Inspection on 06/06/05 for Coriander Road Care Home

This inspection was carried out on 6th June 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

Coriander Road Care Home 19/04/07

Coriander Road Care Home 20/04/06

Coriander Road Care Home 25/01/06

Coriander Road Care Home 05/01/05

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 Coriander Road Care Home 25 Coriander Road Bede Island Leicester LE2 7ER Lead Inspector Jo Vyas Unannounced 6 June 2005 at 2:15pm th 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. Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Coriander Road Care Home Address 25 Coriander Road Bede Island Leicester LE2 7ER 0116 2991782 0116 2470474 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) Macintyre Care Mr. Simon Earl – Acting Manager Care Home 4 Category(ies) of LD Learning disability (4) registration, with number of places Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 23/12/05 Brief Description of the Service: Coriander Road residential home is part of MacIntyre Care providing care for up to 4 people with a learning disability. The property is owned by a housing association not the care provider. The home is made up of two separate buildings (25 and 27) providing care almost independently of each other - two staff groups, two offices, two kitchens and two front doors. Because of the different care needs of service users there is a separation of the 2 units within the home though there is always access from one unit to another should the need arise and the first floor door between the units is open at night to ensure proper fire measures. All rooms are single and bedrooms are decorated to the wishes of the individuals. They are situated on the first floor. There are two dining/ kitchens areas. The back garden area is divided into two, one for each unit. Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 2:15pm and 6:30pm and was carried out as part of the annual plan of inspection. Planning for this inspection included reviewing details of concerns raised by staff and a relative of one of the service users prior to this scheduled inspection and the action taken by the provider to alleviate concerns. The inspection focused primarily on those standards related to issues raised and requirements made at the previous inspection. During the inspection, a service user gave the inspector a tour of the premises and staff and care records were inspected. Two care files were viewed. The inspector spoke to and observed the practice of three staff and most of the service users living in the home. At this time, no questionnaires have been received from service users, relatives or staff who use or work for the service. The inspector has also not received a pre-inspection questionnaire. What the service does well: What has improved since the last inspection? What they could do better: The home has a manager in post but an application has not yet been put into the Commission for Social Care Inspection for registration. Staffing levels are maintained at three staff per shift when all service users are at home. However, since Christmas, the staff have been providing a day service for one service user without any extra resources. This is having an impact on the service i.e. analysing data for service user reviews, keeping documentation up to date and organised and the general cleanliness of the houses. Potentially, this may lead to the needs of service users being overlooked. Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 6 • There were also some poor practises relating to the safe handling of medication and some environmental health and safety issues, which have the potential to place residents at risk. Some maintenance issues are difficult to resolve, as the property is owned by a housing association not the care provider. 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. Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 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 Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 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 Information for prospective service users, relatives and professionals is out of date therefore prospective service users will be unable to make informed choices. EVIDENCE: • The acting manager stated that the Statement of Purpose is currently being updated at Head office to include existing service users views, clear action to be taken when using the complaints procedure and contact details for the Commission for Social Care Inspection. A requirement was made for this to be completed by April 2005. The home has a stable group of service users and no vacancies at present. • Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 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, 8, 9 The individual needs and choices of service users are not fully addressed therefore this potentially puts residents at risk. EVIDENCE: • The home use Person Centred Planning to plan care and meet the needs and aspirations of service users. The plans cover a number of aspects of daily living and also include the service user’s hopes and dreams. The Person Centred Plans are transcribed into A3 books using pictures and symbols or posted on the wall of their bedroom to ensure they are accessible and detailed in the service user’s file. Two service users showed the inspector their plans. The Person Centred Plans were not comprehensive when covering some aspects of daily living for example, all healthcare needs, contact with families, personal and social needs. Plans did not cover current needs and information was out of date. Staff were knowledgeable about the needs of service users but new members of staff would be misled by the current plans. • Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 10 • • • Staff stated that they now provide a day care service for one service user which means staff no longer have the time to keep records organised and up to date. Information about service users was disorganised and staff struggled to locate some information. Service user information is stored in unsecured areas. Risk assessments for service users were completed but again were not comprehensive, disorganised and out of date. Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 11 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) 12, 13, 14, 15, 16, 17 Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. EVIDENCE: • There were good systems in place to offer service users choice and to encourage decision-making. These included a photo board for meals. However, the photos were not used for the meal the inspector observed but the service user was able to make their wishes known easily. The inspector observed choices offered to service users and staff encouraging service users to make decisions. Staff were responsive to the choices and decisions made. Three service users have day service provision. One service user had day service provision until Christmas, when, without consultation, according to the staff, the placement was stopped. Staff now offer a day service to this service user without any extra resources therefore putting a huge strain on the service. The Service Manager stated that they have tried to contact social services to resolve this issue but have so far not received a response. C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 12 • • Coriander Road Care Home • • • Evidence was seen of service users accessing the local community i.e. shops and the park also visiting the theatre, the cinema and the church. At home service users watch TV, listen to music, carry out art and crafts and play games. Service users were observed being offered a choice of snacks and meals. Meals were taken wherever the service user felt most comfortable and were relaxed and informal. Staff encourage and facilitate family/friends contact. Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 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 standard(s) 18, 19, 20 There are good levels of personal and healthcare support to service users. However, there were some poor practises relating to the safe handling of medication, which has the potential to place residents at risk. EVIDENCE: • • • Personal support is detailed in personal care profiles. All residents are registered with a GP and have access to the appropriate healthcare professionals as required. Healthcare monitoring sheets are used to record all healthcare needs and visits. Medication was received, stored and handled appropriately. However, the medication administration record sheets had not been signed on number of occasions but the medication had gone from the dispensing packs. A box of Fybogel was found on top of the medication cupboard. As it didn’t have a pharmacy label on it, staff thought it belonged to an ex- member of staff and threw it in the kitchen bin. The medication cupboard keys were left in the cupboard until a member of staff realised they were there. Certificates were seen by the inspector that indicated that staff have received medication training. • Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 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) These standards were not inspected on this occasion. EVIDENCE: Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 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, 25, 26, 27, 28, 30 The general maintenance and cleanliness of this home is poor, which does not provide service users with a safe and comfortable place to live. EVIDENCE: • • • Bedrooms are highly personalised. The gardens have been recently landscaped although there was one area of concern. A seat made of wood was warped and splintering. The acting manager stated that this would be replaced in the next week. Other areas of concern were; the laminate floor in the lounge (27) is warped and in need of replacing; the grouting in the bathroom of number 27 is in need of attention; the kitchen floor in number 25 is cracked and in need of replacement; a cupboard door in this kitchen is falling off; the cooker (25) is old and grimy and the seal to the oven has split and coming away and therefore must be replaced. Some maintenance issues are difficult to resolve as the property is owned by a housing association not the care provider. The acting manager stated that the kitchen in number 27 is due to be replaced. The general cleanliness of both houses was poor. C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 16 • • Coriander Road Care Home 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) 32, 33, 35 Currently, there are insufficient numbers of staff to fully meet the needs of the service users. EVIDENCE: • • • • • The rota showed that three members of staff cover each shift. A member of staff sleeps at the home over night. Staff stated that staffing is stretched as they are currently providing a day service for one service user. Staff receive a comprehensive induction package, which staff are expected to complete in their first six months of employment and is compatible with the National Vocational Qualification. One member of staff has a National Vocational Qualification level 3 in care and two other staff are completing the National Vocational Qualification level 3. Staff training includes Person Centred Planning, first aid, medication, fire and challenging behaviour. Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 17 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) 37, 39, 41, 42 There is currently no Registered Manager, which potentially may lead to poor practise, leadership and guidance. There are ineffective systems in the home, which potentially may lead to issues around service user’s health, safety and welfare EVIDENCE: • • • There is no Registered Manager in post as yet though the Registered Provider is progressing this and needs to submit a formal application. The acting manager has National Vocational Qualification level 2 and says he will be starting level 4. The home does not have a formal recording of the service user survey. The results need to be published and made available for inspection. The acting manager stated that this is being developed. The Home does not have a formal Quality Assurance system. The acting manager stated that this is being developed. Records are not kept securely and confidentially. C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 18 • • Coriander Road Care Home 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 x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 3 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 3 x 1 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score x 3 1 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Coriander Road Care Home Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score 1 x 1 x 1 3 x C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 19 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 4 Requirement The home’s statement of purpose must include existing service user views and clear timescales for action to be taken when using the Complaints Procedure and the address and telephone number of the Commission for Social Care Inspection. (the timescale for implementation in the last inspection report was 5/04/05.) The Home must be kept in a generally clean and tidy condition. (the timescale for implementation in the last inspection was 5/01/05) An Application for the Registered Manager’s position must be made to the Commission for Social Care Inspection. ( the timescale for implimentation in the last inspection was 17/02/05) The home needs to have formal recording of the service user survey. The results need to be published and made available for inspection. C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Timescale for action 30/07/05 2. 30 23 with immediate effect 3. 37 8 30/07/05 4. 39 24 30/07/05 Coriander Road Care Home Version 1.30 Page 20 5. 41 17 The Home needs a formal Quality Assurance system. The Manager stated that this is to be developed in the coming months. (the timescale for implementation in the last inspection report was 9/11/04). Records need to be kept securely with and confidentially. immediate (the timescale for implimentation effect in the last inspection was 05/01/05) Service user plans must be organised, up to date and reflect current practise. Risk assessments must cover all risks to service users and be organised. The key to the medication cabinet must be securely locked away or kept by a designated member of staff. All medication must be locked in a medication cupboard. 30/07/05 30/07/05 with immediate effect 6. 7. 8. 6 9 20 15 13 13 9. 10. 11. 12. 13. 14. 15. 16. 17. 20 20 20 24 24 24 24 24 24 13 13 13 23 23 23 23 23 23 with immediate effect All medication must be disposed with of appropriately. immediate effect All medication administered must with be signed for on the medication immediate administration sheet. effect ·A seat made of wood was with warped and splintering. This immediate must be removed. effect The laminate floor in the lounge 30/09/05 (27) is warped and must be replaced. The grouting in the bathroom of 30/09/05 number 27 is in need of attention. The kitchen floor in number 25 is 30/09/05 cracked and must be replaced. A cupboard door in number 25 30/07/05 kitchen is falling off and must be repaired. The cooker (25) is old and grimy 30/07/05 and the seal to the oven has split C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 21 Coriander Road Care Home 18. 33 18 and coming away and therefore must be replaced. Staffing levels must be reviewed with regard to providing a day service for one service user. 30/6/05 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. Refer to Standard Good Practice Recommendations Coriander Road Care Home C51 C01 S6391 Coriander Road Care Home V231403 060605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park, Enderby Leicester, LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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