CARE HOME ADULTS 18-65
9 Grace Road 9 Grace Road Leicester Leicestershire LE2 8AD Lead Inspector
Steve Hunnybun Unannounced 24 May 2005 9:30am
th 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 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 Stationary 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. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service 9 Grace Road Address 9 Grace Road Leicester Leicestershire LE2 8AD 0116 2331035 0116 2331005 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 9 Grace Road Limited Mr Robert Phillip Tweddle Care Home 17 Category(ies) of MD Mental Disorder (7) registration, with number of places DE Dementia (2) LD Learning disability (17) PD Physical disability (17) SI Sensory Impairment (6) 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: No person falling within category PD may be admitted to the home unless that person also falls within category LD ie dual disability. Date of last inspection 16th November 2004 Brief Description of the Service: 9 Grace Road is situated in a quiet area on the outskirts of Leicester, close to a variety of community amenities and transport links. The home provides care and support to seventeen adults who have a learning disability in addition to communication difficulties, physical disabilities, dementia and/or sensory impairment. Each resident accesses day care, either via a college, a day centre or the homes own provision. The home has bright and comfortable communal areas, fully equipped bath/shower rooms and a large, enclosed garden. Residents are accommodated in single bedrooms apart from two that are happy to share. Communal areas are on the ground floor and the first floor with access via two staircases and a lift. The communal areas consist of a large, attractive lounge/dining room, two day-care rooms and a sensory room. The home also has a “training kitchen.” The house is pleasantly decorated and furnished. Residents bedrooms have been personalised with possessions and decor. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over four hours and was the home’s first statutory unannounced inspection this year. Three residents files were tracked. One of the residents had lived at the home for about six weeks and the other two for some years. The inspector met with the residents and observed them in their day care provision. He also joined two of them for lunch. Two members of staff spoke with the inspector. What the service does well: What has improved since the last inspection? What they could do better:
The inspector discussed with a member of the management team that one of the files tracked was disorganised and contained several copies of one document. The information in the file was acceptable apart from this. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 Page 6 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. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 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 standard(s) 2 The home is commended for the depth of information gained in its assessments, which will enable staff to meet residents’ needs. EVIDENCE: All files tracked contained comprehensive assessments generated within the home as well as community care assessments from social services. The newest referral also had copies of assessment from his previous placement. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 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 standard(s) 6,7,9 Residents’ needs are reflected in their care plans; they are enabled to make choices and to take risks. EVIDENCE: All residents’ files contained very useful care plans. Each plan is subject to a six-monthly review and this is recorded on a separate sheet. Files also included care plans generated as part of the community care assessment. The residents and the home’s staff had clearly contributed to this care planning process. Residents are enabled to make choices in areas such as the décor of their rooms, their food and day care activities. This was observed on the day of the inspection. All residents have comprehensive risk assessments that inform staff how to enable them to enjoy activities that may otherwise be perceived as risky. Staff have attended risk assessment training and spoke very positively about this. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16,17 Residents are offered suitable activities both within the home and the local community. Appropriate relationships with family and friends are encouraged. The food appears good and is served in relaxed and pleasant surroundings. EVIDENCE: The provision of activities such as painting, drawing and music enhances residents’ quality of life. Residents are enabled to be part of the community; trips and outings are organised to local pubs, parks and sport venues. All files tracked contained information about contact with family and friends. Residents appear to have free access to the home within their risk assessments. The inspector joined a group of residents for lunch and the food appeared tasty and nutritious. Residents reported that it was delicious. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 Page 11 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 standard(s) 18,19 Residents’ personal and healthcare needs are met. EVIDENCE: Residents’ personal and healthcare needs are reflected in their care plans. All residents are registered with a local GP and any appointments are recorded. Care and health needs are referred to in the six-monthly reviews of care plans. Staff observed during the inspection were clearly caring for residents in a caring, sensitive manner. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 Page 12 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 standard(s) 22,23 The home is proactive in listening to residents’ views and keeping them safe. EVIDENCE: The home has comprehensive complaint and protection procedures. Residents appear to be able to make their feelings known even when verbal communication is limited and staff who talked with the inspector seemed to know residents well enough to be able to respond appropriately to their wishes. The home uses the Multi-Agency Vulnerable Adult Protection document No Secrets as well as its own policy. Staff are made aware of their responsibilities through training. A member of staff has recently whistle-blown a colleague and the home were adjudged to have acted appropriately. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 Page 13 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 standard(s) 24,30 The home is comfortable, well maintained and clean, which provides residents with a suitable environment. EVIDENCE: The home is pleasantly decorated, comfortable and homely throughout. All communal areas are bright and welcoming. The inspector saw the bedrooms of the three residents tracked. All were well appointed, pleasantly decorated and personalised with belongings and décor. Staff confirmed that residents are enabled to choose the décor using their preferred method of communication. The home was clean and tidy on the day of the inspection. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Residents are supported by a well-trained workforce. EVIDENCE: The inspector saw a training record that was very comprehensive. Training is included in the business plan so that it is always costed and prepared for. Staff were very positive about the range of training offered. On the day of the inspection a course was due to take place on speech and language therapy. Other titles have included food hygiene, medication, moving and handling, first aid, equality and diversity and adult protection. All staff that spoke with the inspector were on appropriate NVQ courses. 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were examined on this occasion. EVIDENCE: 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 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 x 4 x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
9 Grace Road Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x C51 9 Grace Road V45536 240505.doc Version 1.30 Page 17 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 Regulation none 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 none Good Practice Recommendations 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 Page 18 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park, Enderby Leicester, LE19 1SX 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 9 Grace Road C51 9 Grace Road V45536 240505.doc Version 1.30 Page 19 - 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!
