Inspection on 19/09/05 for Ca Na Gardens

This inspection was carried out on 19th September 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 but made no statutory requirements on the home.

Other inspections for this house

Ca Na Gardens 17/11/09

Ca Na Gardens 28/04/09

Ca Na Gardens 18/12/08

Ca Na Gardens 27/11/08

Ca Na Gardens 29/04/08

Ca Na Gardens 23/05/07

Ca Na Gardens 23/05/06

Ca Na Gardens 16/05/05

Ca Na Gardens 08/10/04

Ca Na Gardens 07/05/04

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 Ca Na Gardens 174 Scraptoft Lane Leicester Leicestershire LE5 1HX Lead Inspector Keith Charlton Unannounced Inspection 19th September 2005 04:00 Ca Na Gardens DS0000006360.V249953.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 Ca Na Gardens DS0000006360.V249953.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. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ca Na Gardens Address 174 Scraptoft Lane Leicester Leicestershire LE5 1HX 0116 2413337 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) Hamra Associates Limited Mr Ray McLaughlan Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 16/5/05 Brief Description of the Service: Ca Na Gardens is a detached home set in a residential area. The home has access to a variety of local community facilities, including a large supermarket.The home is registered for eight people with a Learning Disability. The home offers accommodation on both ground and first floor, which includes a large lounge and a separate lounge/dining area both with patio doors leading onto the rear garden. The home has a very large garden with mature planting, which is accessed and used by service users.The home offers seven bedrooms, six single and one shared. Bedrooms are located on the ground and first floor. The home has a shower room and separate toilet on the ground floor, and a bathroom incorporating a bath and shower on the first floor, and a separate toilet. Ca Na Gardens DS0000006360.V249953.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 Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. This was an unannounced inspection that took place on 19/9/2005. The inspector arrived at the home at 3.45pm and finished the inspection at 7.15pm. On this occasion the inspector ‘case tracked’ two clients. The inspector also observed other clients residing in the home and talked with them where possible, talked with staff, and checked other health and safety records. The Inspector completed the Inspection on 23/9/05 with the Deputy Manager. What the service does well: What has improved since the last inspection? Care plans are now more detailed as to what action needs to be taken to meet the needs of service users. Facilities have been and are currently being updated regarding décor. Water temperatures are now within safe limits so will not scald service users. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 6 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. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Prospective service users/their representatives do not have full information they need to make an informed choice of where they live. Service users needs are assessed prior to admission but staff have not received training as to their health conditions. EVIDENCE: The Home’s Statement of Purpose is still without information with regard to the experience/qualifications of the staff, the views of service users /representatives, the number and sizes of rooms, a clear Complaints Procedure and a statement as to how to ensure that service users privacy and dignity are to be maintained. Service users are assessed before admission as per the Social Service Departments Assessment process. The Deputy Manager has obtained some relevant information but staff training has not taken place as to service users health conditions, e.g. autism, psychosis, celebal palsy with paralysis, anaemia etc. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 9 Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 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 the following standard(s): 6,7. The system of writing care plans and staff being directed to read them results in staff being aware of service users care needs. EVIDENCE: All service users have a care plan, which the Deputy Manager has been working on to ensure they are more detailed. This is greatly improved since the last inspection. Full detail is not yet complete, e.g. dietary Requirements for the service user on a weight reducing diet, activities for a service user whose day care activities have been curtailed by the Social Service Department. Staff said they were asked to read all the service users care plans to make sure all their needs are known. The two residents able to communicate said they were happy with living in the home and they were asked what food they wanted and where to go on holiday. Other service users can undertake various activities subject to Risk Assessment, according to the staff asked, and this was recorded in their Care Plans. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 11 Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 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 the following standard(s): 12,13 Activities meet service user needs. EVIDENCE: Service users informed the inspector of educational classes they are involved in, and one service user showed the inspector her artwork. Some service users were observed to be living independently at the home during the inspection, coming and going from the building to the garden where the trampoline is available and a service user showed the inspector plants that she was growing. Records showed that service users have been on holidays to the seaside and service users spoke enthusiastically of these. Service users are supported well in maintaining relationships with family and friends as recorded in Care Plans, with the a relative visiting during the inspection to take a service user to the cinema. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 13 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 Service users receive good personal support with their physical and emotional health needs on the whole, being well met. Staff need to treat service users with respect at all times. EVIDENCE: Through observation, discussion and records, it was demonstrated that service users receive support in the way they prefer and require it. Both of the service users case tracked were being given good support from the staff. Staff were observed to be speaking to the service users in a generally friendly fashion, asking about what they did that day and assisting them around the home when necessary though there were also some sharper comments telling some service users to sit down. Service users receive health care as required, with service users being registered with a local doctor. This was evidenced in their Care Plans. The policy and procedure for medication has been amended to make it clearer for staff. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 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 Service users/their representatives cannot be confident their concerns will be properly attended to. EVIDENCE: The Complaints Procedure did not give the complainant the opportunity to go to the Commission for Social Care Inspection at the initial stage and that they are entitled to receive a response from the Registered Provider’s within a given timescale. Staff spoken to knew to take their concerns further if abuse was suspected but were not aware of all relevant Agencies to contact in the event of action not being taken by Management. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 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): Clients live in a generally homely and comfortable environment, though some facility issues need too be attended to. EVIDENCE: The inspector looked at service users bedrooms, the communal areas, the garden area and kitchen. Observations of the bedrooms demonstrated that have their bedrooms to suit their needs and lifestyles and standards of cleanliness in the bedrooms were satisfactory. The communal lounge/dining room areas have been decorated to a good standard and these areas were in a reasonable state of cleanliness. The front of the home has been painted and now looks attractive. The back of the home is in need of this attention. There were a number of maintenance issues identified as outstanding - the ground floor shower room skirting and shower base and flooring and stained carpets to the corridor area outside the shower room all needed attention which the Deputy Manager said was being attended to in the following weeks. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 16 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 Service users benefit from a dedicated staff group and the level of staffing is generally sufficient to meet service users needs though recruitment practices need to be tightened. EVIDENCE: The Registered Provider generally meets the required staffing levels. As two service users need one to one attention the Registered Manager ensures there are three staff on duty for early morning/late evening periods and at weekends. Staffing levels need reviewing to see if it is adequate to have two sleeping in staff and not to have an awake staff member when there is one service user who gets up frequently during the night and goes into other service users bedrooms. Also staff work continuous shifts from afternoon to mid day the next day if they are disturbed at night. Staff records showed that references are sought from the last employer to protect service users from unsuitable staff. Records did not show that all staff had the required ID – birth certificates, passports or similar. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 17 Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 18 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): 42 Health and Safety systems do not fully protect the welfare needs of service users. EVIDENCE: A Risk Assessment folder for safe working practices is available. The water temperature for the first floor bath was measured at 43c which is a safe level and meets the National Standard. Radiator covers have been installed to protect residents from scalding. Fire doors were wedged open on ground floor corridor doors. An Immediate Requirements Notice was issued to rectify this potential Health and Safety risk. There was no recorded fire drill since March 2005. A staff member spoken to was not aware of the full fire procedure though another staff asked did know the procedure. Staff said they had read some of the policies and procedures and they are encouraged to do so. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 19 Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 20 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 2 3 2 X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ca Na Gardens Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000006360.V249953.R01.S.doc Version 5.0 Page 21 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 1 Regulation 1 Requirement The Registered Manager needs to ensure that full information is available in the Statement of Purpose as per Schedule 2 if the Care Homes Regulations 2001(this requirement was outstanding from the previous inspection). Staff training needs to take place on all health conditions that service (this requirement was outstanding from the previous inspection). A full complaints procedure is needed (this requirement was outstanding from the previous inspection). All staff need to understand the complete adult protection procedure (this requirement was outstanding from the previous inspection). Some facilities issues need attention. The Registered Provider needs to review staffing arrangements at night to ensure they are adequate. Staff need to have sufficient identification to be able to work DS0000006360.V249953.R01.S.doc Timescale for action 23/11/05 2 3 14 23/12/05 3 22 22 23/11/05 4 23 13 23/11/05 5 6 24 32 23 18 23/12/05 23/10/05 7 34 19 23/10/05 Ca Na Gardens Version 5.0 Page 22 8 42 13 in the Home (this requirement was outstanding from the previous inspection). Fire safety needs to be reviewed and improved 23/10/05 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 Refer to Standard 20 22 Good Practice Recommendations It is recommended that the Registered Manager checks the medication Policies and Procedures with the pharmacist to see if they are sufficient for purpose. It is recommended that the Registered Manager provide a simple procedure for staff to follow if abuse is suspected. Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 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. Extracts may not be used or reproduced without the express permission of CSCI Ca Na Gardens DS0000006360.V249953.R01.S.doc Version 5.0 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!