Inspection on 19/10/05 for 94 Tennyson Road

This inspection was carried out on 19th 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

94 Tennyson Road 12/05/09

94 Tennyson Road 01/07/08

94 Tennyson Road 15/01/08

94 Tennyson Road 28/08/07

94 Tennyson Road 13/10/06

94 Tennyson Road 03/02/06

94 Tennyson Road 11/03/05

94 Tennyson Road 22/12/04

94 Tennyson Road 29/03/04

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

CARE HOME ADULTS 18-65 94 Tennyson Road Luton LU1 3RR Lead Inspector Ansuya Chudasama Unannounced Inspection 19th October 2005 13:40 94 Tennyson Road DS0000014976.V258703.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 94 Tennyson Road DS0000014976.V258703.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. 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 94 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 484079 Advance Support Ltd Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th March 2005 Brief Description of the Service: 94 Tennyson Road is a semi- detached house situated in a quiet residential road in south Luton. The home is owned by Advance Housing and Support Limited and provides accommodation for four service users with mental health needs. The home has four single bedrooms and a bathroom and toilet on the first floor. The ground floor contains a lounge, dining room, toilet laundry room and a kitchen. The service users use a garden at the rear of the house in the summer months. There is a parking area at the front of the house. The home is within walking distance of the town centre and two local parks and the bus stop. 94 Tennyson Road DS0000014976.V258703.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 took place over 2 hours. The inspection comprised of a tour of some of the communal areas, talking to staff, and service users. Two service users’ files and other records were also inspected in detail. On the day of the inspection there were four service users living at the home and the home had no vacancies. The manager was working at the other sister home on the day of the inspection. The staff on duty was told to inform the manager that the inspectors were undertaking an inspection at the home. However the manager did not come to the home. The inspectors ‘s were assisted by Sonia James and Chido shamu (support workers). What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that all new service users have care plans and risk assessments. An immediate requirement was issued for this. All care plans must be completed fully and reviewed as stated in the plan. The staff needs to complete all documents properly and they need to be dated and signed by 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 6 them. The home must record the dates of when service users are admitted to the home. The manager needs to ensure that the home is run as an individual establishment and not combined with the sister home. The staffing rotas needed to be individualised to the home. The manager needs to be supernumerary on the staffing rota to manage the home. The manager also must spend more time at the home to manage her legal responsibilities. The risk assessments for the environment needed to be clear and easy to understand. Concerns raised by service users to staff needed to be followed through and recorded in the care plans. 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. 94 Tennyson Road DS0000014976.V258703.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 94 Tennyson Road DS0000014976.V258703.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): 1,2,4. The home had a statement of purpose and a service users guide but the documents needed reviewing to include information that was accurate and to include all information stated in the standard to help prospective service users to make an informed choice of choosing the home. The admission details of the new service user were not recorded and there fore it was difficult to know when the service user had been admitted to the home EVIDENCE: The information in the statement of purpose needed reviewing to ensure that the information recorded was accurate and clear. The information contained was similar to the other sister home. The service users guide seen did not include all the information stated in the standard. A copy of this document was seen in the lounge and in the service users’ file. A needs assessment was completed for a new service user on the 19/8/05 by the staff. The information needed expanding to state what the service user was able to do and what support the person required. Instead the information recorded stated “to be supervised” or needed “prompting”. The service users front page of his file did not have the date of admission recorded A referral checklist meeting CSCI standard was not completed. A trial stay assessment form had no date and it was not signed by staff. The Advance Housing Supported Ltd confidential assessment form had no date when it was 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 9 completed and it was not signed by staff. Information on likes and dislikes of the service user was not completed. The weekly plan was also not completed. The medication part 1 had no date when it was completed. Information on GP and next of kin details were not completed. The admissions list had the names of the service users of this home and the other sister home. However the name of the new service user was not recorded on the list. The staff member on duty was unable to find out when the new service user was admitted to the home. The staff looked at the service users file and found an entry where it stated that the service users first trial stay at the home was on the 26th of May 05. However the needs assessment form was not completed until the 19.8.05. Another service users file inspected had pre-admission assessments undertaken prior to admission. 94 Tennyson Road DS0000014976.V258703.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): 6,9 No care plans or risk assessments were available for one new service user admitted to the home and so therefore these short falls have a potential to place service users at risk. One service users’ care plan was not completed fully enough in order to identify how the service users needs would be fully met. Service users were not being involved in risk assessments and therefore service users are put at a risk. EVIDENCE: The service user recently admitted to the home did not have a care plan in his file. The inspectors asked the staff on duty for this. She stated that it was being printed in the other sister home. The service users risk assessments were also not available in his file. It was stated that the manager at the sister home was typing these. One risk assessment for riding a bicycle was seen in the file. The staff spoken to stated that she had received training on how to do risk assessments. The staff on duty stated that they tried to help the new service user to do things. However it was stated that the staff found it difficult because the service user went out with friends in the morning and returned in the evening. The inspector was unable to find out what action the home had undertaken to deal with this situation because the service user did not have a 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 11 care plan. The inspector was unable to speak to this service user because he was in bed. Another service users’ care plan inspected was not completed fully and it was stated in the plan that the service user was not available when the plan was being undertaken. The plan was only signed by staff and not by the service user. The plan was reviewed on the 4.5.05 by staff but it was not signed by the service user and did not state if the service user had been involved with this process. A copy of the plan was given to the service user but it was stated that they refused it. There was no information to say why the service user had refused to accept the care plan. A three month review date was set. However there was no evidence to show that this had been undertaken. Risk assessments were carried out on a number of issues but the service user had not signed the risk assessments. It was therefore difficult to know if the service user had been involved with this. 94 Tennyson Road DS0000014976.V258703.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): 11,12,13,14,15,17. The meals in this home are good, offering both choice and variety and cater for service users needs. Service users are supported to access social and educational opportunities to develop their skills. EVIDENCE: The new service users file inspected did not have any information to state what the person did whilst living at the home. One service user spoken to stated that he enjoyed going to college. It was also stated that he did the weekly shopping with another service user. The service user was also a vegetarian and he chose his own meals. All the service users spoken to stated that the food was good and the menu inspected was varied and nutritious. They also enjoyed living at the home and found staff supportive. It was also stated that one of the service user was feeling better and his next step was to move into a flat. It was stated by the service user that they all got on better with each other. The home encouraged service users family and friends to visit the home. One service user stated that he visited his family at weekends. 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 13 94 Tennyson Road DS0000014976.V258703.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): Limited information was available to state how a new service users health care need were being met by the home. These shortfalls have a potential to place service users at risk. The physical and health care needs of one service user spoken were being met by the home. The changing behaviour patterns of one service user were not being met. This unmet need puts the service user at risk EVIDENCE: One service user did not have a care plan and the inspector was unable to find out how the persons health and personal care needs were being met by the home. The inspector was unable to speak to the service user as the person was in bed. One service user spoken to stated that he visited his GP regularly and took his medication as prescribed. He had also stopped smoking for ten days and used nicotine inhaler. The link worker meeting dated 14.9.05 stated that the service user had expressed a desire to wear women’s clothes. There was no evidence found in the care plan to state how the service user was to be supported with this changing behaviour. 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 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 had been given a copy of the complaints policy. They also knew how to complain and they were all able to speak up for themselves. 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home was clean and homely, and met service users needs. The needs of service users and staff who did not smoke were not being met and therefore put them at risk. EVIDENCE: The home was clean and homely. The lounge had new curtains and had been painted and looked very pleasant. All service users had new bedding and the whole house had been painted. The dining room was used as a smoking area. The room was full of tobacco smoke. The home had two service users who smoked and two service users and most of the staff did not smoke. The manager needs to find a solution to ensure the needs of those people who do not smoke are also met. 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 17 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): 33, 35,34,36. The staff rotas were combined with another sister home and the information was difficult to understand about staffing for this home. The home was fully staffed and provided continuity to service users EVIDENCE: The inspectors were informed that the home was fully staffed. It was also stated that two staff had started NVQ level 2 in care and staff training provided was very good. The rotas inspected showed that the rota for the home was combined with the sister home. The rotas were also difficult to understand. The staff spoken to stated that she enjoyed working at the home and had supervision once a month. The staff meetings were held with another sister home. The information was difficult to understand because the inspectors were not aware which staff and service users belonged to which homes. The staff recruitment files were not available in the home. It was stated that these were kept at the sister home. The inspectors were unable to discuss this with the manager as she did not come to the home on the day of the inspection. 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 18 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 risk assessments seen for the environment were not clear and they were difficult to understand. The fire book inspected was kept up to date. A risk assessment was needed for using the stairs leading to the office, as they were very steep. The CSCI were informed that the manager was going to be supernumerary on the staffing rota. However evidence showed that the manager undertook sleep-in duties and also worked shifts. Evidence also showed that the manager did not spend much time at this home. The manager must spend more time at the home to undertake her legal duties. 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 19 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 X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 X 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 94 Tennyson Road Score X 2 X X Standard No 37 38 39 40 41 42 43 Score 1 X X X X 2 X DS0000014976.V258703.R01.S.doc Version 5.0 Page 20 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 YA1 Regulation 4 Requirement 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 registered person must ensure that all documents are dated and signed by staff at all times. The registered person must ensure that the admission date of service users are recorded The registered person must ensure that all service users have care plans and risk assessments. An immediate requirement was issued for this. All care plans must be completed in full and must involve the service users and their representatives. All care plans must be reviewed as stated in the care plan. 5 YA42 13 The registered person must DS0000014976.V258703.R01.S.doc Timescale for action 20/12/05 2 YA1 17 11/11/05 3 4 YA1 YA9YA1 17 12,13 10/11/05 28/10/05 20/12/05 Version 5.0 Page 21 94 Tennyson Road 6 YA19 13 7 YA42 13 ensure that risk assessments are completed with the service users and signed by them. The registered person must ensure that staff act on concerns discussed by service users and this is recorded in their care plan. The registered person must undertake a risk assessment for the stairs leading to the staff office 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 two rotas. This requirement was not met from the last inspection. 28.2.05 10/11/05 12/11/05 8 YA37 10,24 12/11/05 9 YA37 10 The responsible individual must ensure that the two homes are managed as individual homes as stated in the NMS. The registered person must ensure that the risk assessments on the environment are clear and east to understand The registered person must ensure that the pre admissions form is completed before service users are admitted to the home. 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. 12/11/05 10 YA42 13 20/12/04 11 YA2 14 12/11/05 12 YA28 12 09/12/05 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 22 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 YA2 YA33 Good Practice Recommendations Ensure that the information on service users pre-admission assessment form contains more information. Ensure that the staffing rotas are undertaken separately for each home. 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 23 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 94 Tennyson Road DS0000014976.V258703.R01.S.doc Version 5.0 Page 24 - 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!