garden at the rear of the house and looks very attractive. The home is within walking distance of the two parks, public places and a regular bus service is available to the town. The town centre is around one kilometre from the home 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors and started at 12 20pm. It took place over 5 hours. The inspection comprised of a tour of some of the communal areas, talking to staff, and all service users. One service users’ file and other records were also inspected in detail. On the day of the inspection there were three service users living at the home and the home had one vacancy. The manager was off sick on the day of the inspection. Sonia James the support worker assisted the inspectors with the inspection. What the service does well: What has improved since the last inspection? What they could do better: The categories of registration needed reviewing because the home did not have any service users with a learning disability. The care plans needed 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 6 improving to reflect all care needs, aspirations, and goals of the individuals. The plans also needed to be reviewed as stated in the standard. Risk assessments on service users and the environment also needed to be clearer and easy to understand. The manager must be supernumerary on the staffing rota to manage this home and the sister home to undertake her legal duties as stated in the standard. The two homes must also be manages as individual homes and not as one. The concerns regarding smoking in the home was discussed in previous inspection reports. The home must find a solution to meet the needs of staff and service users who don’t smoke in the home. The inspectors were also concerned that the whole house smelled of tobacco smoke. The statement of purpose and service users guide needed reviewing to ensure that the services and facilities provided was accurate and up to date. 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 Tennyson Road DS0000014975.V258695.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 Tennyson Road DS0000014975.V258695.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): The home had a statement of purpose and a service users guide but the documents needed to include information that was accurate and user friendly to help prospective service users to make an informed choice of choosing the home. EVIDENCE: The home had a statement of purpose and a service user guide. The information in the statement of purpose needed reviewing to ensure that the information recorded was accurate and clear. The statement of purpose stated that the CSCI holds these documents in their office. However this is not the case. The commission inspects the homes documents on their inspections but do not keep copies of these documents. The statement of purpose indicated that the home had a services manager, a manager and a pending registered manager running the home. However the status of the person managing the home was unclear. This is further contradicted by the information provided in the staff chart whereby another staff member is identified as the manager of the home. The information on staffing states that the home has eight staff working at the home. However the staff rotas inspected showed that there were only three staff working at this home. Information on the staffing structure for the home was also required. The home needs to state the age range of the service users that the home admits as stated in their registration. Some of the information presented in the statement needs to be non discriminatory. The home needs 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 9 to expand information on adaptations that has been made to accommodate service users who are getting older. The statement of purpose states that “ only in exceptional circumstances would “advance expect the service user not to be aware of the application” to come to the home. The National Minimum standard states that all service users must be aware and involved in the whole admission process. It was stated that the statement of purpose was only given to the care managers. However it must also be given to prospective service users, their families and representatives. The inspectors were given a copy of the service users guide and the information did not meet the standard. The service users spoken to stated that they had been involved in the consultation process in producing the guide and they were aware of its presence. The last service user admitted to the home had visited the home prior to his admission. A pre admission assessment was not seen in the service users file. The staff spoken to stated that they had new admission assessments forms. It was stated that these would be completed for all new service users admitted to the home. Service users spoken to stated that the staff consulted them when new service users were being admitted to the home. Service users contracts were signed by them and kept in their files. 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 10 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): Service users care plans needed expanding to include all assessed needs to adequately provide staff with the information they need to satisfactorily meet service users needs. Risk assessments needed expanding and made clear, and easy for staff and service users to understand. EVIDENCE: The care support plan and Advanced individual plan of one service user was inspected in detail. The care support plan was not detailed and did not explain how the needs of the service user were being met. The Advanced individual plan for the service user had the same information as the care support plan but contained a little more information about the service user. The goals to be achieved by the service user had the time scale of a year. However, there was no evidence in the file to show that the care plans had been reviewed on a six monthly basis by staff or when required. The service user had been at the home for 17 months. The Advanced individual plan had information on personal hygiene but some of the information recorded needed to be in the restriction section. Information on service users health care needs needed expanding and needed to be in the care plan. The service user had a programme on challenging behaviour but this information was not recorded in 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 11 the care plan. The skill teaching objectives did not link with the information in the care plan. Some of the information recorded in the risk assessment was not available in the care plan. The service users smoking chart was seen on the office table, however the chart was not always completed properly and did not have a review date, and it was not signed by the service user or the home. There was no information to state how the service user was being supported by the home to mange his smoking. The information recorded on relapse indicators was also not accurate. The information on restrictions also needed expanding to explain the information recorded. Risk assessments were available in the service users file. However, most of the information recorded in the risks identified, needed to be in the hazards section. The risk assessments needed to be developed further to make them more clear and user friendly. They should be signed by the service users to state that they understand the risks. Some of the risks identified in the assessment information were not recorded in the care plan. 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 12 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): The meals in the homes are good offering both choice and variety. Service users engage in appropriate leisure activities to maintain and develop their independent living skills. EVIDENCE: The service users care plan for healthy diet stated that the service user should eat plenty of vegetables. However the inspectors were informed that if the service user ate too fast, this could lead to the person having problems with his throat, which could lead to choking. This information was not recorded in the care plan. All the service users spoken to stated that the food was nice and they were able to choose what they enjoyed. The service user that was case tracked was spoken to, and it was stated that they helped with house chores, and went out to the befrienders club, and the gym. Outings with the assertive outreach team and the home were also undertaken. The service user also stated that he some times helped with peeling the potatoes but he had never cooked a whole meal with support from staff. The service user liked living at the home and found the staff and service users were nice. All the service users stated 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 13 that they attended house meetings but felt, having them every two weeks was too much and asked for them to be held on a monthly basis. 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 14 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): The health needs of service users are met with evidence of good multi disciplinary working taking place. EVIDENCE: The service user that was case tracked had information on how the person’s personal care needs were being met. This was also confirmed by talking to the service user. It was also stated that he was supported by his social worker who was very nice and took him shopping to buy his clothes. The care plan inspected did not have information to state how the home would manage the service users asthma attacks. Also there was no information recorded in the care plan to explain the service users mental health needs or that the person was on an enhanced Care Programme Approach (CPA). The Health professionals undertook the CPA reviews regularly. The service user and staff spoken to were able to discuss how the health needs of the service user were being met. The service user was supported by health professionals and they monitored the persons mental health, medication and his general well being. The service user had recently seen the opticians and the chiropodist. The service user had signed the medication agreement form. The medication book seen was satisfactory. All staff that gave out medication to service users had received the accredited training. 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 15 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 16 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): The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to. EVIDENCE: The service users spoken to stated that they were given a complaints procedure. This was also discussed in their meetings. Service users had monthly link worker meetings with their key workers and they were able to discuss any concerns. 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 17 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): The standard of the environment within this home are safe, and homely. The home was not free from offensive odours of tobacco smoke and therefore the environment was not pleasant to work for those people who did not smoke. EVIDENCE: The home was clean but smelled of tobacco smoke. Two of the service users were observed smoking and helping with the clearing up after their lunch. It was not hygienic to smoke in the kitchen where food was kept and prepared. The laundry room linked to the kitchen also smelled of tobacco smoke and was used as a smoking area because there were ashtrays full lying in the room. The inspectors were informed that the home had a smoking policy and it was decided by the manager and service users that the kitchen and garden was to be used as a smoking area for all visitors, staff, and service users who smoked. The service users were also allowed to smoke in their bedrooms. The lounge was used as a non smoking area. However sitting in the lounge with the service users showed that the room was clean but it smelled of tobacco smoke. The inspectors were informed that the lounge had been decorated and the room looked pleasant. The home had staff who did not smoke. They had to cook in the kitchen and eat their meal with the service 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 18 users. The service users spoken to stated that they liked their bedrooms and they had recently had their rooms painted. 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 19 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): The staff rotas were combined with another sister home and the information was difficult to understand about staffing for the home. The staff have a good understanding of the service users support needs. EVIDENCE: The staff spoken to stated that she had supervision once a month, and staff meetings were held once a week or every two weeks. The staff meetings for this home and another sister home were held together. The information was difficult to understand because the inspectors were not aware which staff and service users belonged to which homes. The staff rota for the home was combined with the sister home. The staff on duty discussed the needs of one service user that she worked with. It was stated that the home was fully staffed. However interviews were held in July 2005 to employ casual/bank staff to work shifts when the home was short staffed. Evidence showed that the home still used agency staff. The staff on duty enjoyed working at the home. However it was stated that the working conditions could be better if they had better facilities to put their belongings away, and a better organised sleep-in room/office. Management also needed to take in to account the needs of staff who did not smoke. It was stated that the tobacco smoke affected their health, and their clothes and hair also smelled of this. The inspectors also noticed that their clothes and hair smelled of tobacco smoke when they left. 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 20 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 21 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): The health and safety systems in the home are good and protect staff and service users from potential risks. EVIDENCE: The service users spoken to stated that they were involved in fire drills. One service users radiator was still not working. The fire book showed that fire alarm testing, emergency lighting and fire drills were carried out regularly. The environmental risk assessments were difficult to understand. Information on what is a risk and a hazard was missing. The staff spoken to had received training on safe working practices. The CSCI were informed that the manager was going to be supernumerary on the staffing rota. However the rota showed that the manager undertook sleepin duties and also worked shifts. The manager must spend more time at undertaking her legal duties. 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 X 3 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 X 2 X 2 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 1 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 83 Tennyson Road Score 3 2 3 X Standard No 37 38 39 40 41 42 43 Score 1 X X X X 2 X DS0000014975.V258695.R01.S.doc Version 5.0 Page 23 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 YA6 Regulation 15 Requirement The registered person must expand service users care plans to include all areas of assessed need, which makes clear the type and level of support to be provided by staff. The service users plans must be reviewed on a six monthly basis or earlier with the service user and other relevant people. This requirement was not met from the last inspection. 31.2.05 2 YA37 10,18,24 The responsible individual must ensure that the manager is supernumerary on the staffing rota to manage the two homes and undertake her legal duties as stated in the standard. The managers working hours worked at the two homes must be recorded on the staffing rotas This requirement was not met from the last inspection. 28.2.05 3 YA37 10 The responsible individual must ensure that the two homes are managed as individual homes as DS0000014975.V258695.R01.S.doc Timescale for action 09/01/06 12/11/05 12/11/05 83 Tennyson Road Version 5.0 Page 24 stated in the NMS 4 YA28 13 The registered person must find a solution to meet the needs of service users who smoke and those staff and service users who don’t smoke in the home. This standard was not met since the last inspection. The registered person must ensure that the home is kept free from offensive odours. The registered person must ensure that the service users radiator in the bedroom is working properly. This recommendation was not met from the last inspection. 09/12/06 5 YA24 16 12/11/06 6 YA42 13 18/11/05 7 YA42YA9 13 The registered person must ensure that the risk assessments on service users and the environment are clear and easy to understand The registered person must ensure that the service users medical needs are recorded in the care plan. The registered person must ensure that the statement of purpose and service user guide is updated with accurate information about the services and facilities provided by the home. The home must undertake a pre assessment on all new service users admitted to the home. 20/12/05 8 YA19 13 12/11/05 9 YA1 4 20/12/05 10 YA2 14 12/11/05 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 25 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 Refer to Standard YA33 YA33 Good Practice Recommendations Ensure that the staffing rotas are undertaken separately for each home. . Ensure that staff meetings are undertaken separately for each home. 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 26 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 83 Tennyson Road DS0000014975.V258695.R01.S.doc Version 5.0 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!