Inspection on 22/11/05 for Hall Park Drive (67)

This inspection was carried out on 22nd November 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 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

Hall Park Drive (67) 24/04/07

Hall Park Drive (67) 02/11/04

Hall Park Drive (67) 15/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Hall Park Drive (67) 67 Hall Park Drive Lytham St Annes Lancashire FY8 4QZ Lead Inspector Lesley Plant Unannounced Inspection 22nd November 2005 1.00 Hall Park Drive (67) DS0000010067.V252652.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 Hall Park Drive (67) DS0000010067.V252652.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. Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hall Park Drive (67) Address 67 Hall Park Drive Lytham St Annes Lancashire FY8 4QZ 01253 737917 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) Fylde Community Link Mrs Kay Bishop Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2005 Brief Description of the Service: 67 Hall Park Drive is a small care home for adults with learning disabilities, registered for six people. The well-established voluntary organisation, Fylde Community Link Ltd is the registered provider.The home is a large detached bungalow with well-maintained garden areas, including a secluded rear garden. The main living area consists of a large open plan lounge/dining room. Bedrooms are all single and are decorated and furnished to a high standard and according to individuals needs and preferences. The home has specialist bathing facilities suitable for people with mobility difficulties.The staff team support individuals in all aspects of daily living and personal care, according to their assessed needs and as identified via the care planning process. People living at the home are supported and encouraged to maintain and develop their independence and take part in all aspects of community living. The staff team are supported by an experienced and established team of managers and an organisation, which has developed a variety of community based services for adults with learning disabilities in the Lytham St Annes area. Hall Park Drive (67) DS0000010067.V252652.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, started at 1.00 pm and took place over five and a half hours. The people currently living at the home have specific communication needs and therefore discussion with individuals was limited. The inspector spoke with four members of staff and the registered manager and observed the staff and people living at the home. Medication and care records were inspected and some of the written policies were viewed. A comment card providing feedback about the home was received from a health care professional. Key standards not assessed at this inspection will have been addressed at the previous inspection on the 8th June 2005. What the service does well: What has improved since the last inspection? The organisation and the staff team at Hall Park Drive continue to provide a high quality service. Since the last inspection some redecoration has taken place and a Jacuzzi attachment has been acquired for use in the bath. Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 Page 6 There is a focus at present on staff undertaking training in person centred planning, with the aim being that care plan formats will be made more meaningful to the people living at the home. 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. Hall Park Drive (67) DS0000010067.V252652.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 Hall Park Drive (67) DS0000010067.V252652.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): None of the above standards were assessed at this inspection. EVIDENCE: Hall Park Drive (67) DS0000010067.V252652.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): 7 and 9 People are supported to make decisions and risks are assessed and managed in such a way as to maximise independence. EVIDENCE: The people living at the home have communication needs, which are given a high priority and addressed within the care plan. Care plans show how decision-making is supported and encouraged. Guidance for one individual includes; only offering two choices to avoid confusion and explains how this person can make decisions relating to clothing, outings and meals. Staff were seen following this guidance and encouraging choices to be made. Individual preferences are recorded and staff respect these choices. Recorded preferences include where a person likes to sit in the car, morning routines and preferences regarding how elements of personal care are provided. Staff have good communication skills and have built up close relationships with the people living at the home. Advocacy information is available. Risk assessments are in place and cover all aspects of care. For one individual this includes support required with walking and staff were seen following the agreed guidance. Health service professionals have been involved in the risk assessments for one individual who has specific moving and handling requirements. In the main, risk assessments and risk management directives Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 Page 10 are reviewed, but this should be monitored to ensure that all are regularly reviewed. Hall Park Drive (67) DS0000010067.V252652.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): 12, 13 and 16 The numbers and flexibility of staff support, plus the careful way that health needs are balanced with social care needs mean that people are able to lead fulfilled lives. EVIDENCE: The people currently living at the home are mainly elderly, have complex health and communication needs and therefore employment would not be appropriate. One person attends a day centre two days each week. Staff support individuals to take part in a variety of valued and meaningful activities, as identified within the care planning process. Community links and social inclusion form key principles of the organisation, with policies, procedures, staff training and service delivery all acknowledging the value of such participation. The excellent staffing levels, often five staff on duty, mean that outings and activities can be arranged on an individual basis. Health care is given priority, but this does not prevent people from leading full and active lives. Records are kept of all activities outside the home and this information is then summarised within a monthly report, which feeds into the care planning system. One of the records viewed showed that an individual had been out 23 times during October. Activities include; shopping, train rides and visiting Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 Page 12 pubs, cafes and garden centres. The organisation provides a wheelchair accessible vehicle for outings and day trips. The numbers and flexibility of staff support, plus the careful way that health needs are balanced with social needs mean that people are able to lead fulfilled lives. People’s rights are respected. Care plans detail preferred daily routines and likes and dislikes for each person. Times for getting up, going to bed and meals are flexible. There is a high level of communication and interaction between staff and the people living at the home. Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 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 the following standard(s): 20 The current medication practices could pose risks for people at the home. EVIDENCE: The medication cupboard has been renewed and re sited, which allows more space for storage. Staff undergo medication training and two staff check the administration of medicines. Procedures are generally good and accurate records are kept. However, medication is being put into an envelope for day centre staff to administer. Better arrangements need to be put in place for any medication taken out of the home, as medication should not be dispensed into unmarked containers. Eye drops marked to be discarded four weeks after opening were not marked with the date of opening and staff were advised to dispose of these. There was a discrepancy with the dosage of eye drops for one person, with directions on the box saying twice daily but these were being administered just once daily. This needs to be clarified with the GP. Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 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 the following standard(s): 23 Fylde Community Link has policies, procedures, staff training and good practice in place, which safeguard and protect service users. EVIDENCE: The registered manager has a good understanding of issues relating to vulnerability, protection and abuse. These areas are addressed with staff during induction, foundation and NVQ training. Fylde Community Link is an umbrella organisation for Criminal Records Bureau (CRB) clearances and all staff receive clearance at enhanced level. An efficient and organised recruitment process is in place, with appropriate records maintained. The home has written policies regarding receipt of gifts and legal representation, aggression and bullying, including advice on dealing with aggression from service users and a whistle blowing policy. During discussions staff showed a good understanding of the vulnerability of people living at the home and are aware of the need to report bad practice, should this take place. The organisation demands a high standard of care practice from employees and much focus is put on maintaining these high standards. Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 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 the following standard(s): 24 and 30 The home is clean and well maintained, with good quality furnishings suitable for the people living there. EVIDENCE: The home is well maintained, safe and homely, with good quality furnishings and fittings. All accommodation is on the ground floor and accessible, with ramps and sliding patio doors. Regular maintenance inspections of the premises take place, which feed into the renewal and maintenance programme. Since the last inspection some redecoration has taken place and a Jacuzzi attachment has been acquired for use in the bath. Fire equipment is regularly maintained. The home is clean and with good standards of hygiene and appropriate policies in place regarding hygiene and the control of infection. Staff work hard to maintain high standards of cleanliness within the home. Laundry facilities are appropriately sited and there is a separate hand washbasin in the kitchen. Clinical waste is disposed of appropriately. A member of staff explained that infection control guidance is included within both the induction programme and NVQ training, and that gloves are always used when carrying out certain tasks. Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 Page 16 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): 32, 34 and 35 People are supported by a highly skilled, well-trained and well-qualified staff team. The thorough recruitment process offers protection to those living at the home. EVIDENCE: Fylde Community Link provides and pursues high quality training for its staff. All staff are registered for NVQ awards following their induction period. Over 50 of the team have achieved NVQ level 2 or above, with two staff soon to complete their award and two more working towards this. The registered manager and house leader are qualified NVQ assessors. Staff display excellent communication skills and appear motivated and highly committed to their work. The programme of core training includes communication training and staff also receive specialist training to meet the particular needs of those living at the home. This includes training to support an individual who is fed via a PEG system. The viewing of records and feedback from a visiting professional all confirm that staff develop good working relationships with specialists and other agencies. Feedback from one health care worker included; “I have been attending the residents of this home for over five years, and during that time have been consistently impressed with the standard of care and communication shown.” Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 Page 17 Fylde Community Link operates a thorough and comprehensive recruitment process. A recently appointed member of staff confirmed the two- stage interview process, which includes meeting the people who live at the home. Two references and criminal records clearance at enhanced level are obtained prior to staff being employed. Regular reviews take place during the one-year probation period, giving opportunity for any problems to be discussed and competence assessed prior to a permanent contract being agreed. Discussions with staff and the viewing of documentation all confirm that Fylde Community Link sees the training and development of staff as a high priority. The training plan shows a clear pathway through induction, foundation and then NVQ training. All staff complete core training, with additional training needs then identified and addressed. A member of the team explained that training is always discussed during the regular supervision sessions. There is a focus at present on staff undertaking training in person centred planning, with the aim being that care plan formats will be made more meaningful to the people living at the home. Each staff member has their own training and development plan and records are well maintained. The values training during induction includes disability, race and equality issues. Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 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 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, 41 and 42 Excellent quality monitoring systems ensure a high standard of care is provided. Staff training, policies and good practice promote the health and safety of people living and working at the home. EVIDENCE: Fylde Community Link is committed to service user involvement in all aspects of the service, placing great emphasis upon quality monitoring and ensuring that people who live at the home have their views heard. There are formal and informal systems in place. The general manager carries out a monthly quality monitoring visit to the home. New staff have an excellent induction, working alongside an experienced mentor and completing a good core-training programme. The registered manager and the house leader regularly work alongside support staff, modelling good practice. Staff are expected to provide a high standard of care at all times. Regular formal supervision sessions also give opportunity to discuss issues of work practice. Monthly team meetings focus on the people living at the home and opportunities to improve the service. There is an annual development plan for quality assurance, which includes internal and external quality monitoring systems. External systems Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 Page 19 include gaining and maintaining the Investors in People award, affiliation to Quality Guild who carry out annual inspections and innovative monitoring and review work carried out by a team consisting of service users, staff, relatives, board members and representatives from external agencies. Fylde Community Link excels in developing ways for all people; staff, relatives, friends and people living at Hall Park Drive to get involved in how things are run. There are good systems regarding records and staff work hard to keep information well maintained and up to date. The registered manager was advised to check the health profiles as some information did appear to be outdated and advice was also given regarding keeping personal care charts and checklists individually. Discussions with staff confirmed that relevant training such as first aid, moving and handling, medication and food hygiene form the basic training programme for all staff. Staff also confirmed that protective aprons and gloves are available and used for personal care tasks. Risk assessments consider risks relating to both staff and people living at the home. A member of staff, returning to work following an operation, had a renewed moving and handling assessment and a risk assessment is in place for a staff member who has a bad back. Regular fire drills take place and all staff have read and signed the fire procedure. All accidents are recorded. The registered manager was advised to detach each accident recording when completed and so meet data protection requirements. Hall Park Drive (67) DS0000010067.V252652.R01.S.doc Version 5.0 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 x x x x x Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 4 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x 4 x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hall Park Drive (67) Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 4 x 3 3 x DS0000010067.V252652.R01.S.doc Version 5.0 Page 21 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. 1 2 3 Refer to Standard YA20 YA20 YA20 Good Practice Recommendations Medication should not be dispensed into unmarked containers for administration outside the home. The date of opening for eye drops should be clearly recorded. Discrepancies between prescription directions and administration should be addressed. 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