Inspection on 23/11/06 for 92 Black Prince Avenue

This inspection was carried out on 23rd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

92 Black Prince Avenue 30/12/05

92 Black Prince Avenue 10/08/05

92 Black Prince Avenue 13/02/05

92 Black Prince Avenue 20/04/04

Similar services:

Manor Court

Agnes House

The Manor House

21a Johnson Avenue

Applegarth

Thornham Grove

Hunter`s Lodge

Conifer Lodge

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

CARE HOME ADULTS 18-65 92 Black Prince Avenue Market Deeping Lincolnshire PE6 8LU Lead Inspector Mick Walklin Key Unannounced Inspection 23rd November 2006 14:00 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 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 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 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. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 92 Black Prince Avenue Address Market Deeping Lincolnshire PE6 8LU 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) 01778 344215 www.sense.org.uk Sense, The National Deafblind and Rubella Association Mrs Danielle Wheeler Care Home 2 Category(ies) of Sensory impairment (2) registration, with number of places 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 2005 Brief Description of the Service: 92 Black Prince Avenue is a four bedroomed end of terrace house with an enclosed rear garden, situated on an estate. Two residents live at the home. At present, one of the bedrooms is used as a staff sleep-in room, and one is used as an office. The home is one of a number in the area managed by SENSE East, who provide specialist homes for life for people with either single or dual sensory impairment who may also have additional learning or physical disabilities. It is located a quarter of a mile away from a local supermarket, and Market Deeping town centre is approximately one mile away. The town centre contains a range of shops, pubs, banks and food outlets. The home is close to the Peterborough to Bourne bus route with regular services, and they also have sole use of a people carrier. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken using a review of all the information available to the inspector regarding the service history of 92 Black Prince Avenue, and through undertaking a visit to the home. The fieldwork visit took place over 4 ½ hours. The main method of inspection used was called case tracking which involved tracking the support that people who use the service receive through the checking of their records, discussion with the care staff and observation of care practices. A tour of the building was undertaken with the manager. Documents connected with the running of the care home were also inspected. The manager returned a pre-inspection questionnaire prior to the inspection, which confirmed that the range of fees charged is between £2182 and £2307 per week. What the service does well: What has improved since the last inspection? The home already provides very high standards of care, and no issues were identified at the last inspection. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 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 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are good pre-admission assessments to ensure that prospective service users needs can be met. EVIDENCE: There have been no admissions to the home for the last two years, so this standard was not fully assessed on this occasion. However, previous inspections have found that prospective new admissions are thoroughly assessed to identify their support needs. New service users move into the home with comprehensive information, and their transitional process ensures that they are introduced to the home in a way that meets their needs. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Care plans are of a high standard, and fully reflect residents support needs. People who use the service are enabled to make choices and decisions about their lives. Risk assessments enable them to develop independent living skills, whilst risks are minimised. EVIDENCE: Care plans contain excellent information about service users support needs. As well as the care plan, files contain health records, concise ‘pen pictures’, a person centred plan, identifying future plans, and detailed 6-monthly reviews. The people who use the service are unable to participate fully in devising care plans and person centred plans, and this is clearly documented. However, families and placing authorities are fully involved in the reviews. Both people who use the service have sensory impairments, and severe communication difficulties. Care plans contain detailed visual and hearing assessments, communication profiles and guidelines, and behavioural profiles. A recent audit had identified that hearing and visual assessments were not being conducted 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 10 on an annual basis. The manager said that this was difficult to arrange due to the assessors having a backlog of work, and having to prioritise assessments. As previously mentioned, both people who use the service have communication difficulties. Staff were observed to use a variety of techniques to assist them in making choices and decisions. Both service users have communication boards in the kitchen, which gives them photographic information about which staff are on duty, and what sequence activities are planned. Staff said that this gives service users more structure to their day. One member of staff said, “They have limited signing, so we try to keep communication simple so they don’t get confused. We know them well, so we get to know what they like and want”. Staff outlined how residents communicate choice. “One will take you by the hand and lead you to what he wants, or push things away that he doesn’t want. They both chose food when we’re out shopping. They take things out of cupboards or the fridge to indicate meal choices”. There are an excellent range of risk assessments covering household tasks and activities. These are reviewed annually, and ensure that people who use the service are able to develop skills, whilst risks to them are managed. Staff demonstrated a good awareness of their responsibilities, and were observed to provide good levels of support whilst service users were involved in household tasks. One member of staff said, “Our service users will never be totally independent, but we aim to help them get by with as little support as possible. From the moment they get up, we are encouraging them to do things for themselves”. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use the service have varied and active timetables, and are involved as part of their local community. They have good family contact. Menus are varied, and promote choice. EVIDENCE: Both people who use the service attend Bourne Resource Centre during the day, and they have varied timetables. One timetable includes life and work skills, crafts, exercise, bowling tobogganing and dance. Evening activities are timetabled during the week, but are more flexible at weekends. One member of staff commented, “Sometimes there are almost too many activities – every night there is something!” The home has a people carrier to access local facilities. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 12 Both people who use the service went on holiday to Paris Disney this summer, and the manager said that this had been a great success, as well as a big adventure. Regular contact with their relatives is encouraged, and staff facilitate contact and visits. Catering arrangements are of a domestic nature. Menus are prepared on a four-week rotation, and are varied, and reflect service users choices. Service users help with shopping and the preparation of meals. Detailed guidelines for eating and drinking are contained in the care plans, covering posture, equipment, supervision, texture of food and food to be avoided. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The people who use the service receive high levels of support. Heath needs are clearly identified, with good arrangements with health providers. Medication procedures are satisfactory. EVIDENCE: Staffing levels allow for individualised support to be provided for service users. Information about likes, dislikes and preferred routines is contained in care plans. Staff have an excellent knowledge of service users preferences, and they communicate effectively with service users to ensure that their wishes are catered for. Sense have introduced a document called ‘My Health Record’. Both people who use the service have fully completed records which provide excellent information about all aspects of health promotion and health needs. They are registered with the local GP surgery, although one refuses to attend medical appointments. Both have regular medication reviews. There are satisfactory arrangements for dental care. Speech and Language Therapy, and Psychiatry input is available as required. There are good records of all medical 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 14 consultations. One service user had been experiencing behavioural difficulties, and the consultant psychiatrist and Sense’s own behavioural specialist had been actively involved in supporting staff. Staff receive medication training from the manager, and have two observed assessments. In addition, the pharmacist also provides training. The home has transferred to a monitored dosage system since the last inspection. There were two medication errors earlier in the year, both involving the omission of a dose of prescribed medication. New guidance has now been issued about medication errors, which may involve staff being retrained. The home only uses ‘homely remedies’ under the direction of the GP. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are effective procedures in place for dealing with complaints and adult protection issues, ensuring that the people who use the service are safe. EVIDENCE: There have been no complaints since the last inspection, and staff were clear on how to deal with complaints, should they receive one. There is a good stepby-step guide in symbols for residents wishing to make a complaint. The home’s ‘Resolving Issues’ guidelines contain contact details for the Commission. Staff are required to complete an annual adult protection questionnaire as part of their appraisal. This is reviewed by the Training Manager to ensure that staff demonstrate an adequate knowledge of the procedures. Staff interviewed had a good knowledge of the procedures for reporting suspected abuse, and were clear about the location of policies and procedures, including the Lincolnshire Adult Protection Committee procedures, a copy of which is displayed on the notice board. SENSE East has a Protection Committee, which reviews all reports of adult abuse within the organisation. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, well-maintained and domestic environment for service users to live in. EVIDENCE: The home is an end of terrace house, situated on a residential estate, and within easy access of local amenities. It is well decorated and maintained, and suitable for the needs of the residents. Bedrooms are comfortable and personalised to taste. There have been improvements to the décor since the last inspection. Both people who use the service appear happy with the environment. Social tutors are responsible for organising cleaning and domestic tasks, involving service users at every opportunity. There is a weekly environmental checklist, which ensures that cleaning and health and safety checks are carried out, and service users have timetabled domestic activities. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 17 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staffing levels allow good support to be provided to service users. Staff are well trained, and recruitment and selection procedures protect service users. EVIDENCE: There are two staff on duty throughout the day, with two staff sleeping –in at night. This allows for the people using the service to receive individualised support at all times. Staff said that there are enough staff on duty to meet service users needs, and staffing can be increased for certain activities. For example, three staff work on a Thursday evening so that 2:1 support can be provided to one service user whilst out shopping. There has been no staff turnover since the last inspection, and the manager described the team as “a solid, experienced team”, who had worked well in her absence. Staff praised the training that they receive. The manager keeps good training which clearly identify when training is due. Of the nine permanent staff employed, 4 have completed National Vocational Qualifications, 2 have commenced, and 1 is a qualified nurse who will not be undertaking the training. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 19 Two new bank staff have been employed. Their records showed that they have received a thorough initial induction with dates agreed for further foundation training, arranged over 13 days, and 7 modules. Records also contained evidence that their recruitment and selection had been thorough, with the necessary check carried out to ensure that the people who use the service are safe. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. There is excellent management and organisation within the home, leading to good communication and staff morale. Quality monitoring procedures ensure that there is effective consultation about the quality of care provided. Health and safety procedures ensure that people who use the service are safe. EVIDENCE: The manager has set up excellent systems for monitoring the running of the home. Documentation is well organised, and staff said that both they and the service users benefit from this organisation. Staff praised the level of support they get from the manager, both formally and informally. One said, “I get regular supervision, but I know I can see (the manager) at any time – she is a good listener”. A new deputy manager has been appointed, and a new team leader is about to take up post. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 21 Sense East has an excellent system for monitoring the quality of care provided on an annual basis. They use self-assessment questionnaires, staff focus groups and questionnaires for staff, purchasers and parents. The manager undertook an audit in September, assisted by the Policy and Quality Officer, and an action plan has been completed. The Quality Panel will discuss the findings in December, and the final report will then be sent to the manager. Health and safety documentation is well organised. Sense employs a health and safety advisor who conducts regular audits, and staff carry out regular checks. Maintenance and servicing records were up to date, as were health and safety checks. 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 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 Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 3 x LIFESTYLES Standard No Score 11 x 12 4 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 4 x 4 x x 3 x 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 23 N/A 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. 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. Refer to Standard Good Practice Recommendations 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 92 Black Prince Avenue DS0000002501.V320181.R01.S.doc Version 5.2 Page 25 - 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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