Inspection on 16/05/07 for Larch Avenue

This inspection was carried out on 16th May 2007.

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

Larch Avenue 11/05/09

Larch Avenue 22/03/06

Larch Avenue 01/02/06

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 Chris Taylor Key Unannounced Inspection 16 May 2007 11:30 DS0000008006.V331070.R01.S.doc Version 5.2 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 DS0000008006.V331070.R01.S.doc Version 5.2 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. DS0000008006.V331070.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Larch Avenue Address 1a Larch Avenue, Off Hurst Lane Finningley Doncaster DN9 3NH 01302 771713 01302 775086 NONE 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 Post vacant Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places DS0000008006.V331070.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd March 2006 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. Information provided by the registered manager on 12th March 2007 indicated that the current weekly fees for the home are £847.67. The inspection report is included in the home’s Statement of Purpose that is available on request. DS0000008006.V331070.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is what was used to write this report. • • Information about the home kept by the Commission for Social Care Inspection. Information asked for before the inspection, this is called a Pre Inspection Questionnaire. An unannounced visit to the home. This lasted four hours and included talking to support staff and the manager about their jobs and the training they have completed. A tour of the premises was made and a staff meeting was observed. Some of the records, polices and procedures the home has to keep were checked and time was spent talking to service users and observing how they spent their day. Information from surveys, which were sent to out. Five service users surveys were sent out and five were returned. Five surveys were sent to staff and five were returned. And five surveys were sent to health professionals and four returned. • • What the service does well: Service users and staff have good relationships, staff showed kindness and respect towards service users. One survey said, “ All service users are happy and content. Staff are always friendly and welcoming”. The information kept about service users is good and is the right kind of information needed; this helps staff support service users properly all of the time. Staff think it is important for service users to make choices of their own and staff help them with this. This helps service users become more independent. The training staff do is good, it includes training about people with learning disabilities and how to make sure people who have learning disabilities can have more choice and control in their lives. This means staff know how to support service users to be as independent as possible, are treated kindly and with respect. Service users have the chance to say what they think about Larch Avenue and how it could be better. Surveys are sent to service users when they have a DS0000008006.V331070.R01.S.doc Version 5.2 Page 6 review of the support they have. These surveys have pictures to make it easier to understand. Meetings are organised where service users can get together and talk about what it is like getting support from the Trust and how it could be better. 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. The summary of this inspection report can be made available in other formats on request. DS0000008006.V331070.R01.S.doc Version 5.2 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 DS0000008006.V331070.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. People who use this service experience excellent quality outcomes in this area. Service users’ needs are properly assessed prior to admission this helps make sure that staff know they will be able to met service users’ needs before the person moves in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users who live at Larch Avenue moved into the home about ten years ago following the closure of a local long stay hospital. There is a procedure for new admissions, which includes completing a pre admission assessment. This assessment includes information from the service user, family and other professionals and is particularly useful for those service users who have complex needs and /or difficulties with communication. This document also supports staff in making the admission for the service user as smooth and as comfortable as possible. If at this stage the home believes they could offer a service then introductory visits commence and these are taken at a pace set by the service user. Compatibility between service users is given considerable thought and existing service user views are included in this. New placements are under review and further assessments are completed. DS0000008006.V331070.R01.S.doc Version 5.2 Page 9 There have been three new admissions since the home opened and the records checked confirmed the process described had been followed through. DS0000008006.V331070.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. People who use this service experience excellent quality outcomes in this area. Service users’ needs are assessed and are met promoting independence, choice and respect for individuals. This judgement has been made using available evidence including a visit to this service. DS0000008006.V331070.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three service users were selected for the case tracking exercise and their care plans were looked at. The format for care plans includes different sections for every aspect of the service user’s life. Each section has an area to complete, which identifies what the individual’s needs are and what action is needed to met them. This is documented step by step to make sure the support is provide exactly how the service user wants and needs. All the care plans looked at were completed fully and included information about religious beliefs and how the individual should be supported in making choices and decisions. Care plans are reviewed regularly. Also present were risk assessments with the purpose of supporting service users to live as independently as possible with safeguards in place, these were also reviewed regularly. Most service users living at Larch Avenue have very complex needs and the detail in care plans reflected this. However, in order to include service users more some aspects of the care plans could be more user friendly; for instance with the use of pictures, photographs, symbols and plain English. Whilst staff were supporting service users during the morning it was clear that they understood individuals needs. They supported people sensitively and helped people to make choices. Staff are provided with a good induction and ongoing training which makes sure service users are treated with respect, dignity and are supported to make choices in their lives. This was reflected in the observations of staff with service users throughout the visit. One survey received from a health professional said “ I have always been impressed on my visits by staffs endeavours to respect individuals privacy and dignity – the manner in which people are addressed is very dignified in particular” DS0000008006.V331070.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. People who use this service experience excellent quality outcomes in this area. Service users are supported by the staff to make choices about their lifestyle, in developing new skills and to participate in activities; this supports them to lead full and active lives. This judgement has been made using available evidence including a visit to this service. DS0000008006.V331070.R01.S.doc Version 5.2 Page 13 EVIDENCE: During the visit three service users were spending the day at home and three were out at day centres. Service users have the opportunity to attend specialist day centres or college and have days at home to participate in personal shopping, laundry and household tasks. Some service users are of retirement age and the activities they participate in reflect this. Larch Avenue is close to local amenities and there are opportunities to go to pub, library, and church, into town to shop or have a meal or coffee. One service user talked about planning a forth coming holiday, a recent bowling trip and attending Doncaster play football. Additional staffing is provided to ensure service users have the opportunity to participate in activities of their choice on a one or two to one and this was recorded in care plans. There was written information in service user plans about how service users spend their days and these arrangements are discussed with service user representatives and staff. Details about family, friends and significant events are recorded in service user plans. Examples of how service users are supported to maintain relationships with family and friends were given. One service user said that they and take it in turns to help with the supermarket shopping. There is a weekly menu but service users choose what they want to eat particularly at breakfast and lunch. Staff support these meal choices discreetly to make sure service users are choosing a healthy diet. If required nutritional assessments are completed and menus adjusted accordingly. DS0000008006.V331070.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. People who use this service experience excellent quality outcomes in this area. Service users’ personal and healthcare is provided appropriately and sensitively according to individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A whole section on each service user plan related to health care needs. Included was information on health action plans, medical logs, referrals for medical interventions and any further requirements and medication. Service users can access psychology, physiotherapy, and art therapy, speech therapy and specialist community nursing from the local learning disability team. Staff said they have a good working relationship with this team and evidence was seen in case records of specialist assessments and guidance for staff. On the day of the inspection the Consultant Psychiatrists carried out his six weekly reviews of service users at the home. DS0000008006.V331070.R01.S.doc Version 5.2 Page 15 Sometimes service users choice is restricted because of safety and evidence of this was seen in care plans. Medication administration was observed. A monitored dosage system was in use with proper procedures in place for the receipt, storage, administration, recording and return of medicines. Staff receive accredited medication training provided by Doncaster Healthcare Trust and are not permitted to administer medication until their competence it assessed. DS0000008006.V331070.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. People who use this service experience excellent quality outcomes in this area. Service users can be confident that concerns are listened to and appropriate action is taken. There are sufficient effective systems in place to safe guard service users from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are provided with a complaints procedure, which is produced in a user friendly format. Advocates are available to provide an independent voice for service users. No formal complaints have been made directly to the home or The Commission for Social Care Inspection. There is a comprehensive policy and procedure with regard to safe guarding adults and the procedure to take if there is a suspicion of abuse and staff demonstrated a good awareness of this. Staff receive training in adult protection and safeguarding issues during induction and foundation training and as part of NVQ level 2 and 3. During the staff meeting discussions were held about the recommendations made following the Sutton and Merton enquiry, which looked into allegations of abuse at care home for people with learning disabilities in Cornwall. DS0000008006.V331070.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards24 and 30. People who use this service experience excellent outcomes in this area. Service users live in a clean, comfortable and safe home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is purpose built bungalow and provides spacious accommodation for service users. The home is clean and comfortable. It is decorated and furnished to a very good standard and each bedroom was individually decorated. There has been some redecoration and refurbishment since the last inspection including a new kitchen and the installation of ceiling tracking in the bathroom and bedrooms. Bedrooms are due to be redecorated when service users are away on holiday during the summer months. A range of checks is completed on a regular basis to make sure that the house is safe and secure. DS0000008006.V331070.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. People who use this service experience excellent outcomes in this area. Staff are properly vetted and trained to ensure service users receive the care and support they need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prospective staff complete an application form and if short listed attend a formal interview and meet service users. Service users at Larch Avenue do not currently participate in interviewing staff because of the complexity of their needs but the trust does encourage service users to be involved and the manager reported that this does happen in other services. Service users are consulted about what kind of staff they would like and what skills they would like them to have for instance, that they would be able to drive the minibus or be able to go on holiday or go to football matches. DS0000008006.V331070.R01.S.doc Version 5.2 Page 19 Written references and POVA (Protection of Vulnerable adults) first checks are made and staff are not permitted to work in the home until they have a CRB (Criminal Records Bureau) check. Records to confirm this were not available as they are stored at head office. The Commission has provided a form to be completed to be held in the home, which verifies the correct recruitment processes have been undertaken. This has only recently been issued and not all forms as yet have been completed. There are currently no staff vacancies and the rota indicated that there is enough staff on duty, with more staff available for busy periods such as evenings and weekends. There are two members of staff on duty at night, one awake and one asleep. There is a system to ensure staff receive regular supervision. Each member of staff has an annual appraisal from which a personal development plan and work plan are developed. The focus of supervision sessions is to monitor the work plan checklist which includes the key worker role, other delegated responsibilities and training. Staff meetings are held regularly and one was observed on the day of the inspection. The agenda included the manager providing management information, discussion about quality, feedback from service user groups and some discussion about individual service users. Staff training records examined showed a training programme relevant to the needs of the service users. All staff complete a home specific induction programme followed by Learning Disability Award Framework accredited induction within the first 6 weeks. Staff are required to complete NVQ level 2 (National Vocational Qualification). The percentage of staff with NVQ Level 2 is 61 . DS0000008006.V331070.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. People who use this service experience good quality outcomes in this area. The home is managed in such a way that promotes the best interests of service users. Staff take proper precautions to ensure the health and safety of service users. This judgement has been made using available evidence including a visit to this service. DS0000008006.V331070.R01.S.doc Version 5.2 Page 21 EVIDENCE: Trish Lee, the manager, has extensive experience in the field of learning disabilities and her application to be registered as manager with the Commission for Social Care Inspection is being processed. . She places the service users’ needs as her first priority and she demonstrates enthusiasm and imagination in ensuring the best for service users. She is well organised and delegates responsibilities appropriately to all staff team members. She along with other members of staff worked with service users prior to their placements at Larch Avenue. One survey said, “ The manager is very thorough in her approach and appears to endeavour to help clients achieve the best quality of life possible”. There are effective quality assurance systems in place, which include service users’ views. Service user satisfaction reviews take place at six monthly intervals and these are shared with the SYHA (South Yorkshire Housing Association). The SYHA has a service user involvement coordinator who visits the tenant’s meetings at regular intervals to ascertain their views about Larch Avenue using different methods of communication including questionnaires. The Doncaster Healthcare Trust who provide the staff element at Larch Avenue use monthly meetings as a forum for service user involvement in making decisions about the running of the home. Two service users attend “Choice for All in Doncaster” meetings; families are also invited to reviews where their opinions are sought. The home is well maintained by the South Yorkshire Housing Association, essential services such as heating; electrical appliances and plumbing are serviced or replaced as required. There is a system in place to ensure health and safety in the home is maintained. The décor and furnishings are subject to review and replacement. DS0000008006.V331070.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 4 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 4 33 x 34 4 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 x 4 x 4 x x 4 x DS0000008006.V331070.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 DS0000008006.V331070.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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