Inspection on 19/12/05 for Alfrace

This inspection was carried out on 19th December 2005.

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

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

Other inspections for this house

Alfrace 03/07/07

Alfrace 26/04/06

Alfrace 14/07/05

Alfrace 09/02/05

Alfrace 29/07/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Alfrace Newton Lane Wigston Leicestershire LE18 3SH Lead Inspector Joanne Vyas Unannounced Inspection 19th December 2005 14:00 Alfrace DS0000001669.V272405.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 Alfrace DS0000001669.V272405.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. Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Alfrace Address Newton Lane Wigston Leicestershire LE18 3SH 0116 2883352 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) Mr Richard Morgan Mrs Rita Morgan Mrs Rita Morgan Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 14th July 2005 Brief Description of the Service: Alfrace is a home registered to provide care for six adults who have a learning disability. It is a small family run home situated on the outskirts of Wigston. It is staffed by the couple who own the home and their daughter. The couple who are the Registered Person and Manager, also live in the home. Accommodation consists of individual bedrooms, five on the ground floor, a large open plan kitchen, dining area, and lounge, with an open fire. There is also a separate sitting room, for the benefit of residents, with a television and comfortable seating provided, all of which is provided on the ground floor of the property. The home is pleasantly furnished and decorated, to a high standard. It is located within spacious gardens, where fruit and vegetables are grown, which are then consumed on the premises. Residents support the Registered Manager, in maintaining the garden, gaining much enjoyment from this. Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the CSCI is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involved selecting one resident and tracking the care they received through looking at their records, discussion with care staff and residents and observation of care practices. This unannounced inspection took place between 2pm and 4:30pm and was carried out as part of the annual plan of inspection. Planning for this inspection included reviewing the previous inspection report. What the service does well: 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 6 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 Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 7 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, 3, 4, 5 Prospective residents’ needs and aspirations were not fully assessed prior to moving into the home, which may put residents at risk. EVIDENCE: • • • The home has a stable group of residents but has had a recent admission as a result of increasing numbers of residents the home can take. The new resident was very happy to be living in the home and wished that it became his permanent home. Other residents were also happy for the new resident to be living at the home. The Registered Manager stated that the Residents’ Guide had been given to the resident, his family and his social worker prior to moving in. However, there had been some confusion with regard to the home’s terms and conditions document. The Registered Manager was in receipt of an out of date community care assessment completed by the social worker, prior to the commencement of the placement, but did not carry out any formal assessment, including risk assessments, herself. The new resident and his family visited the home and opted to stay for a trial period of two weeks. At the end of the two weeks a review was held, and the resident decided he wanted to stay. • • Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 8 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 There are good systems in place to ensure residents are consulted in all aspects of their lives in order for them to achieve independent lifestyles but these are not consistently formalised. EVIDENCE: • A resident the inspector spoke to, knew exactly what he wanted to do and how he was going to achieve this. The Registered Manager was also knowledgeable about the resident’s views and was looking at ways to enable the resident to achieve his goals. Although all residents who have been living at the home have care plans and risk assessments in place, a new resident had not got these and had been living in the home since October 2005. • Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 9 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, 13, 14, 15, 16 Social activities are well managed, creative and provide daily variation and interest for people living in the home, however choice of activities/holidays can be limited. EVIDENCE: • • Residents attend day services and work placements. Residents attend various clubs and community facilities such as the Liberal club. All residents tend to go to this club but said they enjoy going. One resident said he’d like to go to church and said he would discuss this with the Registered Manager. The Registered Manager was observed interacting with residents positively. The Registered Manager encourages and facilitates family/friends contact. The Registered Manager told the inspector about the holiday she was planning for the residents in the New Year. The Registered Manager plans for residents to go to a respite holiday home where staff are provided and residents have been in previous years. The residents were not aware of any holiday plans but were happy to go to the respite DS0000001669.V272405.R01.S.doc Version 5.0 Page 10 • • • Alfrace holiday home. However, the inspector pointed out that residents have been given a limited choice, which is expensive for the time of year. Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): none These standards were not inspected on this occasion but were inspected at the previous inspection on the 14th July 2005 and were found to be satisfactory. EVIDENCE: Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): none These standards were not inspected on this occasion but were inspected at the previous inspection on the 14th July 2005 and were found to be satisfactory. EVIDENCE: Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): none These standards were not inspected on this occasion but were inspected at the previous inspection on the 14th July 2005 and were found to be satisfactory. EVIDENCE: Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 The number and deployment of staff is sufficient to meet the needs of the residents. EVIDENCE: • Due to the size and the nature of the home, staffing consists only in the form of the Registered Proprietors/Managers. (A total of 3 people – two of which live at Alfrace). The home is staffed sufficiently when residents are at home. A member of staff started the National Vocational Qualification level 4 in Care in September this year. The home does not use any recruitment and selection procedures as only family members staff it. However, all staff have Criminal Records Bureau clearance. • • Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 The Registered Manager ensures residents receive consistent, quality care. EVIDENCE: • The Registered Manager has had 20 years experience in a management position with people with a learning disability. All the residents have a high opinion of her and feel they are able to discuss any issues openly with her. Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 3 3 1 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Alfrace Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X X DS0000001669.V272405.R01.S.doc Version 5.0 Page 17 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 Requirement The Registered Person is required to ensure that all unnecessary risks to the health and safety of residents are identified and so far as possible eliminated. The Registered Person is required to ensure all residents in the home have a written plan with regard to their needs in respect of their health and welfare. Timescale for action 09/01/06 2 YA6 15 09/01/06 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 Refer to Standard YA5 YA14YA12 YA2 Good Practice Recommendations It is recommended that the terms and conditions document is written in a clear format to prevent confusion. It is recommended that more choice be offered to residents with regard to holidays and activities. It is recommended that residents have a full and current assessment of need prior to admission to the home. Alfrace DS0000001669.V272405.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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