Inspection on 18/07/05 for Fenwick Close (1)

This inspection was carried out on 18th July 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fenwick Close (1) 14/03/07

Fenwick Close (1) 07/02/06

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1 Fenwick Close No 1 Fenwick Close Lichfield Road Sunderland SR5 2AH Lead Inspector Lee Bennett Announced Monday 18 July 2005 at 10.00 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. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 1 Fenwick Close Address No 1 Fenwick Close Lichfield Road Sunderland SR5 2AH 0191 5493875 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) Council of City of Sunderland Mrs Lynne Ryan Care Home 3 Category(ies) of LD Learning Disabilities (3) registration, with number of places 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection First inspection Brief Description of the Service: Number 1 Fenwick Close is care home, providing personal care for up to 3 people with a learning disability. Nursing care is not provided, but in-reach and District Nursing services can be arranged where necessary. It is a purpose built bungalow with level access to all of the accommodation. The home is suitable for people with a physical disability or frailty. There is a large enclosed garden to the rear of the home and shared car parking to the front. The home is situated in a suburb of Sunderland, and is a bus ride or car journey away from central Sunderland. The home is near to local public transport links and local facilities, such as a doctors surgery, pubs and places of worship. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place as part of the inspection of numbers 1, 2 and 3 Fenwick Close, over one day in July 2005. The inspection of the three services was conducted between 10:00 am and 5:30 pm. This was a scheduled announced inspection and was the first inspection of this home and the scheme of which it is a part. A tour of the building took place, and a sample of service users’ records was inspected. The inspector was able to chat with the service user present, and observed life in the home. Medication storage facilities and administration records were inspected. A meal was taken with the service user and staff. The judgements made are based on the evidence available to the inspector on the day of the inspection and the pre inspection material, including comment cards from relatives, that were received prior to the inspection. What the service does well: What has improved since the last inspection? What they could do better: There are some minor snagging items regarding the premises, which are to be expected with a new building. The medication held by the home, on behalf of the service user is, overall, well managed. However, staff need to detail the reason why medication is omitted on the administration record when the ‘other’ code is used, and where ‘variable 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 Page 6 dose’ medication is administered, the amount give needs to be clearly recorded. 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. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 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 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 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, and 4. Prospective service users have the information they and their representatives need to make an informed choice about where to live. This can assist in service users, and their representative making informed decisions about their care needs. Service user’s care needs are assessed prior to their move to the home, and periodically thereafter. This will help ensure that each service user’s needs are met at the home and inappropriate admissions avoided. Service users’ personal and social needs are met at the home. Prospective service users have the opportunity to visit the home prior to moving in, as part of a gradual admissions process. This can help them in getting to know staff, the home’s routines and layout, and in being prepared for their move EVIDENCE: A ‘Statement of Purpose’ and Service Users’ Guide’ document has been developed to provide service users and their representatives with information about the services and facilities available at the home, and the main terms and conditions of their stay. The manager is to review this documentation periodically to ensure that it remains up to date and contains the information specified in the Care Home Regulations 2001. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 Page 9 The service user living at the home had a care managers’ (social workers’) assessment undertaken prior to their admission. This details their abilities and needs. Staff in the home will also complete periodic re-assessments, which outline personal care, health care, social and psychological needs. From these assessments, plans of care are then developed to guide the practice of staff, which is then translated into the way in which staff deliver care. The evidence outlined within the service user’s care plans and their progress notes, along with the Inspector’s observations, indicated that the service is able to meet their needs. Staff have received training relevant to learning disabilities and general care topics, such as, medication awareness, manual handling, control and restraint and so on. Additional advice and guidance can also be sought from visiting professionals, such as the Occupational Therapist, for manual handling issues, and the Community Learning Disability team. Prior to any service users move to the home, a gradual introductory period exists, whereby prospective service users and staff meet and get to know one another. Staff visit the service user in their current residence, and trial stays are also arranged. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 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 standard(s) 6 and 10. The Service users assessed needs are reflected within their individual plans of care and can help to identify needs and provide guidance for consistent care practice. Information regarding service users is handled in a confidential manner, that will help ensure their privacy is maintained. EVIDENCE: A personalised care plan file has been developed that covers a broad range of need areas. These are linked to regular monitoring and daily recording of progress in areas such as health, personal care and activities. A summary overview has been developed, to offer a pen picture. Individual care plans are then developed to guide the practice of staff. This documentation highlights personal abilities, strengths, and preferences, as well as areas of need. Staff are also able to comment on and describe service users’ strengths, abilities and needs. Care files, and other personal information is stored securely, and Sunderland Council’s Social Services Department has a policy on confidentiality to guide staff in this area. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 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) 11 and 17. An active and fulfilling lifestyles is promoted by developing a community presence and by offering occupation and diversion within the home. This will assist in a full, valued and enjoyable life being supported. A varied, wholesome, nutritious and well-presented menu is offered. This can contribute to general good health and wellbeing. EVIDENCE: As the staff team gain an increasing awareness of the abilities, needs and preferences of the service user living at the home, new activities and occupation are being offered. On the day of the inspection the service user was assisting with gardening, and staff were observed to spend constructive one to one time with him. A private vehicle is available to assist with community access and activities. The service users dietary needs, are outlined within his care plans. Dietary needs are monitored (for example by keeping a weight and menu record) and supported by practical assistance and prompting. There is a record kept of the meals planned and provided. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 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 and 20. Staff help to ensure that the service user’s physical and emotional health needs are met. This can contribute to ensuring fair access to health services and the promotion of general health and welfare. Medication arrangements are appropriate for the needs of service user, and are managed in a safe manner. EVIDENCE: Regular access to primary and secondary health care services, such as GP and psychiatric services, occupational therapy and speech and language support, is supported, and a nurse is currently available within this and a neighbouring home for additional support and advice. Contact with health care professionals is documented within the service users care records. Locked storage has been installed for medications, with internal and external medicines being stored separately. The amount of storage is currently adequate, but will need to be extended should further service users be admitted to the home who require medication to be stored and handled by staff, as it is currently nearly full to capacity. Printed administration records are kept, and a sample signature list is maintained to identify which staff are responsible for each medication administration. Due to their levels of need, staff assist in this area and they have undergone training in relation to medication administration as part of their induction. More in depth training is 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 Page 13 planned for the near future. Recording arrangements in relation to variable dose medication and when medication is omitted need to contain further detail, and are a requirement of this report. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 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 assessed on this occasion. EVIDENCE: 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 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, 29 and 30. The home is well maintained, homely, safe and clean. This can help promote a positive image for service users, and ensure they remain comfortable and safe. Service users bedrooms are furnished to a good standard. This can contribute to their comfort during their stay at the home. Aids and adaptations have been provided to promote service users’ independence and safety. EVIDENCE: 1 Fenwick Close is a purpose built bungalow, and provides level access throughout. Communal areas consist of a lounge and a separate kitchen / dining room. Domestic style furnishings and fittings are provided, and adaptations, such as grab rails and an accessible shower, have been installed. There are no communal bathing or shower areas, which are all provided on an en-suite basis in service users’ own bedrooms. Bedrooms have been decorated and furnished in line with personal tastes. All of the bedrooms exceed 12 square meters in size. A regular, planned cycle of cleaning is implemented. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 Page 16 The laundry area can only be accessed via the dining room / kitchen, so it is important that staff adhere to good hygiene practice and do not deal with laundry during periods of food preparation, serving and clearing away. As part of the home’s registration, compliance with relevant fire and building regulations will have been sought, nevertheless, the registered manager was advised to verify with the Fire Safety Office whether additional fire detection and appropriate ventilation is required in the boiler room. Several door closure devices, that are used to hold fire doors open, required attention at the time of the inspection, and appropriate remedial work had already been arranged by the manager to ensure these function properly. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 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) 33 and 35. Service users are supported by an effective staff team, who have received training relevant to their roles and the purpose of the home. This can ensure that service users are supported in a safe manner by staff who have an understanding of service users needs. EVIDENCE: On the day of the inspection there were between one and two support staff on duty, with a nurse providing support for this and another care home. A member of staff is available through the night on a waking basis. There are on-call arrangements between the three care homes that operate on the site. As the service expands staffing levels will need to be kept under review and formally agreed in liaison with CSCI, to ensure staffing levels remain adequate. Staff were observed to interact well with the service user present, and to be responsive to her needs. Staff have receive a broad range of training, relevant to the purpose of the home the needs of service users likely to live there, health and safety, and to care in general. The manager is responsible for keeping clear records of the training staff have received, which can assist in the planning of future training for the staff team. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 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 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, 41 and 42. The home is well managed and record keeping arrangements assist in ensuring service users interests are well served. The home is generally safe and free from hazards to service users. EVIDENCE: The home’s manager has recently been registered with CSCI, and has relevant qualification and experience to undertake her job role. The manager has experienced in working within care settings for people with a learning disability. The records required by the Care Homes Regulations 2001 to be available in the home, such as care plans, medication records and menus were available for inspection, however staffing recruitment records are held in a centralised location by the Council. A separate inspection of these records is to be arranged following the inspection, nevertheless, these records need to be retained at the care home, which is a requirement of this report. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 Page 19 At the time of the inspection, there were no observed hazards, with the exception of the door closures noted above. 1 Fenwick Close B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 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 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 4 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 x x x x x 3 Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1 Fenwick Close Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x x 2 3 x B52-B02 S62829 No1 Fenwick Close V229709 180705 Stage 2.doc Version 1.40 Page 21 NA 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 YA20 Regulation 13(2) Requirement Timescale for action 19/7/05 2. YA41 17(2) and 19(4)(b) The registered manager must ensure that staff record on the Medication Administration Record 1, the reason for medication being omitted when the other code is used, and, 2, indicate the qualtity of medication administered for each administration for the variable dose medications. The registered person must 26/10/05 ensure that the records specified in schedule 4 of the Care Homes Regulation 2001, are retained in the home for inspection. 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. 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