Inspection on 01/07/05 for 98 to 100 Gloucester Avenue

This inspection was carried out on 1st July 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

98 to 100 Gloucester Avenue 15/02/07

98 to 100 Gloucester Avenue 01/02/06

98 to 100 Gloucester Avenue 07/10/04

98 to 100 Gloucester Avenue 28/04/04

98 to 100 Gloucester Avenue 18/02/03

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Hyndburn Respite Facility 98/100 Gloucester Avenue Accrington Lancashire BB5 4BG Lead Inspector Lynn Mitton Unannounced 1 July 2005 10:00 st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service 98/100 Gloucester Avenue Address Accrington Lancashire BB5 4BG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01772 563002 Lancashire County Council Mrs Rebecca Toman CRH 5 Category(ies) of Learning disability (LD) 5 registration, with number of places Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1 Rebecca Toman is registered as manager of Gloucester Avenue (respite facility) only 2 The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission Date of last inspection 07 October 2004 Brief Description of the Service: Gloucester Avenue provides personal and social care for up to 5 adults with a learning disability and additional support needs aged over 18 years. This facility offers respite/short term care only. At the time of the inspection there were 4 people accommodated. The establishment belongs to Lancashire County Council.The home is two semi-detached houses ajoined, located approximately one mile from the centre of Accrington.The home offers single bedrooms, and has a large lounge/dining room. Two of the bedrooms and one bathroom are on the ground floor for service users with mobility difficulties. The home is maintained to a good standard throughout. The care staff team aims to offer a homely environment. Service users are either private or Local Authority funded. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted approximately 7 hours. There were 4 service users accommodated at this time. A tour of the communal areas of the home took place. Over the course of the inspection two of the staff on duty, plus the registered manager were spoken to, interaction between the service users and staff members were observed. Throughout the report there are various references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of service users. Records pertaining to these people were inspected. Policies and practices were also read. Three service users relatives had completed the Commission’s comment card, and three service users had completed the service users survey. These indicated that they were very pleased with the level of service received at Gloucester Avenue. What the service does well: The inspector saw that there had been 5 independently written compliments to the service in 2005. The Commissions comment cards included comments such as “Gloucester Avenue is an excellent provision which provides a service which is invaluable to us as a family” and “Our son is a regular user of respite at Gloucester Avenue and he always enjoys his stay there, and we have close contact with the staff there”. Information needed to ensure that staff could meet service users needs was in place before service users used the service. Comprehensive and up to date plans of care were in place for service users, ensuring that service users individual care and health needs were know by staff. Whenever possible service users were able to take responsible risks. Staff from the home kept in contact with service users families and they valued this. Service users told the inspector that the food served at Gloucester Avenue was “good”, and that they “could choose what they liked to eat”. There were clear complaints and protection policies and practices in place. Staff spoken to had a good understanding of adult protection issues and how to deal with any complaints made. The standard of décor and furnishings provided a comfortable and homely environment for service users. The standard of cleanliness and hygiene in the home was good. Staff spoken to by the inspector talked about the importance of working closely together and supporting each other as a staff team. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 & 5 Written information about the home should provide a clear picture of the homes’ facilities and services. The admission procedure for new service users ensured that all information about their care needs was obtained before they arrived for a stay. This enabled staff to have a clear understanding of what they needed to do for them. The responsibilities of both parties were made clear in the documentation. EVIDENCE: An updated statement of purpose and service user guide had been produced. These documents did not contain the required information needed for prospective service users to understand how the home was run and what facilities were offered. The service user guide had been completed pictorially. Any new service users wishing to stay at Gloucester Avenue would have an assessment completed prior to their admission. The inspector saw completed assessments on the service users files case tracked. The admission procedure had been documented so that service users and their families would know what needed to happen before they could stay at Gloucester Avenue. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 9 Contracts explaining the terms and conditions of service users stay at Gloucester Avenue were seen by the inspector. The registered manager discussed the difficulty in being able to complete these documents fully as they were not always informed by purchasers of the service of the number of nights service users could stay at Gloucester Avenue. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 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 standard(s) 6 & 9 The care needs of service users were identified and documented. Service users individual needs were know by staff. Service users were enabled to make day to day decisions about their lives. Regular reviews of care plans and risk assessments ensured that any changes were regularly documented and that any action needed was taken. The risk assessment and management framework supported service users to take responsible risks. EVIDENCE: Service users had a comprehensive care plan in place that included a plan of action of how to address service users specific needs. One care plan was examined in detail during the inspection. It gave a good account of that persons’ specific support needs and how these should be met by the care staff team. It also contained a personal profile, lifestyle information, and individual behaviour records. Daily records seen gave a good account of events and activities undertaken during the time spent at Gloucester Avenue. Whenever possible, service users were given information and options to help them make positive decisions about their own lives. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 11 Risk assessments were an integral element of the service users care plan and a number had been completed. Each risk assessment included a management strategy. The care plan and risk assessments had been recently reviewed. Staff spoken to by the inspector talked about the importance of care plans in meting each service users needs. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 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 standard(s) 15 & 17 Service users were enabled to keep in touch with their family and friends as was appropriate given the purpose of the home. Individual dietary needs were appropriately catered for. EVIDENCE: Family and friends may visit Gloucester Avenue at any reasonable time, although usually families maintained contact by phone in order to ask how service users were during their stay. Reference to this was made in the homes documentation and any contact made would be recorded on service users daily record sheets. Some service users choose to stay at Gloucester Avenue at the same time because they get on well together. A record was made of meals served to service users. Menus for the home were decided on a daily basis, dependent on the number of service users at the home and their preferences. Any specialised dietary requirements would be accommodated, this included use of halal meat, diabetic and soft diets. Gloucester Avenue did not employ a cook. Care staff prepare meals and service users were encouraged to participate in the shopping, preparation and Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 13 planning of meals to the best of their ability. Staff were ready to offer assistance with eating where necessary, discreetly, sensitively, and individually, whilst independent eating is encouraged. Adapted cutlery/crockery was used for those who need it. Service users spoken to by the inspector said the food was good and the 3 service users comment cards also confirmed that service users enjoyed the food served at Gloucester Avenue. One service user told the inspector that the food was “nice” and another that “ we can choose what we like to eat at teatime”. Three service user comment cards completed indicated that they felt that privacy was respected. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 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 standard(s) 19, 20 Service users health needs were being attended to. Mostly good practice was in place with regards to the administration, safekeeping, storage and disposal of service users medication. EVIDENCE: The service user case tracked had a care plan last updated in June 2005. On this there was information regarding meeting the service users health needs and how this would be done. Policies and practices for managing and administering medication were in place. Service users consent to administration of medication should be obtained and recorded in care plans. A clear account of how medicines should be supplied by next of kin to Gloucester Avenue in order for staff to safely administer them was discussed. For example, some medication was labelled “take as prescribed by GP”. The difficulties of keeping up to date between visits with any changes in medication was also discussed. Methods of minimising any risks by improved communication with service users next of kin prior to any stay at Gloucester Avenue. Good practice was in place regarding keeping information leaflets about drugs being administered to service users. Two staff administering medication had obtained accredited training by completing the “Safe Handling of Medicines” distant learning training course. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 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 standard(s) 22 & 23 There were clear complaints and protection policies and practices in place. Staff spoken to had a good understanding of adult protection issues and how to deal with complaints made by service users. EVIDENCE: There had been no complaints since the last inspection. The complaints procedure was now available in a pictorial format, which was more appropriate for some service users living at Gloucester Avenue. Staff spoken to were able to describe the complaints procedure and how they would deal with someone making a complaint. Staff spoken to were also able to give definitions of different types of abuse and how they would act if they witnessed abuse of any kind. The inspector was advised that all staff working at the home had completed CRB (Criminal Records Bureau) as part of their application process. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 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 standard(s) 24 & 30 The standard of décor and furnishings provided a comfortable and homely environment for service users. The standard of cleanliness and hygiene in the home was good. EVIDENCE: The furnishings and fittings were compatible with the needs of the service users. The conversion of the homes garage for alternative storage space of specialist equipment was still in the planning stages and being pursued by the registered manager. During the inspection a locksmith visited Gloucester Avenue with a view to installing thumb locks which would need staff only needed one key for all the locks in the home. The treatment/changing bed was in need of re-covering the registered manager was pursuing this at the time of the inspection. There had been a number of incidents of young people playing on the garage roof. The inspector was satisfied that appropriate action had been taken in this regard. The home was clean and tidy, and there were no offensive odours. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 17 Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 35 Full documentation regarding the recruitment of staff would demonstrate the intention to safeguard service users. Staff spoken to and observed by the inspector demonstrated a good understanding of the needs of the service users. Regular team meetings and supervision ensured that staff were clear about what was expected of them. Staff should continue to complete their NVQ training to enable them to better meet the needs of service users. EVIDENCE: The inspector noted that 3 care staff members were completing their NVQ level 3 training. All staff had completed LDAF (Learning Disability Award Framework) induction and foundation training. 2 staff were completing British Sign Language Stage 1 training. The registered manager was completing the A1 Assessors training Certificate. The inspector case tracked 1 employee file had most of the information required available to the inspector. Criminal Record Bureau records were not available to the inspector nor a job description. There was evidence of staff training, and that 1:1 support meetings took place with the manager and individual staff members. Monthly team meetings took place and minutes of these meetings were seen. One completed Relatives Comment Card wrote that they appreciate the close contact between staff and themselves. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 19 The inspector observed service users being supported by competent staff. Staff spoken to by the inspector talked about the importance of working closely together and supporting each other as a staff team. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40 & 42 The registered person and the Commission were being kept informed about the home. Staff training must be completed to ensure the health safety and welfare of service users and staff are safeguarded. EVIDENCE: Regular reports on behalf of the registered person were being regularly completed. The registered manager is due to begin NVQ 4 training in Care and Management in September 2005. The inspector advised that completion of this was a high priority in accordance with conditions of registration with the Commission. Some staff training was still outstanding with regards to ensuring the complete health, safety and welfare of service users and staff, for example in 1st Aid, food hygiene and moving and handling. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 Hyndburn Respite Facility x x x x 3 Standard No 31 32 33 34 35 36 Score x x x 2 x x Version 1.20 Page 22 F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc 16 17 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 2 2 2 x Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 23 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 & 16 Requirement A statement of purpose must be produced in Accordance with Schedule 1 of the care home regulations. This document should be supplied to the Commission and a copy be available at the home. A service user guide must be produced in accordance with the Care Home Regulations. A copy of this document should be made available to the Commission and each service user. All medication received into the home must be labelled clearly so that staff administering it have clearly defined instructions. All service users must complete consent forms. All staff administering medication must have appropriate and verified training. Documentary evidence as described in Schedules 2 & 4 of the Care Home Regulations must be kept at the home and be available to the inspector. The registered manager must acheive NVQ 4 in care and maangement training by 2005. Staff should be trained in order Timescale for action 16th September 2005 2. YA1 5 16th September 2005 3. YA20 13(2) 23rd December 2005 4. YA34 & YA 41 Schedule 2&4 7th October 2005 5. 6. YA37 YA42 9(2b) 13(4c) 31st December 2005 31st Page 24 Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 to ensure the safety of service users. December 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA40 Good Practice Recommendations All the homes policies and procedures should be reviewed, signed and dated by the senior staff. Develop opportunities for local staff to be involved in the development of Lancashire County Council’s policies and procedures, or conversely develop policies and procedures pertinent to Gloucester Avenue. 2. Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, Clayton-Le-Moors Accrington Lancashire. BB5 5JB 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 Hyndburn Respite Facility F57 F57 S40870 Gloucester Avenue V221123 May 11th 2005 Stage 4.doc Version 1.20 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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