Inspection on 01/02/06 for Gardens Lane 32-34

This inspection was carried out on 1st February 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gardens Lane 32-34 12/10/09

Gardens Lane 32-34 14/06/07

Gardens Lane 32-34 07/10/05

Gardens Lane 32-34 09/02/05

Gardens Lane 32-34 31/08/04

Gardens Lane 32-34 22/05/03

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

CARE HOME ADULTS 18-65 Gardens Lane 32-34 32 - 34 Gardens Lane, Rear Of Health Centre Conisbrough Doncaster DN12 3JX Lead Inspector Ms Rosemary Reid Unannounced Inspection 1 & 2 February 2006 13:00 st nd Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 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 Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 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. Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gardens Lane 32-34 Address 32 - 34 Gardens Lane, Rear Of Health Centre Conisbrough Doncaster DN12 3JX 01709 770322 01709 770322 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) South Yorkshire Housing Association Mr Bryan Carr Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Five named service users over the age of 65 can remain at the home One specific service user over the age of 65, named on variation dated 8th August 2005, may reside at the home. 7th October 2005 Date of last inspection Brief Description of the Service: Nos. 32 & 34 Gardens Lane provide care for up to twelve adult service users of either gender with learning disabilities. Six service users live at No.32 Gardens Lane and a further six at No.34. Both properties are purpose built bungalows with the space, facilities and equipment to accommodate people with associated physical disabilities including wheelchair users. The home has two adapted minibuses that enable access to the wider community. The accommodation is located in Conisborough, a former mining village close to Doncaster. Doncaster main town is about 4 miles away and Conisborough has local facilities such as shops, libraries and health centres close by. Service users enjoy a range of day care provision including access to a local social centre and social education facilities at St Catherine’s Hospital during the working week, Monday to Friday. Annual holidays, regular outings and social events are provided for everyone. The service is provided by a partnership between South Yorkshire Housing Association and Doncaster Healthcare Trust. South Yorkshire Housing Association own and operate the service with Doncaster Healthcare Trust providing the staff. This partnership provides and operates three other such schemes in the Doncaster area Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 1st February 2006 from 8:00 – 12:30 and on the 2nd February 16:00 – 17:30 both bungalows were visited. Notices were placed in the entrance to the home to inform residents, staff and visitors to the home that an unannounced inspection was taking place. The majority of residents at Gardens Lane have severe learning and physical disabilities and their verbal communication is limited. Observation of the interaction between residents and staff was undertaken in both bungalows. A tour of the buildings was taken and found to be clean, tidy and without offensive odours. The daily activity on the first day of the inspection was that many of the residents went to the day centre across from the home. The inspector went with the residents and saw the provision that the community centre made for them for example higher tables so that residents’ wheelchairs could go up to the table. No relatives visited the home during the two visits. Four residents’ files (two files in each bungalow) were case tracked along with medication, staffing rota and Adult Protection issues. No complaints had been received by the Commission from residents, social workers or relatives. There had been no Adult Protection issues at the home. Staff must be congratulated as the delivery of care continues is at a high standard. There are very little changes to the group of service users who live at 32 – 34 Gardens Lane. However, as the residents are getting older there is now an equal balance of residents who are over 65 years old and a letter was sent to South Yorkshire Housing to include the Older People category within the home. An application to include Older People category within the registration has been received and approved. For the residents who are 65 years and over the National Minimum Standards for Older People apply. What the service does well: Both bungalows are well decorated and in good repair. Users regularly visit or use local amenities such as the local community centre, local shops and local pubs. All service users enjoy going away for holidays and risk assessments are undertaken. Away from Garden Lane they socialise with old friends and meet new people through a variety of day-care facilities provided at St Catharine’s Hospital, the community and two service users have part time day jobs. Both friends and family are welcome to visit at Garden Lane, share a meal and mark special occasions. Staff were observed promoting independence and choice for example at breakfast was a range of fruit juices for residents to choose which one they wanted that morning. A member of staff sat with residents while the residents Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 6 had their breakfast, this was to ensure safety and to prompt residents to be independence by feeding themselves where possible. Residents bedroom are personalised with the help and assistance of their key worker. The DHT (Doncaster Health Trust) and SYHA (South Yorkshire Housing Association) undertake audits and monitoring visits take place on a monthly basis and the record of the visit are sent to the CSCI. 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. Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 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 Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 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): These standards were not assessed. EVIDENCE: Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 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): 6, 9 The home has a clear care plan system to ensure that residents changing needs and direction for staff are included within the care plan to support residents in their day-to-day life at both bungalows at Gardens Lane. EVIDENCE: The majority of residents at Gardens are highly dependent, some of which have increased needs due to the ageing process. Each service user has an individual programme package, which addressed service users changing needs and directed staff to care for those residents. Daily working notes were up to date to evidence the care that was provided. The review dates were diaried for the year on the annual planner. Four care files were examined and there were in depth risk assessments in place. Accidents are recorded and body maps are used. All care plans had an individual photograph of the each of the residents. All of which are examples of maintaining safety and protecting residents. Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 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): 11 - 17 The home provides a range of activities both in and out of the home for the stimulation and enjoyment, which benefits residents. Residents have options at meal times and menus are formulated to include the known likes of the service users that include health-eating options to ensure that residents have good nutrition. EVIDENCE: Activities are recorded. The majority of residents go to social education centres several times a week and on a Wednesday to the local community centre across from the home. Each resident has a Lifestyle Diary. Records show residents have outings such as and holidays for example one resident had been Spain other residents had been to Lanzarote, Lourdes and Fleetwood/Blackpool. Risk assessments for the holidays had been undertaken. Mealtimes are flexible but a pattern of breakfast, lunch and tea is adhered to. The staff at the home works to a healthy eating menu for the wellbeing of the residents. Staff were observed promoting independence and choice for example at breakfast was a range of fruit juices for residents to choose which Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 11 one they wanted that morning. A member of staff sat with residents while the residents had their breakfast, this was to ensure safety and to prompt residents to be independence by feeding themselves where possible. Risk assessments are in place for potential risks at meal times for example choking on food or fluids. Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 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 the following standard(s): 18 - 21 Residents’ physical and emotional health care needs were met by the involvement of doctors, hospital, physiotherapists and occupational along with the community nurses. Medications were administered as prescribed and the staff at the home work to their medication policies, which promotes the wellbeing of residents. The ethos of the home promotes dignity, respect and independence for residents. Where there is a need staff use advocacy services for a resident and relatives are informed of advocacy services, which promote and advance residents’ rights. EVIDENCE: The DHT(Doncaster Health Trust) ethos, induction for staff, the Statement of Purpose, the Service User Guide, along with the policies refers to dignity, respect and independence. Through observations staff were seen to treat residents with respect and dignity and two relatives confirmed this. The home’s diary and care records show that there was involvement of the Primary Care Team and appointments kept at hospital/clinics. Weights of residents are recorded and action taken for weight gain or loss. Medication records were examined which were satisfactory. Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 13 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): 22 - 23 The SYHA and DHT have policies and procedures to protect residents from abuse. The home has a clear complaints system, which residents and relatives have used to record their grievances and/or concerns EVIDENCE: The home has a complaints policy and all complaints are recorded. No complaints were made from the previous inspection. Records show that when a complaint is made action is taken by the manager to resolve their grievances. Records show that all new staff goes through the induction programme, which includes Adult Protection issues. House meetings take place. No Adult Protection Meetings or investigations have taken place for the residents at Garden Lane. Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 14 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): 24 30 The two bungalows are purpose built and are suitable for its stated purpose and residents stay in a comfortable, homely environment. Both bungalows were clean, tidy and without offensive odours all of which benefits the well being of residents. EVIDENCE: Both bungalows are decorated in different ways and have their own atmosphere to provide individuality for the residents of each bungalow. There are comfortable communal areas with a variety of seating for the residents at Garden Lane along with sufficient toilets and bathrooms for the needs of the residents of both bungalows The hygiene standards in both bungalows were found to be high. Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 15 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): 35 The home has appropriate staffing levels that support residents in their day-today needs. Records show that staff have attended induction and training courses, which develops their skill and knowledge base to meet residents’ needs. EVIDENCE: Staffing rotas were examined and found to be appropriate to support residents in their day-to-day life. The DHT has robust recruitment policies and procedures. There are job descriptions for all levels of staff. Criminal Record Bureau and POVA checks are undertaken on all staff. The DHT has an induction for all new staff and LDAF (Learning Disabilities Wards Framework) training. There is a training strategy organised by the Doncaster Health Care Trust. Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 16 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): 37, 42 There are policies and procedures, which promotes the health, safety and welfare of residents. Staff undertake all necessary health and safety checks to ensure the residents are not at risk. EVIDENCE: Bryan Carr is the Registered Manager who is a qualified nurse with years of care experience and has worked at the home since it opened. The staff group said that they felt supported by the management team. All health and safety checks such as fire checks were undertaken. Temperatures of fridges/freezers, food are taken and recorded. Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X X X X 3 X Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gardens Lane 32-34 DS0000007988.V279859.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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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