Inspection on 08/12/05 for 90 Brackenborough Road

This inspection was carried out on 8th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

90 Brackenborough Road 18/10/07

90 Brackenborough Road 03/05/06

90 Brackenborough Road 13/06/05

90 Brackenborough Road 08/03/05

90 Brackenborough Road 04/10/04

90 Brackenborough Road 04/03/04

90 Brackenborough Road 03/11/03

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

CARE HOME ADULTS 18-65 90 Brackenborough Road Louth Lincolnshire LN11 OAQ Lead Inspector Mr Ken Hague Unannounced Inspection 8th December 2005 08:00 90 Brackenborough Road DS0000032053.V272019.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 90 Brackenborough Road DS0000032053.V272019.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. 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 90 Brackenborough Road Address Louth Lincolnshire LN11 OAQ 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) 01507 600590 01507 600590 Northern Life Care Limited T/A U.B.U. Mr Paul Smith Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Conditions of Registration. The placement of any service user in the home must not exceed a period longer than six months. 13th June 2005 Date of last inspection Brief Description of the Service: 90 Brackenborough Road is a care home owned by Northern Life Care Ltd. There is a registered manager in post. The care home is a detached house situated on the very edge of the town of Louth. The care home is a detached house which has been adapted by the company to provide respite care for service users with a learning disability. The home has enclosed gardens at the rear, car parking is available on the road outside the property and there is a small car park directly at the front of the home. The home is a two-level building, the access to the first four is via a staircase. There are no facilities for service users with a physical disability to use the top floor of the care home, although there are facilities on the ground floor to enable wheelchair users to be offered services and respite care. The accommodation consists of a communal lounge, dining room, kitchen and utility room. On the ground floor there are three bedrooms and two bathrooms. On the upper floor there are two bedrooms and one bathroom. Lincolnshire County Council have contracted with Northern Life Care Ltd to provide respite care for people with learning disabilities. There is no other care home offered as an alternative choice. 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a three hour period. The main method of inspection used is called case tracking which involved selecting a resident and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. A tour of the premises was conducted and care records were inspected. Two members of staff were interviewed. There was only one resident staying in the home on a day of the inspection. This resident wasnt able to communicate due to hearing difficulties and having no speech. What the service does well: What has improved since the last inspection? The individual residents care plans have been improved since last inspection. Risk assessments are now being completed for residents at the time of the initial assessment. in the home. All residents are now given a copy of the terms and conditions for their stay at the care home. Staff are being provided with supervision in accordance with the National Minimum Standards. A gardener has now been appointed to maintain the garden of care home. 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 90 Brackenborough Road DS0000032053.V272019.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 90 Brackenborough Road DS0000032053.V272019.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): 1,3&5 Residents are provided with information which allows them to make an informed choice whether the homes resources can meet their needs. New residents are assessed and a care plan and risk assessment completed prior to them coming to stay at the care home. A copy of the individual’s terms and conditions for their stay at the home is given to them prior to their admission. EVIDENCE: The home has updated its statement of purpose, which sets out the resources of the care home offered to residents. This document meets the National Minimum Standard and was seen at this inspection. The home gives a service user guide to all new residents. These two documents enable residents and families to make an informed choice as to whether their needs can be met by the resources of the care home. The individual care records inspected all contained details of the terms and conditions for the residents stay at the care home. 90 Brackenborough Road DS0000032053.V272019.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&9 Resident’s needs are identified at the initial assessment. A care plan is then written which includes a full risk assessment. The care plan includes the wishes and choices of residents. The risk assessments enable the home to balance the residents wishes and choices against any identified risk. EVIDENCE: The individual care records seen during this inspection all contained a comprehensive assessment carried out prior to the resident been admitted. This assessment was used to formulate an individual care plan for each new resident. This sets out the needs of the resident and how these can be met by the resources of the care home. The care plans included the choices and wishes of individual residents. There was evidence of relatives being involved in the assessment process and the completion of care plans. One resident’s family had recorded their wishes in relation to her hair care and bathing. The care plan describes this process in detail. This included the resident’s choice of toiletries and the manner in which she likes to be washed. The care plan included this statement, “at the end of the Bath pour water out from the bath she likes to watch water falling down”. There were comprehensive risk assessments on resident’s individual files. If any risk was identified the management of that risk was recorded in detail. 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 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 the following standard(s): 13,14 &16 Staff respect the rights, dignity and privacy of residents. EVIDENCE: Observations made during this inspection provided evidence that residents are treated with respect and provided with services in a sensitive and dignified manner. Staff were observed ensuring that the privacy and dignity or the resident was respected while personal care was being provided. They made sure that the resident was dressed appropriately when she went out into the community for her day-care. 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 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 the following standard(s): 20 Staff have not been provided with training in the Administration and management of medication by a competent trainer. Residents therefore could have been placed at risk. EVIDENCE: A member of staff stated that she had received no formal training in the Administration and management of medication. She confirmed that she was giving out medication in the care home. The registered manager confirmed that he had been providing staff with medication training but had not received training himself for over two years. 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 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 the following standard(s): 22 & 23 The home has robust procedures for handling complaints and allegations of adult abuse, and staff were clear on the action to take in the event of this occurring. EVIDENCE: The home’s policy and procedures manual contains a policy on the identification and management of abuse. The home has a copy of the Lincolnshire County Council vulnerable abuse procedures in its procedures manual. The complaint policy of the care home meets the National Minimum Standards. The home has received no complaints since the last inspection. The Commission for Social Care Inspection has received no complaints during 2005. 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 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 the following standard(s): 24 & 30 Residents live in a clean, comfortable and homely environment. The home is well maintained throughout. EVIDENCE: A tour of the care home was made and all areas were found to be clean and smelt fresh. The home has a rolling maintenance programme. Decorating has been carried out in a number of areas of the care home. A new carpet has been fitted in one bedroom. The registered manager confirmed that two more bedroom carpets are to be replaced in April 2006. There are other areas of care home, which will be decorated in the spring of 2006. 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 The home has a stable workforce with a flexible rota, which provides consistency of care for residents living in the home. The registered manager takes into account the skill mix of his staff and the dependency levels of residents when planning rotas. EVIDENCE: The Company has a recruitment policy which meets the National Minimum Standards. The registered manager stated that this policy is being followed, however he was unable to produce evidence that the member of staff on duty during this inspection had been recruited in accordance with the Company policy. He stated that the documents necessary to evidence this were at the main office of the company. The home must ensure that evidence of appropriate recruitment can be produced to inspectors if required at any visit. 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38 &42 The home is well run, with good leadership and guidance for staff. recordkeeping is of a high standard, the health and safety and welfare of residents is promoted. EVIDENCE: Care home records provided evidence that supervision and appraisals are being provided to all staff at the frequencies set out in a National Minimum Standards. Staff confirmed this to be the case. There were no health and safety issues identified at this inspection. 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 3 14 3 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x 2 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 90 Brackenborough Road Score x x 1 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x DS0000032053.V272019.R01.S.doc Version 5.0 Page 17 No 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 YA20 Regulation 13-2 Requirement The registered person must ensure that all staff receive training in the administration and management of medication. The registered person must be able to produce evidence at any inspection to demonstrate that the recruitment policy the home is being followed. Timescale for action 28/02/05 2 YA34 19-1 28/02/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 Page 18 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 90 Brackenborough Road DS0000032053.V272019.R01.S.doc Version 5.0 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. 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