Inspection on 07/10/05 for Gardens Lane 32-34

This inspection was carried out on 7th October 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 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 01/02/06

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 7th October 2005 12:30 Gardens Lane 32-34 DS0000007988.V263945.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 Gardens Lane 32-34 DS0000007988.V263945.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. Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 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.V263945.R01.S.doc Version 5.0 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. 9th February 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.V263945.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 12:30 to 17: on the 7th October. The inspection focused on the requirements from the previous inspection in February 2005, four residents’ files were case tracked along with medication, staffing rota, training, and Adult Protection issues. It was found that the group of 12 service users accommodated at Garden Lane remain unchanged with no departures or admissions; the staff group has had very little change either. All of the residents had a full annual review. Each resident had a file with assessments, care plan, monthly reviews and up to date information in the daily recording. There were no visitors to the home during the inspection. The majority of residents at Gardens Lane have severe learning and physical disabilities and their verbal communication is limited. During the inspection the inspector sat in the lounge and observed residents and staff. A tour of the buildings was taken. The home was clean, tidy and was without offensive odours. What the service does well: What has improved since the last inspection? The previous inspection was in February 2005 and action had been taken to comply with the requirements. Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 Page 6 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.V263945.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 Gardens Lane 32-34 DS0000007988.V263945.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): 1- 5 The home provides prospective service users and/or their relatives with information they need to make an informed choice. Assessment are undertaken to ensure that the home can meet residents needs. Contracts are given to each resident to preserve the rights of occupancy. EVIDENCE: The home has a written Statement of Purpose and Function and all service users are provided with a ‘Resident Information Pack’ containing a SYHA Statement of Purpose, SYHA brochure, SYHA Tenants Charter, SYHA Equal Opportunities Policy, SYHA Complaints procedure, SYHA General booklet and a Licence agreement. These are all in printed form. South Yorkshire Housing Association have now produced a video illustrating their services in this and other partnership homes to enable users without literacy skills to be aware of the organisation of care available in these homes. Prior to admission the registered manager and or the deputy manager of Garden Lane undertake full assessments. Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 Page 9 The statement of purpose and function includes required information and that the Commission for Social Care Inspection is another avenue for complaints and representations. This information includes the address and telephone number of the local Commission for Social Care Inspection office. . It is eight years since there has been a new admission to the home. All admissions are planned. Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 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 the following standard(s): 7 - 10 The home has a care plan system, which ensures that residents changing needs and direction for staff are included within the care plan to support residents in their day-to-day life at Gardens Lane. EVIDENCE: The residents at Gardens Lane are highly dependent some of which have complex needs. Each service user has a file, 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 four care files were examined and there were risk assessments in place. Accidents are recorded and analysed 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.V263945.R01.S.doc Version 5.0 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 the following standard(s): 11 - 16 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 healthy-eating options to ensure that residents have good nutrition. EVIDENCE: Service residents have been on holiday for example Blackpool, Salou, Norfolk, Lanzarote, and Jersey along with day trips. Two service users currently work for a local company for 4 and 3 days per week respectively. All other service users have a choice of day care at the Prosper, Eclipse and Solar facilities at St Catharine’s hospital but not all choose to attend. Every Wednesday service users enjoy a morning visit to the Ivanhoe Centre, a local community centre to play Bingo. Doncaster Healthcare Trust is exploring the possibility of service users having access to the local Doncaster Metropolitan Borough Council run Social Education Centre. Each resident has a Lifestyle Diary. Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 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 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. The home’s diary and care records show that there was involvement of the Primary Care Team and appointments kept at hospital/clinics. Medication records were examined which were satisfactory. Weights of residents are recorded and action taken for weight gain or loss. Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 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 had been recorded from the previous inspection. Records show that when a complaint is made action is taken by the manager to resolve their grievances. House meetings take place. Records show that all new staff goes through the induction programme, which includes Adult Protection issues updates take place through the mandatory training. There have not been any Adult Protection Meetings or investigations for the residents at Gardens Lane. Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 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 they are suitable for its stated purpose and residents stay in a comfortable, homely, safe environment. The home has sufficient number of toilets and bathrooms for residents’ needs. SYHA are improving the bungalows for the benefit of residents and staff. EVIDENCE: There are sufficient toilets and bathrooms for the needs of the residents of both bungalows. There are comfortable communal areas with a variety of seating for the residents at Gardens Lane. Each service user has a bedroom, which is furnished and decorated in a style that reflects the residents’ personality or interests. Bedrooms were seen to have residents’ personal belongings for example pictures, keepsakes, photographs, posters, audio equipment and televisions/VCRs, videotapes, CDs, models and soft toys that bring pleasure and entertainment to residents. Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 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): These standards were not assessed. EVIDENCE: Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 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 - 43 There are policies and procedure, 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 the Registered Manager is a qualified nurse with years of care experience and has worked at the home since it opened. All staff appear comfortable with the atmosphere in the home and their level of including others in observations, decisions and opinions and supporting each other is good. The Inspector found that the pages of service users care plans are kept clean and secure in plastic wallets. These records contain all the essential information including next of kin details and the named nurse details and their role. Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 Page 17 Alhtough the records are in written form and unlikely to be understood by service users there are regular satisfaction surveys undertaken between the service user and their special interest person using symbols to express satisfaction/dissatisfaction The South Yorkshire Housing Association provie the local Commission for Social Care Inspection office with a copy of their annual business report and financial statement ; these confirm that the business is financially viable Gardens Lane 32-34 DS0000007988.V263945.R01.S.doc Version 5.0 Page 18 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 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 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 Gardens Lane 32-34 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000007988.V263945.R01.S.doc Version 5.0 Page 19 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.V263945.R01.S.doc Version 5.0 Page 20 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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