Inspection on 15/06/05 for CARE Shangton

This inspection was carried out on 15th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

CARE Shangton 05/11/08

CARE Shangton 16/01/08

CARE Shangton 15/03/07

CARE Shangton 27/01/06

CARE Shangton 21/10/04

CARE Shangton 10/06/04

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 Care Shangton Melton Road Shangton Leicester LE8 0PS Lead Inspector Judith Roan Unannounced 15 June 2005 09:30 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 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 Stationary 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. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Care Shangton Address Melton Road Shangton Leicester LE8 0PS 01858 545401 01858 545777 careshangton@freeuk.com Care (Cottage & Ruaral Enterprises) Michael Keighley RI Leonard John Walker Care Home 56 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of LD Learning disability registration, with number of places Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: To be able to admit one named resident in category LD/PD (dual disability) To be able to admit a named service user in category LD/SI (learning disabilities and sensory impairment) That by the 1st November 2005 the home will revert to the previous maximum number of service users i.e. 51. The additional 5 persons as per variation number V10120, accommodated by the home, must have moved to alternative accommodation by that date. Date of last inspection 21 October 2004 Brief Description of the Service: The CARE Community provides accommodation for 56 adults with learning disabilities in five cottages and three flats that have been adapted and staffed according to individual need.The village is situated in a rural area and is isolated from mainstream communities, but service users attend a variety of community facilities and the organisation provides an excellent variety of meaningful day service activities, supported employment opportunities and access to colleges. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Service Users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 5 residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The report also includes information gained from comment forms from forty nine service users, their families and a pre inspection questionnaire The inspection took place during the morning and afternoon, over a period of 9 hours and was carried out on an unannounced basis What the service does well: The service has good information for service users that is produced in an accessible booklet. Service users considering CARE as a provider have an opportunity to visit and test out the service prior to making a decision to stay on a long-term basis. CARE is able to meet a wide range of needs within the many cottages based at Shangton. One of the cottages has developed a service that is able to meet the needs of service users who are maturing. This enables people to move within the community as their needs change. The system in place for monitoring fire safety, use of hazardous materials and activity risk assessments is well maintained CARE have a robust staff recruitment policy and procedure in place and there is relevant documentation on staff files. New support workers are supported to complete the induction-training programme that includes the Learning Disability Award at level two. Community involvement by service users is good with a range of day activities, at work placements, colleges and leisure facilities Activities on site provide many options for service users to choose from. Service users are actively involved in the planning, purchasing food, preparation and cooking of meals throughout the day. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5 The policies, procedures and practices ensure that service users have good information to make an informed choice about the service provided. EVIDENCE: CARE Shangton has a clear statement of purpose with a service users guide written in an accessible format. Every service user who wishes to consider Shangton as a possible service to move into has the opportunity to visit and spend time at the service before making a decision to move in on a trial basis. Service users need to have had a care management assessment completed by representative of the sponsoring authority and funding agreed. A full assessment of a service user needs is completed either prior to admission or immediately in an emergency. A contract setting out terms and conditions of the placement is agreed with every service user and again is produced in an accessible format. During the trial period a meeting is arranged with the service user, sponsoring authority, family and representatives at the service to discuss whether the placement is meeting the service e users needs. At this time it is agreed whether the placement is to continue. Service users who had moved into the home recently confirmed that they had had a trial period and that they were included in all the meetings to agree their future care needs. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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 standard(s) 6,7 Service users are enabled to take an active part in the preparation of their care plan and make decisions about their lives. EVIDENCE: Service users spoken with told the inspector that they were aware of their care plan and had been supported to make decisions through a person centred approach. CARE has been introducing person centred care planning with service users at Shangton. One service user was happy to show the inspector their plan that they had presented at a recent family day. As a result of their plan the service user had realised a long-term wish. Of the comments received from service user seven out of the forty-nine replies said that they would like to be more involved with decision making within the home. All but two service users said that they liked living at Shangton and felt well cared for. Family comments include ‘My relative is very happy indeed at his present location’ an another said that Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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 standard(s) 13,14,15,16,17 Practices at CARE support service users to be involved in a range of activities within the community and maintain relationships with family and friends. Individual rights are protected with staff supporting service users to make informed decisions about their daily lives. EVIDENCE: Service users spoken with during the inspection and records seen confirmed that service users have a range of activities to choose from during the day. There are opportunities for service user to develop skills at college and for some to extend these in supported work placements. At Shangton there is an extensive day service that supports service users with various crafts and produce. Service users are involved with work tasks around the site such as grounds maintenance, catering, administration and health and safety checks. The day service also provides for service users who live at other CARE homes within Leicestershire. Service users are fully involved with choosing activities they wish to do and have clear goals that they are working towards. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 Page 11 Several service users said that they would like more social activities in an evening and at weekends. Service users prepare breakfast and tea with support from staff within each of the units on site. The midday lunch is served in the communal dining room where a choice of meals are prepared and served by service users on supported work placements. The inspector sampled the food and can confirm that meals are healthy, balanced and well presented. The large dining room is congenial and enables service users to socialise with friends from other homes within the CARE in Leicestershire. Several service users were preparing for a holiday the following week. Day services will be closed during this time. An alternative programme of activities that include day trips is scheduled. Service users who remain on site will have a holiday away later in the summer. Holiday destinations are varied and service users were supported to make a choice about where and who they wised to travel with. The cost of the holiday is part met by CARE as clearly stated in the contract. In general service users comments received by the inspector were positive about the activities available. Twelve service users would like more suitable activities to be provided, whilst thirty-seven said that they were happy with the options. Family contact is encouraged and all but two comment cards received by the inspector agreed that they were kept informed about important matters. The registered manager informed the inspector that there had been a recent relatives day where a service user had presented their person centred plan and staff explained about the processes involved. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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 standard(s) 19,20,21 Care practices generally promote and protect service users with their health care needs EVIDENCE: The inspector spoke with service users and support workers and was satisfied that health care needs met. One service is presently in hospital and support workers have been proactive in ensuring that the service users needs are met at present and in the future. Support workers from CARE are maintaining support at the hospital during the service users stay. The inspector was informed that one service user had requested that they did not wish for their bodily functions to be recorded. This was respected, but staff must ensure that a risk assessment is undertaken to confirm that the service users is aware of potential health problems so that they can inform health care professionals if the need arises. Medication records seen were satisfactory. The inspector was able to track that service users had had their medication administered and that staff had signed the records appropriately. Not all medication records had a photograph of the service users included. The manager must ensure that all records have an up to date photograph in place. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 Page 13 The support for service users who are maturing having lived at Shangton for many years is very positive. CARE have been working with the University of Stirling on a project of supporting service users who have developed a dementia. Support workers have received training and developed skills to meet the needs of this group. One of the cottages has been re-designed to ensure that the accommodation has additional space and provides an environment that supports people with memory loss. The cottage will be completed next week when the carpet is fitted. To ensure minimum disruption to service users the work has been co-ordinated to be done whilst service users are on holiday. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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 standard(s) 22,23 The policies, procedures and care practices fully protect service users living at CARE. EVIDENCE: CARE has a good policy that service users and staff are aware of. A recent disclosure was handled promptly and professionally by the Protection of Vulnerable of Adults co-ordinator and all staff involved. Support to the service users has enabled them to remain within CARE with additional support. The inspector did not fully review the complaints procedure on this visit but had received a positive response from relatives on the comments cards. The registered manager was to take action to ensure that all relatives are aware of the policy and procedure as a few relatives were unaware of its existence. Service users spoken with during the visit were aware of how to express a concern and this was supported in all but four of the comment cards received. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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 standard(s) 24,30 Although considerable work has been undertaken to improve the cottages and communal facilities on site CARE have not fully achieved the requirement made at the last inspection. EVIDENCE: The inspector was able to view the progress made on internal decoration to cottages and communal facilities. The registered manager was able to confirm that work was due to be completed in Ashgrove the following week when the carpet was to be laid. Work to extend and improve the kitchen in Silverdale is in progress and service users are presently using the facilities in the adjoining cottage Rosetree. The registered manager informed the inspector that work in a service users living in the Shangton flats was due to commence. The registered manager must ensure that the present work is completed in a timely manner. The inspector noted that several areas that are used by staff are still in need of redecoration. The registered manager needs to submit the programme of redecoration for the following year. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 Page 16 The inspector was concerned that the grounds appeared to be in need of maintenance. It is recommended that the registered manager ensures that the grounds are maintained on a regular basis. Service users living in Hinwick lodge under the temporary registration are not ready to move on. It was agreed that further discussions are to take place with CARE management team and the Commission for Social Care Inspection (CSCI) to consider future developments. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35 The recruitment and training policies, procedures and practices ensure that service users are protected and supported by competent staff. EVIDENCE: Staff files were reviewed and found to contain all relevant documentation required in the recruitment of staff. Managers and support workers confirmed that all staff complete the comprehensive induction programme and that ongoing relevant training. Recruitment of support workers in the past has been an area of concern. The registered manager was able to confirm that due to recent radio advertising the number of applicants had risen and that all vacancies had been appointed to. Staff spoken with expressed that they enjoyed working for CARE and had a positive view of the organisation future direction. All staff confirmed that training opportunities were good. Service users are included within the recruitment process and the inspector was able to gain from those spoken with that they felt valued in being part of process. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 Page 18 Comments received from relatives informed the inspector that generally they considered there to be sufficient staff on duty. Seven relatives were concerned about the high use of agency workers covering vacancies/absences which did impact on the quality of the service. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,42 CARE ensures that service users are listened to and that positive action is taken. Not all health & Safety monitoring ensures the full protection of service users. EVIDENCE: CARE undertakes quality of service monitoring at several levels within the organisation. Service users are encouraged and supported to make comments about the service through cottage meetings. Meetings with families are arranged to share information about the developments and to gain their views about the service. The responsible individual also monitors the service and regular reports are received at CSCI. The service has a health and safety manager who is responsible for the development of policies and procedures and has an overview of practice on site. The inspector was shown how all safety checks in relation to fire electrical Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 Page 20 and gas equipment is undertaken. All records are well documented and up to date. Support staff and where appropriate service users are included within the process undertake Health & Safety checks in houses. The inspector was concerned about the checks undertaken by staff on fridge and freezer temperatures. It was agreed with the registered manager that all staff would be reminded that these need to be completed on a daily basis. A requirement is therefore made to ensure compliance. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Care Shangton Score x 2 3 3 Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 Page 22 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 YA6 YA19 Regulation 15(1) 13 (4) b,c, Requirement The Registered Manager is required to ensure all service users who monitor their own health needs have a risk assessments to demonstrate their suitability in monitoring their health and welfare is met. The Registered Manager is required to ensure the care home is kept in a good state of repair externally and internally. A programme of internal decoration over the next twelve months to be submitted to the commission. The Registered Manager must ensure that staff undertake the required daily monitoring of fridge and freezer temperatures Timescale for action 31.7.2005 2. YA24 23 31.8.2005 3. YA42 13 (4) 31.7.2005 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. Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 Page 23 Refer to Standard Good Practice Recommendations Commission for Social Care Inspection First Floor Newland House Campbell Square Northampton NN1 3EB 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 Care Shangton C51 S1656 Care Shangton V229251 150605 stage 4.doc Version 1.30 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. 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