Inspection on 03/02/06 for 83 Tennyson Road

This inspection was carried out on 3rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 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 17/10/05

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 Mr Pursotamraj Hirekar Unannounced Inspection 3rd February 2006 14:37 83 Tennyson Road DS0000014975.V272314.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.V272314.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.V272314.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.V272314.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 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. Ann Dalton is the registered manager. 83 Tennyson Road DS0000014975.V272314.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 carried out at 2.37 pm on 03.02.06 and at 1.17pm on 06.02.06 over 4 hours by PursotamRaj Hirekar. The manager and the support worker co-ordinated the inspection through out. The method of inspection included study of care plans, risk assessments, related care documents, conversations with service users, discussion with the manager and staff and tour of the home. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure to draw up care plan with the involvement of the service users, together with family, friends and relevant specialists The home must ensure that the service users smoke only in designated areas that are practicably free from avoidable risks to the health and safety of service users. The home must provide adequate rest between shifts to the staffs to ensure the quality of care service delivery is not compromised. The home should ensure that the staff deployment rota indicate the actual time spend by the manager at this home. The home should ensure exclusive staff meeting are also held. 83 Tennyson Road DS0000014975.V272314.R01.S.doc Version 5.0 Page 6 The home should speed up the completion of all care plans review and transfer all the information on new care plan tool. 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.V272314.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.V272314.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): 1,2, The home had made appropriate arrangements to provide relevant information to prospective service users, to enable them to take a decision prior to their admission. EVIDENCE: The statement of purpose and service users guide was reviewed in September 2005 to incorporate the shortfalls that were identified in the previous inspection which include, standalone staff teams for 94 Tennyson Road and 83 Tennyson Road, emphasis on 83 Tennyson Road being 24 hours service, not for nursing care, clear organisational structure, age of service users. The revised statement of purpose and the service users’ guide were comprehensive and self-explanatory detailing services and facilities offered by the home to enable potential service users to take a decision. A new service user who joined on the 16.01.06 his needs were assessed and a care plan was prepared, signed by the manager, social worker and the service user. 83 Tennyson Road DS0000014975.V272314.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 In the absence of a multi disciplinary team to provide inputs on needs and risks assessment the service users actual needs may not be met. EVIDENCE: The home had taken adequate steps to revisit existing care plans and risk assessments of service users and developed a new care plan format. The new care plan format developed was comprehensive and structured in way that enabled to record the information systematically which can be easily understood. The new care plan format had considered and focussed on the outcomes of risk and needs assessments. However, the work was in progress. The outcomes of the review conducted on 24.10.05 for a service user was being transferred on the new care plan tool. The manager said that all service users’ care plans would be on the new tool before 01/04/06. The manager and the staff have taken adequate steps to revisit care plans and update on the basis of the reviews undertaken. The service users’ needs and aspirations were assessed. However, the assessments were not comprehensive to cover all physical, mental and health needs of the service user. The needs assessment needed inputs from a 83 Tennyson Road DS0000014975.V272314.R01.S.doc Version 5.0 Page 10 multidisciplinary approach with subject specialist detailing various dimensions of changing needs and goals of service users. 83 Tennyson Road DS0000014975.V272314.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): 12,13, 16 Service users were encouraged to lead a normal life. EVIDENCE: In consultations with the service users, the home had developed a daily schedule of home activities that they attended which included cooking, washing and cleaning, that they do on rotation. The staff encouraged the service users to improve their daily living skills in personal hygiene, shopping, healthy eating, visiting the bank and the post office. The other service user spoken to have stated, that he had enjoyed his stay at the home and the staff were supportive to meet his needs. 83 Tennyson Road DS0000014975.V272314.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: 83 Tennyson Road DS0000014975.V272314.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: 83 Tennyson Road DS0000014975.V272314.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 30 The home was free of offensive odours. However, the home must closely monitor new service user from smoking in the non-smoking area. EVIDENCE: The manager, staff and the service users have designated the dining area for smoking when not used for dining purpose. The new service user who was admitted on 16.01.06 smokes in communal areas including the dinning room. The manager had said that a member of the staff is working with the service user to help him understand and accept to smoking only in the designated areas. The manager also said that Advance had just concluded a consultation on smoking policy and the new policy would be implemented by the end of February 2006. However, the details of the new smoking policy were not available on this inspection. The home was clean and free of offensive odours. The manager said that the carpets were regularly shampooed. 83 Tennyson Road DS0000014975.V272314.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 The staff were qualified and appropriately trained for their jobs. The home must provide adequate rest between shifts to the staffs to ensure the quality of care service delivery is not compromised. EVIDENCE: The staff and the service users have had good working relations. The service users stated that the staffs were good and attended to their needs as and when required. The staff were qualified, experienced, trained and had clarity of their roles and responsibilities. The discussions with the staff and study of staff deployment rota indicated that the casual staff member on duty on the day of this inspection started her work at 7.00am on 05.02.06 and continued until 2.00pm on 06.02.06. The other staff member who had started at 2.00pm on 06.02.06 would continue until 4.30pm on 07.02.06 that include one night shift. The current pattern of staff deployment which, makes staffs work continuously for three shifts can be harmful to the staffs as well as service users. The home must ensure that the staff get sufficient breaks between shifts and perform their roles and responsibilities in the best interest of the service users without compromising on quality of service delivery. 83 Tennyson Road DS0000014975.V272314.R01.S.doc Version 5.0 Page 16 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, 42 The recently introduced improvements to manage the home effectively were a positive step forward. However, needed to speed up before any service users are exposed to risk of harm. EVIDENCE: The home now has a registered manager. The manager had taken appropriate measure to ensure that the care plans were systematically prepared and comprehensive in nature. However, this work was in progress and needed speedy action. The need and risk assessments of service users must have the involvement of subject specialists along with trained support worker as and when required to pre-empt any risk of harm and also to meet the actual needs of the service users. The manager and the staff have good working relations that promote the interest of service users. The home had an independent information management system on staff rota and staff personal files. However, the staff meeting were held in conjunction 83 Tennyson Road DS0000014975.V272314.R01.S.doc Version 5.0 Page 17 with the sister home and there was no clarity on how much time the manager spends at the other home, 94 Tennyson Road. The manager said that they would revisit the staff meeting and managers time schedule and implement as required by the NMS. 83 Tennyson Road DS0000014975.V272314.R01.S.doc Version 5.0 Page 18 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 X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X 3 X X 2 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 83 Tennyson Road Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 3 X DS0000014975.V272314.R01.S.doc Version 5.0 Page 19 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(1) Requirement The home must ensure to draw up care plan with the involvement of the service users, together with family, friends and relevant specialists The home must ensure that the service users’ smoke only in designated areas that are practicably free from avoidable risks to the health and safety of service users’. (Previous requirement 09/12/06) The home must ensure that the staffs have adequate rest between shifts and that the quality of care service delivery is not compromised. Timescale for action 01/04/06 2. YA28 13(4) 28/02/06 3. YA34 13(4) (c) 15/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA37 Good Practice Recommendations The home should ensure that the staff deployment rota indicate the actual time spend by the manager in relation DS0000014975.V272314.R01.S.doc Version 5.0 Page 20 83 Tennyson Road 2. 3. YA37 YA37 to the other sister home The home should ensure exclusive staff meeting are also held The home should speed up the completion of all care plans review and transfer all the information on new care plan tool 83 Tennyson Road DS0000014975.V272314.R01.S.doc Version 5.0 Page 21 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.V272314.R01.S.doc Version 5.0 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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