Inspection on 20/04/06 for Ayeesha-Raj

This inspection was carried out on 20th April 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ayeesha-Raj 03/09/09

Ayeesha-Raj 30/08/07

Ayeesha-Raj 16/01/06

Ayeesha-Raj 02/06/05

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 Ayeesha-Raj 89 Loughborough Road Mountsorrel Leicestershire LE12 7AU Lead Inspector Kim Cowley Unannounced Inspection 20th April 2006 1.30 Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 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 Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 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. Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ayeesha-Raj Address 89 Loughborough Road Mountsorrel Leicestershire LE12 7AU 01509 413667 01509 413667 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) Cherre Residential Care Ltd Vacant Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Ayeesha Raj is registered to provide care for twenty adults with learning disabilities. Formally known as David Leslie, it was bought by Cherre Residential Care Ltd in April 2005. This company also owns a further two homes in the Leicester area. Ayeesha Raj is situated on the main road running through Mountsorrel. It is located close to the centre of the village and has good access to public transport services into Leicester and Loughborough. The original house, a large detached property, has been extended to provide three shared and fourteen single bedrooms. It has three lounge areas, all of which are located on the ground floor. The garage has been converted into a games area for service users. There is a patio garden and off road parking for staff and visitors. Fees range from £1,269 to £1,328 per month. Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included a visit to the home, and inspection planning. Prior to the home visit, the inspector spent half a day reviewing the last inspection report, and information relating to the home received since that inspection. During the course of the inspection, the inspector checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means that the inspector looked at the care provided to four residents living at the home by talking with the residents themselves; talking with the Provider and staff who support their care; checking records relating to their health and welfare; and viewing their personal accommodation as well as communal living areas. Other issues relating to the running of the home including health and safety, and management issues, were inspected. Four other residents, three members of staff, and the Provider were also interviewed. The staff team was commended. What the service does well: Ayeesha-Raj was taken over by a new Provider in 2005, and since then significant improvements to the premises, record systems, and care, have been made. The home has a lively atmosphere and relationships between staff and residents appeared excellent. Residents interviewed made many positive comments about the home including: ‘I like this home. I love it here.’ ‘This my home and I want to stay.’ ‘I like the residents and the staff.’ ‘It’s lovely food here, it’s excellent.’ All resident have an individual programme of leisure and/or educational activities. A day care organiser works with residents and staff to achieve this. Discussions with residents indicated they lead full and active lives. Comments included, ‘We have a disco once a month in the big lounge and two DJs come in’, and ‘We have our own car. We go to Bradgate Park. We went to Skegness for a day trip.’ The staff team comprises of a mixture of experienced and new staff. The Provider said the staff have come together as a team, and are working and communicating well. All residents interviewed praised the staff team. The following comments were made, ‘The staff are funny – they make me laugh’, ‘The staff are kind to you’, and ‘The staff help me if I’ve got a problem.’ Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 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 Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ needs are adequately assessed prior to moving into the home. EVIDENCE: Prospective residents are fully assessed by social services and staff at the home prior to admission. Following this, they have a three-month trial period. In this time their needs are re-assessed and their risk assessments re-visited and amended to reflect any changes in their lifestyles. Records relating to past admissions were examined. These were of good quality and indicated that efforts had been made to involve the resident and their family in the assessment process. One resident said, ‘I came to look at the home first with my social worker’, and another commented, ‘My (relative) came here first to look round. Then I came and stayed overnight. Then I moved in.’ Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 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, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health and personal care needs of residents are satisfactorily met. EVIDENCE: Overall, care records are in good order. Records showed that all care plans/risk assessments were updated in December 2005. Residents were involved in this process and some had signed to show they were in agreement with changes made. One resident said, ‘I’ve got a care plan here and I can see it if I want.’ Residents’ individual needs would be better reflected if profiles and medical information are kept up to date. In discussion residents indicated they are supported in taking responsible risks. One resident discussed the arrangement for when she goes out alone. She said ‘I go to Loughborough on my own. I have a mobile phone with the home number on it. If I am late they phone up and ask where I am.’ Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 10 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, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents lead full and active lives. EVIDENCE: All resident have an individual programme of leisure and/or educational activities. Some attend colleges and day centre, other do voluntary work in the local community. Local resources are used including the library, cafes, pubs, and transport links. A day care organiser works with residents and staff to ensure that varied activities are on offer. The home has a ‘people carrier’ and residents go out on day trips. Discussions with residents indicated they lead full and active lives. Comments included: ‘I go to college and learn independent living skills.’ ‘We have discos once a month with dancing.’ ‘We have a disco once a month in the big lounge and two DJs come in.’ ‘I go swimming at Soar Valley Leisure Centre.’ Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 11 ‘I do into town and buy CDs and magazines.’ ‘I do gardening in Mountsorrel to help people who can’t do their own gardens.’ ‘I go out cycling on my bike.’ ‘We play games and do jigsaw puzzles.’ ‘We have our own car. We go to Bradgate Park. We went to Skegness for a day trip.’ ‘I have visitors – we can go to my room or talk in the bottom lounge.’ There are TVs, DVD players, and music centres in the lounges for communal use. Some residents also have these in their rooms. Residents are encouraged to be independent and to make choices about their lifestyles. Care staff do the cooking. Food is bought locally from a farm shop, and also from supermarkets. Menus are planned a week in advance, in consultation with residents, and there is a choice at every meal. For health and safety reasons residents are only allowed in the kitchen one at a time and under staff supervision. One resident showed the inspector the menu book. Records showed that a healthy and varied diet is provided. Residents made many positive comments about the food including: ‘My favourite meal is spaghetti bolognaise. We tell the staff what we like.’ ‘The food’s nice. I like curries – hot one like madras. The staff make those for me.’ ‘I like my Sunday dinners – one week we have Yorkshire pudding with it, the next week we have stuffing.’ The current residents are white and from England and Scotland. The staff team are multi-cultural. One resident has a particular interest in Asian culture. Staff support his interest, taking him to local festivals and giving him the opportunity to sample different Asian foods. Residents’ religious needs are documented in their care plans and they have the opportunity to attend local places of worship. Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 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): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents choose how much assistance with personal care they would like. A range of health care professionals provides services to the home. Medication is securely kept and properly administered. EVIDENCE: Residents need differing levels of personal support. Staff talk to residents about what help they need, and this is recorded in their care plans. Residents are registered with local GPs, dentists, opticians, and other health care professionals. Records showed that staff take a holistic approach to their care. Medication is stored, handled and disposed of appropriately. Since the last inspection medication administration records have been improved. A ‘counter signature’ system has been set up, so two members of staff always witness administration. The Provider said she audits medication records once a month to ensure they are being kept properly. Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 13 All staff have received in-house medication training, with additional training provided by the contract pharmacist. Some staff have completed a 13-weeks ‘Safe Handling of Medication;’ course. One resident commented, ‘The staff give me my medication. They keep a record of that. They keep medication locked away.’ Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 14 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, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents feel able to talk to staff about concerns and staff know how to protect residents from abuse. EVIDENCE: The complaints procedure is displayed communally and in each resident’s bedroom. All residents interviewed said they knew how to complain. One commented, ‘If I have a complaint I tell the staff – they listen.’ Another said, ‘If complaint I’d tell Hema or other staff on duty.’ Policies and procedures are in place to protect resident from abuse and the staff on duty were familiar with these. All staff have received training in adult protection procedures and are reminded regularly throughout staff meetings and one to one supervision sessions. Records showed that staff have dealt appropriately with situations where residents may have been at risk. Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 15 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, 26, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a comfortable and well-maintained environment. EVIDENCE: The home is spacious, and well furnished and decorated. There is a good range of communal areas including three lounges and a dining room. There is a patio garden with seating areas and a large detached lounge/games room. The home is situated in the centre of Mountsorrel village with nearby cafes, shops, bus routes, a library, and pubs. Residents who smoke are asked to do so outside where there is an undercover area for their use. The home has three shared rooms. Not all the residents in question were happy with this arrangement, feeling it compromised their privacy. It is would be beneficial if all residents who share rooms are asked for their views on sharing. If they are not happy steps could be taken to allocate them a single room wherever possible. Since the new Provider took over the following improvements have been carried out to the premises: Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 16 • • • • A new boiler and central heating system (including a back-up system) has been installed Thermostats have been fitted throughout out the home (with the exception of the kitchen) to reduce the risk of scalding An area of loose flooring has been replaced Improvements have been made to the kitchen and the fire escapes following recommendations from the fire department All areas inspected were clean and tidy. One resident said, ‘The house looks good. Oliver ((a staff member) does the cleaning – he comes every day. I keep my room tidy. Oliver does the laundry.’ Records showed staff and contractors properly maintain the home. Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 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): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Friendly and professional staff meets residents’ needs. EVIDENCE: At present the home does not have an Acting Manager and the Provider is fulfilling that role until one is appointed. She is supernumerary. A new Acting Manager is due to start at the home on 24.04.06. The Provider said following a successful probationary period he will be put forward as the next Registered Manager. There are three staff on duty during the day and one waking and one sleeping staff member on duty at night. Staff have an eight-week induction and are encouraged to complete Learning Disability Award Framework training if they have little or no experience of people with learning disabilities. NVQ training is underway in the home and some staff have already achieved their awards at Level 2 and 3. Person Centred Planning (PCP) has been introduced into the home. The Provider is a PCP facilitator (who is studying to become a trainer) and also employs a licensed trainer to work with staff in her homes. NAPPI (NonAyeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 18 Abusive Psychological and Physical Intervention) training is also available to staff. The staff team comprises of a mixture of experienced and new staff. The Provider said the staff have come together as a team and are working and communicating well. All staff interviewed confirmed this. Staff receive one to one supervision sessions every eight weeks and an annual appraisal. Staff meetings are held every month. Recruitment processes are robust. Agency staff are not used. The home has a lively atmosphere and all residents interviewed praised the staff team. The following comments were made: ‘The staff are funny – they make me laugh.’ ‘The staff are kind to you.’ ‘If you have to go to hospital the staff come with you.’ ‘The staff help me if I’ve got a problem.’ ‘My key worker talks to me and helps me.’ The staff team is commended. Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 19 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, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a well managed home where staff take account of their views. EVIDENCE: The Provider, who has substantial experience in providing care to people with learning disabilities, runs the home along non-institutional lines with the emphasis being on resident choice. The result is a homely environment with residents who are confident about speaking out and determining their own care and lifestyles. All residents and staff interviewed made positive comments about the Provider including: ‘Hema is a nice helpful person.’ ‘Hema has made us more independent – she lets us try new things.’ ‘I like what Hema’s done. It’s better now she’s here. She’s made it safer.’ ‘Hema lets us do what we want.’ Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 20 Monthly residents meetings are held chaired, at the residents’ request, by staff. These are minuted and attendance is good. The Provider said residents could also approach her or any of the other staff at any time if they wish. One resident commented, ‘We have a residents meeting once a month so we can say what we think about living here.’ The Provider said that staff and residents contribute to the home’s policies and procedures, business plan, and aims and objectives. Appropriate policies and procedures are in place for protecting the health and safety of residents and staff. Following consultation with the fire department improvements have been made to the premises (see ‘Environment’). All residents interviewed were aware of fire safety. One said, ‘If the fire alarm goes off you go out straight away at the back. And then you wait until they call our names. Staff then check the home and see where the fire is.’ Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ayeesha-Raj DS0000063000.V290720.R01.S.doc Version 5.1 Page 23 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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