CARE HOME ADULTS 18-65
Freedom Care Ltd (70 Conway Drive) 70 Conway Drive Shepshed Loughborough Leicestershire LE12 9PP Lead Inspector
Chris Wroe Unannounced Inspection 7th December 2005 1.45pm Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Freedom Care Ltd (70 Conway Drive) Address 70 Conway Drive Shepshed Loughborough Leicestershire LE12 9PP 01509 821185 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) freedom.care@ntlworld.com Freedom Care Ltd Mr Joseph Matthew Kinch Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 27th July 2005 Brief Description of the Service: Freedom Care Limited at 70 Conway Drive is in the village of Shepshed. The home is registered for two people with learning disabilities to live in it. Each resident has their own bedroom, and there is a lounge and dining room for residents to use. There is a garden at the back of the home, which residents can use. At the back of the garden there is a snoezelen for residents to relax in and enjoy. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced – staff did not know the inspector was coming. The inspection was on 7th December 2005, lasting for two hours. The inspector spoke with one resident, who told the inspector about things they liked doing. The main way the inspection was done was using ‘case tracking’. This means looking at the care and support the residents get. This is done by checking records, talking to the residents and to care staff, looking round the home and watching how staff support the residents. At the last inspection, most of the key standards were checked. At this inspection, the inspector checked the remaining key standards, to make sure good care was continuing. Members of staff helped with the inspection. Because only two residents live in the home, some information in the report is less detailed, to maintain confidentiality. What the service does well: This is based on aspects checked during this inspection. An assessment process is in place, but there have been no new assessments recently. Care plans are updated and reviewed, and staff have a good awareness of the changing needs of residents. Ongoing reviews are held with social services and health professionals. Residents living in the home are given support and encouragement to be part of the community. They are involved in many different activities, and have friends outside the home. The home is clean and hygienic, and members of staff know about infection control. There are procedures in place for staff to follow. Laundry facilities are suitable for the residents’ needs. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 6 Residents are able to say what they like and don’t like about the home. Staff use pictures to help aid communication. The owner has recently developed surveys to use with other organisations to gain their views of the service. Staff continue to show a very good understanding of the needs of the residents, and were seen to communicate positively with the residents, with respect. 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. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Residents benefit from ongoing assessment of their needs. EVIDENCE: An assessment process is in place in the home, but there have been no new assessments recently, because the same residents are living in the home. The assessment process is ongoing: care plans are updated and reviewed, and staff have a good awareness of the changing needs of residents. Ongoing reviews are held with social services and health professionals. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 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 the following standard(s): All key standards under this section were checked at the last inspection. EVIDENCE: Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 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 the following standard(s): 13 Residents benefit from a good lifestyle in the home. EVIDENCE: Residents living in the home are given support and encouragement to be part of the community. They are involved in many different activities, and have friends outside the home. Staff support residents to go out and to do things they enjoy. Residents have access to public transport, and one resident enjoys going on the train. There is also a car at the home, which is used to take residents out. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents mainly benefit from support in medical treatment and care. EVIDENCE: Medication records showed that medicines were given out properly. Care records showed that medicine used to help residents to calm down was used under proper guidance, only when needed. There was a mistake noted in the records when handwritten details about medication were transferred from one record to another. It is recommended that, to prevent errors and make sure that residents are safeguarded, staff ensure that handwritten records of medication on the Medication Administration Record (MAR) sheets are signed by two members of staff. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Residents are mainly protected from harm. EVIDENCE: Staff are well looked after in the home, and protected by staff. Care records show good recording of any incidents of concern. Whilst the home manages incidents well, two serious incidents, which may have affected the well-being of residents, were not reported to the Commission for Social Care Inspection as required under Reulation 37,Care Homes Regulations 2001. The owner must ensure this is done, to make sure that the Commission can have a overview of the home and the care of residents. This issue was raised at the last inspection, and the owner must ensure that action is taken. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Residents benefit from living in a clean, hygienic environment. EVIDENCE: The home is clean and hygienic, and members of staff know about infection control. There are procedures in place for staff to follow. Laundry facilities are suitable for the residents’ needs. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All key standards under this section were checked at the last inspection. EVIDENCE: Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Residents benefit from being able to give their views about what they like and dislike. EVIDENCE: Residents are able to say what they like and don’t like about the home. Staff use pictures to help aid communication with residents. Staff communicate well with residents, and treat them with respect. The owner has recently developed surveys to use with other organisations to gain their views of the service. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 16 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 X 3 X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Freedom Care Ltd (70 Conway Drive) Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X X X DS0000035080.V269336.R01.S.doc Version 5.0 Page 17 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 YA23 Regulation 37 Requirement The owner must ensure that serious incidents, which may affect the well-being of residents, are reported to the Commission for Social Care Inspection, to make sure that the Commission can have an overview of the home and the care of residents. Timescale for action 31/12/05 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 YA20 Good Practice Recommendations It is recommended that, to prevent errors and make sure that residents are safeguarded, staff ensure that handwritten records of medication on the Medication Administration Record (MAR) sheets are signed by two members of staff. Freedom Care Ltd (70 Conway Drive) DS0000035080.V269336.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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