Inspection on 30/08/05 for Ivy Dene

This inspection was carried out on 30th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Ivy Dene 19/09/06

Ivy Dene 24/02/06

Ivy Dene 05/01/05

Ivy Dene 28/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Ivy Dene 20-22 Doncaster Road Ferrybridge Knottingley WF11 8NT Lead Inspector Mavis Pickard Unannounced 30 August 2005 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. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ivy Dene Address 20-22 Doncaster Road Ferrybridge Knottingley WF11 8NT 01977 671499 01977 672370 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) Ivy Cottage (Ackton) Limited Mrs Margaret Eyre Care Home - Personal Care only 14 Category(ies) of Learning Disability - 13 registration, with number Physical Disability - 1 of places Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 5/1/05 Brief Description of the Service: Ivy Dene is a care home providing personal care and accommodation for 13 adults with a learning disability and who may exhibit challenging behaviours and 1 person with a physical disability. The home is owned by Ivy Cottage (Ackton) Ltd a small private company with two other residential homes catering for similar service user groups.The home, which is located in Ferrybridge, Knottingley is close to local amenities.The service, which has been operating for about 3 years and is situated in a former older peoples residential facility and provides accommodation on 2 levels. An upper floor flat, which has a separate entrance, is used as a semi-independent unit for 4 of the more able people accommodated.The service provides single accommodation throughout and has appropriate communal facilities, which meet the needs of people presently accommodated. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the unannounced inspection was undertaken over a 3 hours period the service was running well. The registered manager has recently been managing this service and its sister home Ivy Cottage until a new manager can be employed at Ivy Cottage. The manager said that that recently a manager had been appointed for Ivy Cottage who will apply for registration with the Commission in due course. Staff and service users at this home will now benefit from the managers full managerial attention. What the service does well: What has improved since the last inspection? What they could do better: Although the home has undertaken a quality assurance audit to seek the views of stakeholders about the services provided. The outcomes should be made available for the purpose of regulation. Staff spoken to say that their views are not sought by this method. To achieve this would be of benefit for service users and staff. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 Page 6 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. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.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 Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.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) 2 It is not clear that prospective service users and/or their representatives always have the pre-assessment information they need to make an informed choice about going ahead with a placement. EVIDENCE: The manager said that all potential service users are assessed prior to being accommodated and that the service users and/or their representative has the information they need to make a choice about the placement. The manager said that the organisation would, during this period ensure that potential services users past history, present needs and whether they would ‘fit in’ with current people living at the home be taken in to consideration, before any plans are made to accommodate them. A recent application to vary the registration of the home to accommodate a potential service user has been returned as it is not clear from the information supplied that the above type of assessment has been comprehensively undertaken. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 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 standard(s) 7 & 9 Care plans reflect changing needs. Service users are supported to take risk. EVIDENCE: Care plans show and service users say that they are treated as individuals and that they live their lives as far as possible as they would want. Service users said that staff support them to take part in a range of leisure activities and that any risks that the activities or pastimes may raise are discussed before the individual makes a decision to go ahead. All areas of daily living are subject to detailed risk assessments to which the individual and/or their representative have been party. Several service users are being supported to achieve a healthy weight by taking part in a nationally recognised system of healthy eating. This is paying dividends for all. A service user who is working towards independent living said that she is delighted to have been helped by staff, through encouragement and the provision of a healthy eating plan, to loose over 10kilos. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 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 standard(s) 12,13,14,16 &17 Service users take part in appropriate activities in the home and in the community and are encouraged to forge new friendships and to maintain links with their family. The home provides an appropriate diet. EVIDENCE: The home employs an activities organiser who takes responsibility for ensuring that the activities provided reflect the wishes of the individual. Personal development is high on the agenda of the home and people accommodated are encouraged to develop their potential. Service users spoken with said that they enjoy visiting with their family and enjoy being with their friends inside and outside the home. From direct and indirect observation it is clear that there is mutual respect shown in the home between service users and staff. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 Page 11 The home is proactive in ensuring that people accommodated have a varied, nutritious and healthy diet. [Please refer to standards 6-10] Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.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) 18 & 19 Service users emotional, physical and personal needs are met. EVIDENCE: From speaking with service users during this and previous visits to the home and speaking with staff it is clear that people living in the home receive personal support at the level they request and require and that their health needs are met. The home’s staff says that it is their aim to promote independence for all residents and to provide support tailored to their individual need. Direct observation of management and staff during this and previous visits to the home evidence that service users are supported emotionally and physically to achieve their potential. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 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 standard(s) 22 & 23 Service users have their views listened to and are protected from abuse. EVIDENCE: The manager said that the home has an appropriate complaints policy and procedures would be followed should a complaint be made about the service provided. There have been no complaints recorded since the previous inspection. Service users spoken with during this visit said that they are sure that should they have concerns about anything in the home they can speak in confidence to staff or to the manager and that they will be listened to. Staff at the home have been trained with respect to the protection of vulnerable adults and know what to do should an incident of an abusive nature be alleged. Staff spoken with understood the process available to them in respect to ‘Whistle Blowing’. There is information made available to service users that advises them about potentially abusive situations and who they can go to in confidence should they be worried about any such situation. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 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 standard(s) 24,29 &30 Service users live in a clean, comfortable and homely environment. A service user does not have all the equipment needed to maximise their independence. EVIDENCE: The home is registered to accommodate 14 adults and provides accommodation over 2 floors. 4 more able service users occupy a ‘flat’, which has a discrete external entrance but can in an emergency be accessed through the main building. The flat is not serviced by a shaft lift, a service user spoken to who is very happy to live be living in the flat and who has a physical disability, told the Inspector that as the stair way has only one hand rail it is difficult for them to negotiate the stairs. This concern was raised with the manager who said that she is aware of the situation and is presently taking advice from the local fire safety officer about being able to provide a second hand rail to assist the service user. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 Page 15 The flat is self contained with its own kitchen, sitting room and private accommodation, service users here are supported to undertake all the activities of daily living including shopping, cooking, cleaning and washing, in the main this is to prepare them to move on to supported or independent living. The remaining 10 service users live the rest of the house in a more conventional ‘care home’ setting with the usual facilities and an activities room. Throughout the home the facilities provided are of good quality and meet the needs of people accommodated in a comfortable and homely way. On the day of this visit the home was noted to be clean and fresh with no detectable unpleasant odours. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 35 Service users understand the roles and responsibilities of staff working in the home. Staff are trained to the work they are required to perform. EVIDENCE: Service users spoken with said that they know what the roles of the staff are and that they understood which staff are carers and those who are not. They said they understood the role of the manager. Staff spoken with understood their own roles and responsibilities and understood the roles and responsibilities of others working in the home including the registered manager. They also knew the roles and responsibilities of the staff that work at differing levels within the wider organisation. From speaking with the manager and staff it is clear that staff undertake the training required to meet the needs of people accommodated. The home maintains a training matrix and updates of mandatory training are provided to all staff. 73 of support staff has attained National Vocational Qualifications [NVQ] at level 2 or above. The home now meets the current National Minimum Standards [NMS] in respect to Standard 32(6). Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 Page 17 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) 39 Service users views underpin the development of the home. EVIDENCE: The manager said that the home has a system that allow the views of service users and others be sought. A recent survey has resulted in feedback about the service, however to date this is not made available in a format accessible for the purpose of regulation. The Inspector agreed to look at the collated outcomes of this survey during the next visit. Staff spoken to during this visit indicated that their views of the way the home conducts itself are not sought by the above system. To do this would be a useful tool for the registered person/ registered manager and would enable them to collect the views of staff in an anonymous way. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 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 x 1 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 1 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x 3 x Standard No 31 32 33 34 35 36 Score 3 x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ivy Dene Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x 1 x x x x J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 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. 1. Standard 2 Regulation 14(1)(c) Requirement Placements must not be considered until the service users and/or their representative has all the information they need to make an informed choice about the suitability of the proposed placement. Suitable environmental adaptations must be made to provide support for service users who are physically disabled. The results of service user surveys must published and made available to service users and others including the Commission. Timescale for action with immediate effect[ 30/8/05] 2. 29 23(2)(n) 30/9/05 3. 39 24(2)(3) 30/10/05 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 39 Good Practice Recommendations The views of staff should be sought as part of the quality assurance and monitoring of the home. Ivy Dene J51J01 S37871 Ivy Dene V224631 300805.doc Version 1.40 Page 20 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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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