Inspection on 30/08/07 for Ayeesha-Raj

This inspection was carried out on 30th August 2007.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ayeesha-Raj 03/09/09

Ayeesha-Raj 20/04/06

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 David Bacon Unannounced Inspection 30th August 2007 10:00 Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 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.V344636.R01.S.doc Version 5.2 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.V344636.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ayeesha-Raj Address 89 Loughborough Road Mountsorrel Leicestershire LE12 7AU 01509 413667 F/P 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.V344636.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 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 two shared and sixteen 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. Copies of inspection reports are kept in the office for service users and members of the public. The range of fees is up to £329 per week. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place during August 2007 and the visit to the home was undertaken over approximately 5 hours. The care received by three residents was looked at in detail. This process is called “case tracking” and individual residents care records and general home records were looked at as part of this along with discussions with residents about their experience of life within the home. The inspector spoke with five residents, two staff members and the new acting manager/head of care who has been recruited since the previous inspection. Eight quality satisfaction questionnaires completed by residents were viewed during the visit. Prior to the visit, the inspector reviewed the previous inspection report and any information relating to the service since that inspection was assessed as part of the overall review of the service. A partial tour of the premises was conducted including areas relating to the residents who were case tracked. Staff records were also inspected along with policies/procedures and administrative systems. What the service does well: What has improved since the last inspection? Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 6 The number of shared bedrooms has been reduced from three to two and the acting manager said that consideration is now given to the wishes and care needs of residents when placements are made in shared rooms. Some improvements have been made to the homes care recording systems, which now more clearly reflect the current needs and wellbeing of residents. The physical state of the premises is being improved with several areas having been recently repainted to provide a more homely environment and further work is planned. 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. The summary of this inspection report can be made available in other formats on request. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 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.V344636.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are satisfactory procedures for assessing and introducing new residents to the home. EVIDENCE: Residents care needs are assessed prior to admission by home staff as well as social services. The acting manager said that prospective residents are encouraged to visit and or stay at the home prior to admission and that this is flexible, as per the needs of the individual. Resident’s stay for a trial period during which time their care needs continue to be assessed and a review of stay is then held for all parties, prior to any decision being made. The assessment information seen clearly detailed the care needs of each resident and included: personal care, health, emotional wellbeing, communication, independence and activities. Any specialist supporting services input was included along with guidance for staff. Individual contracts are in place for each resident, which set out the terms and conditions for living at the home. Staff and residents are currently updating the homes service users guide in the aim of more clearly documenting the services provided in a format more appropriate for residents. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 9 The residents spoken with were satisfied with the admission process and comments included: “I didn’t have to stay here but I liked it so I said yes”. “I came here a few times first and it was good”. “I have lived here a while but the staff have always been good to me”. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are supported to make decisions about their daily lives. Individual care plans reflect the needs of residents, who are protected by clear risk assessments and they are supported to maintain their independence. EVIDENCE: The care records viewed clearly identified the individual care needs of residents and how these were to be met and included any preferred routines, aims, objectives, risks and how these were to be minimised. For example, the records of one resident prone to becoming anxious clearly instructed staff as to how to minimise any potentially distressing situations. The resident spoke about this and said: “They help me when I’m not well, they know how to help me”. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 11 Staff were observed being very supportive and respectful towards residents, whom they encouraged to make decisions and be involved in all aspects of their daily routines. Care records were regularly updated to reflect any changing care needs and there was evidence of annual placement reviews being held. Records did not fully document resident’s involvement in this process although the residents spoken with said they had been included. Policies and procedures promoting and safeguarding residents rights, confidentiality and data protection is in place and providing guidance to staff. Residents said that they were treated well by staff and supported to make decisions regarding their day-to-day lives. Comments included: “I can mostly do what I want, I have a key worker to help me decide what I should do”. “I have a care plan, which I helped write”. “We agree things and it is all in my plan”. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 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. 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 this service. Resident’s rights are respected and they are supported to develop any life skills or interests. Resident’s users enjoy the homes provision of meals. EVIDENCE: The records seen identified where residents are supported to use community resources such as the local pub, shops, church and also amenities in Leicester and Loughborough. Individual activity plans are in place, which are flexible depending on the needs and wishes of the residents. The care plans seen evidenced how residents were supported to develop life skills specific to the needs and interests of the individual. For example, maintaining and developing friendships, relationships and independence skills. Detailed risk assessments provide staff with clear guidance to assist residents Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 13 to minimise any risks. One resident said: “If I have boyfriend trouble they try to help me and explain things, it’s for my own safety”. The residents spoken with said they meet every month to discuss life within the home and any topics of interest, including: meals, activities and relationships. Resident’s dietary needs and preferences are noted upon admission and then reviewed as necessary and a choice of foods is available at each mealtime. The homes staff generally prepare the food each day although some residents are involved in preparing their own meals, alongside staff. The resident’s spoken with were satisfied overall with the homes provision of meals. Comments included: “Yes, the food is nice, you can say what you want”. “I’m going out to buy lunch but I can get it here, there is a choice of foods”. “I like the food, I have what I like mostly”. “You don’t have to eat anything, you have a choice”. “We sometimes help make the food or the staff mostly do it”. A daily record of the meals provided is maintained along with health and safety checks. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users have access to a range of local healthcare services and their personal care needs are appropriately met by staff. EVIDENCE: Residents spoke positively about the homes staff and confirmed they were satisfied with the care provided and that their wishes and feelings were respected. Comments included: “They treat me well, if I need anything then I just say”. “I have a key worker, we spend time together each week”. “I can talk to the staff and they help you if you have a problem”. “They help sort things out for you and they are fun”. “My key worker comes with me when I need it but for nice things too”. Care records clearly instruct staff as to individual residents care needs and preferences and residents are involved in the devising and updating of their own plans where this is possible. Individual wishes or instructions regarding bereavement are documented. Any health and medical needs of residents were clearly identified within the care plans seen and records instructed staff as to any instructions or advice received from supporting health agencies. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 15 Residents are supported to administer their own medicines if they are assessed as able. Policies and procedures regarding the administration of medicines provide guidance to staff whom receive awareness training regarding this subject matter. Medication is stored appropriately and administration records are satisfactory. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 16 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. 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 this service. Systems are in place for residents to raise concerns or complaints and the home staff are made aware as to how to protect residents from the risk of abuse or harm. EVIDENCE: There have been no formal complaints and two safeguarding adult referrals since the last inspection, which have been resolved. The residents spoken with said they were aware of complaint policies and procedures and felt able to express any views to staff and that they would be appropriately acted upon. Comments included: “If you want to complain it’s on a paper on the wall, that tells you how”. “I can talk to the staff, they will listen”. “I can complain if I like and they will do something about it”. The complaints procedure is displayed in the home and is being included in the updated service users guide. Staff have received some training on how to safeguard vulnerable adults from abuse, of which policies and procedures are in place and the staff spoken with were aware of the correct action to be taken in the event of residents being at risk. Risk assessments are undertaken, specific to residents care needs, which are reviewed and updated as necessary. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is clean and improvements continue to be made to create a more comfortable and homely environment for residents. EVIDENCE: The home is generally well maintained, with Ayeesha-Raj providing a simple but comfortable standard of accommodation, of which is being updated. For example, several hallway areas have recently been painted. The acting manager confirmed that there is now a rolling programme of refurbishment to create a more homely environment for residents. There is ample space in communal areas, which include three lounges and a dining room. The residents spoken with said that they were satisfied with the accommodation and supported to personalise their own rooms, which was further evidenced during a tour of the building. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 18 Risk assessments of the premises are undertaken and any required action is taken as necessary. Staff receive awareness training regarding health and safety and cleaning materials are safely stored. The number of shared bedrooms has been reduced since the previous visit and the acting manager confirmed that residents requesting to have single bedrooms would be allocated a single room when possible and that consideration would be given to the feelings and wishes of residents when placements are made in double rooms. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents receive good levels of support from a well-trained staff team. EVIDENCE: Residents confirmed that there are enough staff to meet their needs. Three care staff members are on duty during daytime hours and one waking and one sleeping in staff work at night. Separate cleaning staff are deployed during the week and care staff oversee the cleaning of the home at weekends. The staff team are a mixture of new and experienced staff and are from culturally diverse backgrounds. The acting manager said that efforts are made to reflect the cultural needs of residents, through recruitment. A head of care/acting manager has recently been appointed who said they will be applying to become the registered manager of the home. Recruitment records are in place and generally contain application forms, criminal record bureau checks and two references. However, one file did not contain one reference although this was located following the visit. Other Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 20 records show that recruitment policies and procedures are in place, including equal opportunities. Staff undertake a twelve-week induction to the home and also receive training in subjects such as NAPPI (Non-Abusive Psychological and Physical Intervention), protection of vulnerable adults, basic food hygiene, health and safety, first aid, medication awareness, national vocational levels 2 and 3, complaints, record keeping and Fire safety. The staff spoken with confirmed they had received an induction and ongoing training appropriate for the work they perform. The acting manager said that awareness training in more specialised subjects such as behavioural management and epilepsy are booked. A training plan is now in place and any outstanding training needs are identified. Resident’s comments regarding staff included: “I like the staff, I get on with them and they help me when I need it”. “They are good and I do like to see them, they are good to talk to”. “I can go to the staff if I need help and they are helpful”. “There are arguments sometimes with the people here but the staff help us all”. Staff meetings are held each month of which records are maintained and staff receive formal supervision. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 21 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. 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 this service. Resident’s rights are promoted and safeguarded. Systems are in place to measure the quality and satisfaction levels of the services provided. The health and safety of the home is adequately maintained. EVIDENCE: The provider undertakes regular monitoring visits to the home to check on the quality of service provided, of which copies are maintained in the home. The residents spoken with were satisfied with the management of the home. Comments included: “I like living here because the staff help you and the manager is good, you can talk to them”. “I can go to the manager or staff, they are very fair”. “I can see the manager whenever they are here and they help you if you have problems”. Policies and procedures safeguarding Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 22 resident’s rights are in place and staff receive guidance regarding these, of which have recently been updated. Residents meetings are regularly held and quality satisfaction questionnaires are now used. The acting manager evidenced that the views of residents were assessed and acted upon as necessary. The staff members spoken with were satisfied with the management of the home and said they felt able to discuss any views and that these would be respected. Systems are in place to promote health and safety within the home following comprehensive risk assessments being undertaken and staff attend awareness training regarding this subject matter. Regular fire safety checks are undertaken and a fire risk assessment is in place. The residents spoken with were aware of evacuation procedures. Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 23 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 3 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 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 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 3 3 X 3 X X 3 X Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 24 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 YA37 Regulation 8 Requirement Confirmation must be received detailing the action being taken to register a manager for the home. Timescale for action 01/12/07 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.V344636.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ayeesha-Raj DS0000063000.V344636.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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