Inspection on 01/02/06 for Larch Avenue

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Larch Avenue 11/05/09

Larch Avenue 16/05/07

Larch Avenue 22/03/06

Larch Avenue 01/03/05

Larch Avenue 24/08/04

Similar services:

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Larch Avenue 1a Larch Avenue, Off Hurst Lane Finningley Doncaster DN9 3NH Lead Inspector Ms Rosemary Reid Unannounced Inspection 12:50 1 February 2006 st Larch Avenue DS0000008006.V261402.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 Larch Avenue DS0000008006.V261402.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. Larch Avenue DS0000008006.V261402.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Larch Avenue Address 1a Larch Avenue, Off Hurst Lane Finningley Doncaster DN9 3NH 01302 771713 01302 771713 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 Limited Jennifer England Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Larch Avenue DS0000008006.V261402.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2005 Brief Description of the Service: Larch Avenue provides residential care for up to 6 adults service users of either gender with Learning Disabilities. 1a Larch Avenue is a purpose built bungalow with the space, facilities and equipment to accommodate people with additional physical disabilities including wheelchair users. The accommodation is located at the edge of Finningley village. The home has a minibus enabling access to the wider community. All service users attend a range of day care provision including work and education settings during the working week. Regular outings, social events and annual outings are provided for everyone after a risk assessment. 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. All service users have a Licence agreement with South Yorkshire Housing Association. This partnership provides and operates three other such residential schemes in the Doncaster area. Larch Avenue DS0000008006.V261402.R01.S.doc Version 5.0 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 13:00 – 5:00pm and on 2nd February 3:30 – 4:50 to meet with the registered manager Mrs Jenny England. A notice was placed in the entrance to the home to inform residents, staff and visitors to the home that an unannounced inspection was taking place. This was the first time that the inspector had visited the home and was introduced to and spoke with each resident. The main inspection method was observation of daily routines and the quality of interaction between staff and residents. The interaction between residents and staff was good humoured and caring. The inspection also focussed on hygiene and cleanliness at the home. A senior carer was in charge during the first part of the inspection and the inspector also discussed practice at the home with her and the qualified staff who came on duty later on the afternoon along with other staff. A tour of the buildings was taken and found to be clean, tidy and without offensive odours. No relatives visited the home during the inspection. Residents were doing a variety or activities for example, going shopping with staff, attending day care, listening to music and going for a walk accompanied with a member of staff. Two residents’ files were case tracked along with medication, staffing rota and Adult Protection issues. The Commission had not received any complaints from residents, social workers or relatives and no Adult Protection meetings had taken place. No complaints were received from residents during the inspection. What the service does well: On entering the home it was evident from the smell of cooking that residents were having lunch. The atmosphere was welcoming, homely and relaxed with one member of staff eating sitting along with the residents. The home has a newsletter with many photographs that have been taken when on leisure activities. Residents had short breaks, holidays and activities take place in and out of the home. Records show that staff had consulted with residents in Residents Meetings and individual conversations about what they wanted to do for short breaks, activities and holidays over the next day, weeks and months. Larch Avenue DS0000008006.V261402.R01.S.doc Version 5.0 Page 6 Residents’ bedrooms were seen to be personalised with the help and assistance of their key worker. There was evidence of privacy and the promotion of independence along with residents’ right being preserved. 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. Larch Avenue DS0000008006.V261402.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 Larch Avenue DS0000008006.V261402.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): These standards were not assessed. EVIDENCE: Larch Avenue DS0000008006.V261402.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): 6, 7, 9 The Trust’s care planning system ensures that residents’ changing needs are assessed needs and are met. It is the Trust’s policy that reviews of the each individual resident’s care is undertaken six monthly. Staff at the home did not appreciate that the National Minimum Standards for Older People applied to the residents who were over 65 years old. The staff at the home support and give time to residents to make decisions about their daily lives. There are risk assessments undertaken to ensure that residents are supported and that residents are supported within the community. EVIDENCE: Each of the two service users files examined had on going assessments ensuring that developing needs are met at all times. However, the care plans of residents who are sixty-five had not been reviewed on a monthly basis. Staff were observed to give residents time – time to go at the pace of the individual resident. For example, a resident accompanied by a member of staff were observed going to the day centre to escort another resident back to the home. It serve the purpose of escorting a resident back to the home and Larch Avenue DS0000008006.V261402.R01.S.doc Version 5.0 Page 10 another benefit was for one of the residents to see what took place at the day centre and for that resident to make informed choice should in the future make the decision to attend this day centre. Larch Avenue DS0000008006.V261402.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, 16, 17 The home provides a range of activities both in and out of the home for the stimulation and enjoyment, which benefits residents. Records show that there has been involvement of an Advocacy Agency, which preserves the residents rights. 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: Most of the group of residents at 1a Larch Avenue have lived there for many years and are very much part of the local community. When going on outings, shopping and holidays residents are part of the wider community. Within each resident file there is a timetable as to what days individual residents attend day care. Residents are able to choose what they want to do when they are at home. Residents House Meetings are held with minutes recorded. Records show that residents and staff discuss about what activities and where residents want to go on holidays. Dependent on assessment individual residents go to day care centres. Menus are formulated at the weekend and include the preferred food items of residents. Residents accompanied by staff purchase Larch Avenue DS0000008006.V261402.R01.S.doc Version 5.0 Page 12 the shopping for the home. The staff at the home works to a healthy eating menu for the wellbeing of the residents. On the day of the inspection a staff member and a resident had been shopping on the resident’s return the resident was asked what she wanted for her lunch and she stated what she wanted and a member of staff made the meal for her. From observations of staff residents were treated with good humour, respect and dignity. Larch Avenue DS0000008006.V261402.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): 18, 19, 20 Residents’ physical and emotional health care needs were met by the involvement of the Primary Health Care Team. 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. EVIDENCE: The home’s diary and care records show that there was involvement of the Primary Care Team and appointments kept at hospital/clinics. On both days of the visits observed staff discuss a resident care with a health worker. One resident who felt tired went to their bedroom and later got up and had a walk accompanied with a member of staff. The home has policies and procedures with regard to the administration of medication. Medication records were examined, which were satisfactory The DHT ethos, induction for staff, the Statement of Purpose, the Service User Guide, along with the policies refers to dignity, respect and independence. Larch Avenue DS0000008006.V261402.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): 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. In the past there have been involvement of Advocacy Services and the manager would contact the agency if needed for the residents. Records show that there are Residents/house meetings where residents can make their views known and make complaints through the complaints process. Larch Avenue DS0000008006.V261402.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, 30 The home is a purpose built bungalow, which is generally well maintained, warm, clean and safe, which meets the needs of its residents. The hygiene standards within the kitchen and other parts of the home were at a high level which promotes preventative cross infection. EVIDENCE: 1a Larch Avenue had its tenth anniversary last year. The atmosphere was warm and welcoming. The views from the dining-lounge and kitchen are of open countryside. The kitchen although very clean, is in need of replacing and the manager said that it was going to be replaced in the next financial year. All of the residents’ bedrooms had been personalised to suit the personality of the individual with their own items. One resident said: “I love my room.” Another resident was observed spending time relaxing in the bedroom looking at music CDs. After getting ready to go out with a member of staff one resident locked their bedroom door and put the key in the safe keeping of the drawer in the office. On their return the resident retrieved the key and returned their coat etc to the bedroom. When not in use the kitchen is kept locked. There was a high standard of cleanliness throughout the home and without offensive odours. Larch Avenue DS0000008006.V261402.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, 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 levels are as follows there is one qualified nurse and two support staff. The Trust 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 and five new starters had completed LDAF. There is a training strategy organised by the Doncaster Health Care Trust. Records show that staff had attended training courses and there are four staff that have NVQ Level 2 and doing NVQ3 along with three further staff who are enrolled on NVQ level 2. Larch Avenue DS0000008006.V261402.R01.S.doc Version 5.0 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 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): 42 There are policies and procedure, which promotes the health, safety and welfare of residents. Staff and the providers undertake all necessary health and safety checks, which promotes the health and well being of the service users EVIDENCE: The home is adequately maintained, and staff receive regular health and safety related training and checks are undertaken for example fire prevention, moving & handling, food hygiene. Accident records are correctly kept so that any trends and patterns can be identified and dealt with. The Trust and the SYHA undertake audits for the routine checks and services are carried out on the building, equipment and appliances. Larch Avenue DS0000008006.V261402.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 X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 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 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Larch Avenue Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000008006.V261402.R01.S.doc Version 5.0 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation Reg 15(2) Requirement The registered person must ensure that service users who are 65 years and over have their care plans assessed on a monthly basis. Action was taken by the manager Timescale for action 31/03/06 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 Larch Avenue DS0000008006.V261402.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. Extracts may not be used or reproduced without the express permission of CSCI Larch Avenue DS0000008006.V261402.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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