CARE HOME ADULTS 18-65
94 Tennyson Road Luton LU1 3RR Lead Inspector
Mr Pursotamraj Hirekar Unannounced Inspection 03 February 2006 11:35 94 Tennyson Road DS0000014976.V272377.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.V272377.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.V272377.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.V272377.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th October 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. Ann Dalton is the registered manager. 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.V272377.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out at 11.35 on 03.02.06 and at 12.00 on 06.02.06 over 4 hours by PursotamRaj Hirekar. The manager and the support worker coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, related care documents, conversations with service users, discussion with the manager and staff and tour of the home. What the service does well: What has improved since the last inspection? What they could do better:
The home must ensure that risks are assessed according to the health and social services protocols and in discussion with the service users and relevant specialists: and risk management strategies are agreed, recorded in the individual plan, and reviewed. The home must ensure that service users are not exposed to unnecessary risks to safety and so far as possible eliminated and carry out risk assessment of the service user who had just started driving a car. The home must ensure recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The home must ensure to promote and make proper provision for the health of service user who had stopped smoking and those service users who do not smoke. 94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 6 The home should undertake risk assessment of staircase leading to the office by relevant specialist. The home should ensure that the staff deployment rota indicated the actual time spend by the manager at the home. The home should ensure exclusive staff meeting are also held. The home should speed up the completion of all the care plans using the new format. 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.V272377.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.V272377.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 The home had made appropriate arrangements to provide relevant information to prospective service users, to enable them to take decision prior to their admission. EVIDENCE: The statement of purpose and service users guide was reviewed in September 2005 to incorporate the shortfalls that were identified in the previous inspection report which include, standalone staff teams for 94 Tennyson road and 83 Tennyson Road, emphasis on 83 Tennyson Road being 24 hours service, not for nursing care, clear organisational structure, age of service users. The statement of purpose and the service users’ guide would be sent to the prospective service user to make an informed choice and decision prior to the admission. The preadmission form of a new service user was completed. The staff meetings and staff supervision record were dated and signed by the manager and the concerned staff member. The service user and the manager did not sign need assessment done by the support worker also, date of admission was not recorded. The assessed needs were not comprehensive to cover all physical, mental and health needs of the service user. The needs assessment needed a multidisciplinary approach with subject specialist contributing in the best interest of the service user. 94 Tennyson Road DS0000014976.V272377.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, In the absence of a multi disciplinary team to provide input on needs and risks assessment, the service users’ actual needs may not be met. EVIDENCE: The home had taken adequate steps to revisit existing care plans and risk assessments of service users and developed a new care plan format. The new care plan format developed was comprehensive and structured in a way that enabled the recording of information systematically in a way which can be easily understood. The new care plan format considered and focussed on the outcomes of risk and needs assessments. However, the work was in progress. One service user whose risk assessment did not include bathroom-associated risk had an accident in the bathroom and was in hospital taking treatment. The support worker stated that they were not aware of this service user’s bathroom risk. The current practice of one staff member conducting needs assessment and risks assessment was not in the interest of the service users. The assessed needs and risks were not comprehensive to cover all physical, mental and health needs of the service users. Also, did not cover all dimensions of changing needs and goals of service users.
94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 10 The needs and risks assessment needed a multidisciplinary approach with subject specialist contributing in the assessment and review to meet the changing needs and associated risks of the service users. 94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16 Service users were encouraged to lead a normal life. EVIDENCE: In consultations with the service users, the home had developed a daily schedule of home activities that they attended which included cooking, washing and cleaning, that they do on rotation. The staff encouraged the service users to improve their daily living skills in personal hygiene, shopping, healthy eating, visiting the bank and the post office. One service user had got back his driving licence and bought a car and had started driving. The home must do car driving risk assessment of the service user before he was on his own driving the car, taking into consideration of his unstable behaviour and medical history. The other service user had stated that, he had enjoyed his stay at the home and the staff were supportive to meet his needs. He also expressed a desire to restart computer classes and start swimming. The support worker said the home plan to start his computer classes in September 2006. The home must reassess the needs of this service user and launch an action plan to meet his needs without losing more time.
94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Poor record keeping and inadequate monitoring of administration of medication may put the service users at risk. EVIDENCE: The home’s policy to administer, control and monitor medication was not clear. The manager had said that the service users collect their medicine and administer on their own. The staff member on duty recorded only how much and what medicine was brought in. There was no record of expiry date of medicine, how much and when the medicine need to be taken, whether the service users were actually taking the medicine as prescribed, do they take the correct medicine, what do they do with the medicine not used. These lapses in administering, control and monitoring of medication puts the service users at risk. 94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: 94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28 Incomplete risk assessments of environment did not ensure the safety of service users. EVIDENCE: One service user who had stopped smoking in October 2005 continues to use the inhaler. Of the 4 service users, one service user, the manager and one staff member smoke. In the interest of service users who do not smoke - three service users, the home must introduce a strict policy for designated smoking area and no smoking policy for all visitors to prevent any harm to non-smoking service users. The manager said that they would organise a staff and service users’ meeting to discuss the issue and implement the outcomes. The staircase leading to the staff office risk assessment was carried out by a support worker on 10.12.05 and recorded that there was a banister on both the sides of the staircase, which was false. The home should do away with one staff member conducting risk assessments and move on to taking the services of subject specialist to conduct risk assessment and record only factual data. 94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32,36 The staffs were qualified, trained and met the needs of the service users. EVIDENCE: The staff and the service users have had good working relations. The service users stated that the staffs were good and attended to there needs as and when required. The staff were qualified, experienced, trained and had clarity of their roles and responsibilities. The manager appropriately supervised the staff and the staff deployment rota was maintained, which needed to record the actual time given by the manager at the home. 94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39,42 The recently introduced improvements to manage the home effectively were a positive step forward. However, needed to speed up before any service users are exposed to risk of harm. EVIDENCE: The home now has a registered manager. The manager had taken appropriate measure to ensure that the care plans were systematically prepared and comprehensive in nature. However, this work was in progress and needed additional speed. The need and risk assessments of service users’ must have the involvement of subject specialists along with trained support worker as and when required to pre-empt any risk of harm and also to meet the actual needs of the service users. The home must also ensure that the administration of medicines was monitored and recorded. The manager and the staff have good working relations that promote the interest of service users. 94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 17 The home had an independent information management system on staff rota and staff personal files. However, the staff meetings were held in conjunction with the sister home and there was no clarity on how much time the manager spends at this home. The manager said that they would revisit the staff meeting and managers time schedule and implement as required by the NMS. 94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X 2 X X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 X X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
94 Tennyson Road Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X 3 X DS0000014976.V272377.R01.S.doc Version 5.0 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13 (4) Requirement Timescale for action 31/03/06 2. YA12 13 (4) (c) 3. YA20 13 (2) 4. YA28 12 (1) a The home must ensure that risk is assessed according to the health and social services protocols and in discussion with the service user and relevant specialists: and risk management strategies are agreed, recorded in the individual plan, and reviewed The home must ensure that 15/03/06 service users’ are not exposed to unnecessary risks to safety and so far as possible eliminated and carry out risk assessment of the service user who had just started driving a car. The home must ensure 28/02/06 recording, handling, safekeeping, safe administration and disposal of medicines received into the care home The home must ensure to 15/03/06 promote and make proper provision for the health of service user who had stopped smoking and those service users who do not smoke. (Previous requirement 09/12/05) 94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 20 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. 3. 4.. Refer to Standard YA24 YA37 YA37 YA37 Good Practice Recommendations The home should undertake risk assessment of staircase leading to the office by relevant specialist The home should ensure that the staff deployment rota indicate the actual time spend by the manager The home should ensure exclusive staff meeting are also held The home should speed up the completion of all the care plans using the new format 94 Tennyson Road DS0000014976.V272377.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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