Inspection on 23/05/07 for Ca Na Gardens

This inspection was carried out on 23rd May 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 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

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 23/05/06

Ca Na Gardens 19/09/05

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 Mrs Diane Butler Unannounced Inspection 23rd May 2007 07:50 Ca Na Gardens DS0000006360.V337405.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 Ca Na Gardens DS0000006360.V337405.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. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ca Na Gardens Address 174 Scraptoft Lane Leicester Leicestershire LE5 1HX 0116 2413337 0116 2433639 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.V337405.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 29th September 2006 Brief Description of the Service: Cana Gardens is a care home providing personal care and accommodation for up to eight people with a learning disability. The home, which is located on the outskirts of Leicester city centre, offers six single rooms and one shared room. Communal facilities include a lounge and a separate lounge/dining area. Both of these rooms have patio doors, which lead onto a large garden to the rear of the home. There are a variety of local amenities close by including a large supermarket, small local shops, health centres, temples, churches and takeaways. Current charges are £320 per person. The most recent CSCI (Commission for Social Care Inspection) inspection report is included in the welcome pack situated in the reception area of the home. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which took place over a five and a half hour period on Wednesday 23rd May 2007. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses on the outcomes for service users living in a home. In order to do this, the inspector ‘case tracked’ three residents. This means the inspector checked their care records and where possible met with them. Observation was also used to evidence whether care and support needs were being met. The inspector was able to talk to the administrative manager and two support workers on duty at the time of the visit and observed them going about their daily work. Questionnaires were also sent to the eight service users currently living in the home and their relatives to gain their views of the agency. Three service user questionnaires were returned and one relative questionnaire was returned. Comments received during the inspection included: “I’m happy here, they look after me”. “I like living here”. “I feel safe”. What the service does well: There is a relaxed and friendly atmosphere throughout the home and the support workers go about their daily work in an unhurried and professional manner. Privacy and dignity is maintained at all times and the service user spoken with confirmed that they were well looked after and their needs were being met. Care plans are thorough in content and include all the actions to be carried out to meet the needs of the service users. A healthy balanced diet is offered, service users are able to choose what to eat on a daily basis and mealtimes are unrushed and flexible. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Ca Na Gardens DS0000006360.V337405.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 Ca Na Gardens DS0000006360.V337405.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): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are appropriately assessed before moving into the home to ensure that their care and support needs can be met. EVIDENCE: A statement of purpose is in place, this document, which is available to all prospective service users and their families, provides information about the home and explains what services can be offered. The inspector was informed that any prospective service user would be invited to look around the home and a meeting would be held with them, their relative if at all possible and any relevant professionals such as the service users social worker. A copy of the needs assessment completed by their social worker would also be obtained and a decision would then be made as to whether the service users care and support needs could be met. If the manager feels that the service users needs could be met they would be invited to stay at the home for a number of short respite stays to enable them to get used to the home. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 9 No new service users have been admitted since the last inspection in May 2006. Three service users were case tracked during the inspection. On checking their paperwork all were found to include a comprehensive needs assessment completed by their social worker. The manager explained that once admitted into the home the care and support needs identified in the needs assessment document would be transferred to the homes care plan documentation. This was confirmed on checking the care plans belonging to the three service users case tracked. One resident spoken with stated that they looked around the home before they moved in. A service user questionnaire received stated, “My social worker brought me in for a respite period”. Ca Na Gardens DS0000006360.V337405.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. Service user plans are comprehensive in content, providing all the relevant information to enable the support workers to meet the service users individual needs. EVIDENCE: All three service users case tracked had both a care plan and a person centred plan in place. All the care plans seen on this occasion were thorough in content and had been reviewed following a review meeting attended by the service user, their relative, their key worker and on one occasion with the community nurse who was involved in the service users care. Care plans are reviewed on an annual basis or sooner if changes in the service users care and support needs occur. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 11 Service users living in the home are able to make decisions on a daily basis, these include when to get up and when to go to bed, what to wear, what to eat and where to eat it, and what activity they wish to complete in their free time. Evidence was seen during the inspection of the service users making their own decisions. This included one service user deciding what to have for their evening meal. Support workers enable the service users to take responsible risks on a daily basis and risk assessments are in place for all activities undertaken. Ca Na Gardens DS0000006360.V337405.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. Service users are provided with a varied and balanced diet and choices are offered at all times. EVIDENCE: Six of the eight service users are encouraged and supported to attend activities provided at local day centres. For the remaining two residents activities are provided by the home. This includes trips out, shopping, swimming and going for walks. Records of these activities, which are planned for on a day to day basis, are kept within the service users file. During the visit one service user was assisted to visit the local supermarket and another was supported to take a walk round the local neighbourhood. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 13 Daily routines within the home promote privacy and choice. Service users can choose whether to be alone or join the other service users, they are encouraged to assist in the daily chores of the home and for those service users who are able, are supported do their own laundry. During the visit one of the service users asked if they could help with the cleaning chores and assisted with the dusting. A healthy balanced diet is offered, service users are able to choose what to eat on a daily basis and mealtimes are unrushed and flexible. During the visit it was evident that mealtimes are both relaxed and informal and the service users had the opportunity to choose what to eat. On checking the menus it was noted that three choices are offered for the main evening meal, though the administrative manager stated that if the service users didn’t want any of the choices on offer they could always have something else. Specific diets are catered for including vegetarian and gluten free and there is always a vegetarian and gluten free choice on the menu. The support workers monitor the service users weight on a monthly basis and healthy eating is encouraged and promoted at all times. The administrative manager explained that relatives and friends are encouraged to visit the home at any time. A questionnaire received from one of the service users relatives supported this statement, which stated that the home always helps their relative keep in touch with them. Ca Na Gardens DS0000006360.V337405.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are looked after well in respect of their health and personal care. EVIDENCE: Service users are encouraged to be as independent as possible, for those less able to care for themselves, support and guidance is offered in a sensitive and flexible manner. Personal care is provided in private and one support worker explained that the male support workers only assist the male service users with personal care. Service users are able to choose when to get up and when to go to bed, particularly at the weekends and are encouraged to choose what to wear. On checking the records held for the three service users case tracked it was evident that the administrative manager and the support workers assist them to access healthcare services when needed. Services contacted on the service users behalf included GP’s, community nurses, opticians and chiropodists. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 15 Medication records belonging to the three service users case tracked were checked, All medication had been appropriately signed into the home and where returns to the pharmacist had taken place these too had been recorded correctly. The records for the medication taken on a regular basis were in order, though on checking the records for the medication given ‘as and when’ needed, it was noted that there was an error in the recording. The administrative assistant stated that this would be looked into straight the way. A telephone call was received two days following the inspection to confirm that a new record book has been purchased to ensure that no further errors occur. All staff required to administer medication have completed safe handling of medicines training. Ca Na Gardens DS0000006360.V337405.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. Service users feel safe and are protected from harm. EVIDENCE: A complaints procedure is in place and the resident spoken with during the visit and questionnaires received prior to the visit demonstrated that the service users were aware of whom to talk to if they weren’t happy about something. The service user spoken with on the day of the inspection confirmed that they felt safe in the home and stated, “I would talk to xxxx [the administrative manager]. On checking the complaints file it was noted that no complaints had been received since the last inspection, however on checking the resident records it was noted that the administrative manager had received one verbal complaint. This complaint, which regarded a member of staff, was looked into and actions were taken to address the issues raised. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 17 The administrative manager stated that this complaint had been received before the complaints file had been developed which is why it was not recorded in the complaint file. The inspector was informed that it would be recorded in the complaints file immediately. All support workers have attended training in the protection of Vulnerable adults since the last inspection and both support workers spoken with during the visit were aware of the actions to take should they suspected any form of abuse was taking place. On checking the money held on behalf of one of the service users case tracked it was noted that the service users do not currently have individual bank accounts. A petty cash is kept, which is used for the service users, a record of each transaction carried out by, or on behalf of the service users is kept and receipts, where applicable, are held. A discussion took place with the administrative manager about the use of one account for all service users. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 18 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): 24,25,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with a comfortable and homely place to live. EVIDENCE: All areas of the home seen on this occasion were appropriately maintained and suited to the service users needs. The decoration and furnishings throughout the home are of a good standard and are presented in a comfortable and homely way. There is a lounge, dining room and kitchen on the ground floor for the service users to use and a large garden can be found to the rear of the home, which the service users are able to enjoy. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 19 A number of improvements have been made to the home since the last inspection, these include the redecoration of the kitchen, dining room and lounge areas, new carpets have been laid in the downstairs corridor, the stairway and the first floor landing and the administrative manager is also in the process of redecorating a number of the service users rooms. The room belonging to one of the service users case tracked was seen during the visit. It was found to be clean, appropriately furnished and included the service users personal belongings. All areas of the home seen on this occasion were clean and fresh. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 20 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): 32,33,34,35,36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff. EVIDENCE: It was evident during the visit that the support workers were well aware of the needs of the service users and of their roles and responsibilities within the home. All support workers are given a copy of their job description during the recruitment process to ensure that they are fully aware of what is expected of them once employed. An appropriate recruitment procedure is in place, application forms are completed, references are collected and a POVA 1st (Protection of Vulnerable Adults) check and CRB (Criminal Records Bureau) check are obtained. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 21 A period of induction is provided to all new support workers, this includes both an in house induction, learning about policies and procedures and routines of the home and a formal induction training entitled ‘First Steps’. Both support workers spoken with confirmed that they received the induction training and both confirmed that they had read the required policies and procedures. On checking the training records held it was evident that a number of training sessions have been provided since the last inspection, these include training in: Safeguarding Adults, Basic awareness. Autism and Aspergers syndrome. Learning disability and mental health. Equality and diversity. Emergency first aid. Safe handling of medicines. The pre inspection questionnaire received prior to the visit stated that nine support workers have obtained their NVQ (National Vocational Qualification) level 2 or above. Both of the support workers spoken with during the visit confirmed that they are in the process of completing their NVQ level 3 and on speaking with the administrative manager the inspector was informed that a further four support workers are due to commence the NVQ level 3 in the near future. On the day of the inspection a relaxed atmosphere was evident with support workers going about their work in an unhurried and competent manner. On speaking with the two support workers on duty at the time of the inspection, the inspector was informed that they felt there were currently enough support workers on each shift to support the service users appropriately and without feeling rushed. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 22 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): 37,39,40,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and welfare of the service users are promoted and protected. EVIDENCE: At the time of the visit the administrative manager was in charge of the home. The inspector was informed that the current registered manager is looking to step back from his post and an application has been submitted to the CSCI (Commission for Social Care Inspection) for the administrative manager to become the registered manager. It is the intention of the registered manager to remain as the Responsible Individual for the home. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 23 Policies and procedures for the health, safety and welfare of the service users are in place and all support workers are made aware of these during the induction process and are required to read them and sign to say that they have both read and understood them. These policies are then reviewed on an annual basis and the support workers again work through them to ensure they remain fully aware of their contents. Staff meetings are held on a regular basis and regular supervision sessions are provided to enable the administrative manager to gather the support workers views of the service being provided. Minutes of the last staff meeting held on 14th March were seen. Meetings are also held with individual service users and their relatives to gather their thoughts of the service they receive. Details of the last resident meeting held on 19th May were also seen. Six support workers are currently completing Health and Safety training through the North Warwickshire and Hinckley College and Infection Control training, food hygiene training and 1st aid training have also been completed. All the necessary checks to ensure the health and safety of the service users are carried out including the testing of the hot water and the testing of the fire alarms. Whilst checking the daily records belonging to the three service users case tracked it was noted that one service user had had a fall resulting in a cut to the knee. On checking the accident book this incident had not been entered. The administrative assistant stated that all support workers would be reminded of the importance of recording all accidents in the accident book Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 24 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 3 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 3 X 2 X Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 25 No 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. 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. 1 2 Refer to Standard YA23 YA42 Good Practice Recommendations It is recommended that service users are provided with individual bank accounts. It is recommended that all support workers are reminded of the correct procedures for the recording of accidents. Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Ca Na Gardens DS0000006360.V337405.R01.S.doc Version 5.2 Page 27 - 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!