Inspection on 17/03/06 for Larches, The

This inspection was carried out on 17th March 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Larches, The 29/03/07

Larches, The 14/12/05

Larches, The 04/01/05

Larches, The 20/07/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Larches, The 59 Larches Road Kidderminster Worcestershire DY11 7AA Lead Inspector Dianne Thompson Unannounced Inspection 17th March 2006 10:30 Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 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 Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 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. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Larches, The Address 59 Larches Road Kidderminster Worcestershire DY11 7AA 01562 829000 01562 829001 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) Sunnycroft Homes Limited Sheila Anne Bishop Care Home 6 Category(ies) of Past or present alcohol dependence (6), registration, with number Learning disability (6), Mental disorder, of places excluding learning disability or dementia (6), Physical disability (6) Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home to accommodate one named individual who has cerebral palsy with associated physical disability, learning disability and challenging behaviour 14th December 2005 Date of last inspection Brief Description of the Service: The Larches offers accommodation and personal care for up to six adults. The home is registered to provide a service for the following categories of service users: • • • • Past or present alcohol dependence Learning disability Mental disorder excluding learning disability or dementia Physical disability These conditions are most likely to be associated with an acquired brain injury. The home is situated in a residential area of Kidderminster on a public transport route. The town centre is approximately ½ a mile from the home. Accommodation is provided in single rooms, one of which is adapted for wheelchair use and is ensuite. Sunnycroft Homes Limited operates the home, and the registered manager is Ms Sheila Bishop. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on a weekday morning. Time spent planning for the inspection included reading previous inspection reports, considering notification reports, monthly provider reports and reviewing the history of the home. The focus of this inspection included meeting with service users and staff; following up on recommendations from the previous inspection and to assess key standards not assessed during the previous inspection. What the service does well: The Larches provides care and support for 6 people in Kidderminster. Information about the home is provided to all prospective service users so they can decide whether they would like to live at The Larches and whether the home will meet their needs. Records are stored in a way that makes sure service users confidences are kept. Service users have the opportunity for personal development, and are supported to make decisions regarding their lives and routines. Service users are protected by the homes medication policies and procedures, and staff training makes sure that they are suitably trained to deal with it. Service users are given the support they need to raise any concerns they may have. Policies and procedures are available in the home to advise and guide staff in protecting the service users. The Larches is well managed, and service users benefit from a stable staff team. The home’s recruitment policies and procedures make sure that suitable staff are employed. Regular staff training and supervision is provided to make sure that staff develop their skills and knowledge to provide appropriate care and support for service users. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 6 The Larches is well managed and structures support the delivery of good care. Health and safety matters are addressed to reduce the risks to people in the home. 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. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 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 Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Information about the home is provided to all prospective service users so they can decide whether they would like to live at The Larches and whether the home will meet their needs. The procedures are well documented and they are followed for all new admissions. EVIDENCE: The home has had no new admissions since the previous inspection. There are policies and procedures in place for the home to follow when considering a new service user. These policies and procedures state that information will be made available to the prospective service user and their representatives, and opportunities will be made for prospective service users to visit the home during the assessment process. An initial care plan would be drawn up and this would be regularly reviewed and amended as necessary. Information about the home is included in the service user guide, together with the home’s terms and conditions. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 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): 10 Records are stored in a way that makes sure service users confidences are kept. EVIDENCE: The home has a records management policy and procedure, which includes a policy on confidentiality. All records are kept in the homes’ office and managed in a confidential way. Daily records are kept in individual files in a cupboard in one of the communal rooms. These records are kept securely and are accessible for ease of recording information. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 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 the following standard(s): 11, 16 Service users have the opportunity for personal development, and are supported to make decisions regarding their lives and routines. They are consulted and their choices are respected. EVIDENCE: Four service users were at home at the time of the inspection, and time was spent talking about their activities and their home. Service user files were examined and evidence shows the home encourages service users to participate in activities, both in house and in the local community. Ideas and suggestions for activities are discussed on a regular basis – both short and long term discussions/plans. Activities include hydrotherapy, Physio, animal husbandry, and attending the local college. One service user is planning to celebrate a significant birthday later this year. Another service user has saved money for a clothes-shopping trip in preparation for a caravan holiday and is looking forward to this. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 11 One service user was due to attend college in the afternoon to do drama, and said that she enjoys this. Some service users have been involved in local debates at the local college. A local newspaper recently sought opinions from service users regarding access for people with a disability in Kidderminster. Evening events include attending a local disco. All service users are encouraged to be involved in the running of the household, which includes cleaning. Evidence of this involvement is recorded in the time management records. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, Service users are protected by the homes medication policies and procedures, and staff training makes sure that they are suitably trained to deal with it. The policy for reporting medication errors should be amended. EVIDENCE: The home’s medication policies and procedures were examined. These policies and procedures are very informative and provide clear information for all staff to follow in the safe administration of medication. The policy on reporting medication errors should be amended to include reporting all errors to the Commission for Social Care Inspection. Medication is stored in a locked medication cabinet. This cabinet is well organised and each service users medication is stored separately. Administration records were checked and indicate that prescribed medication is being administered as required. Each service user has a descriptive record of their prescribed medication. There is evidence that service users complete a ‘Statement of Agreement’ for the administration of medication. The dosage and times/frequency required is suitably recorded. A list of specimen staff signatures for those staff able to administer medication is evident in the medication administration file. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 13 The frequency of weight checks is now recorded on those weight charts seen. This recommendation of the previous inspection has now been met. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 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 Service users are given the support they need to raise any concerns they may have. Policies and procedures are available in the home to advise and guide staff in protecting the service users. EVIDENCE: Information regarding adults at risk, operational guidelines, abuse guidelines and procedures are available for service users and staff in the home. The guidelines include protocols should an incident of abuse occurs or is reported. The home has a responsible reporting procedure (whistle blowing), which clearly promotes the reporting of any concerns that staff may have. Neither the home nor the Commission for Social Care Inspection have received any complaints since the previous inspection. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 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): These standards were not assessed during this inspection. EVIDENCE: Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 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): 33, 34, 35, 36 The Larches is well managed, and service users benefit from a stable staff team. The home’s recruitment policies and procedures make sure that suitable staff are employed. Regular staff training and supervision is provided to make sure that staff develop their skills and knowledge to provide appropriate care and support for service users. EVIDENCE: The home manager was not on duty at the time of the inspection, therefore staff records were not available for inspection. The home is well managed by the manager and senior staff, and staff said they are well supported. The home has a stable staff team, which includes a driver, although there is a staff vacancy. The home is currently recruiting to fill the staff vacancy. Staff levels appear adequate to meet the needs of service users, and the home’s recruitment policies and procedures are followed to make sure that suitable staff are employed. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 17 There is evidence that staff meetings take place, with the most recent on 4/1/06. Service user meetings are held quarterly, as requested by service users. Staff training is actively encouraged and supported for all staff. The proprietors offer cash incentives and bonus schemes for completion of training, including NVQ. Staff stated that they receive support from the management team in training, development and supervision. The senior member of staff on duty has successfully completed an Introduction to Management course, while enrolment to Bromsgrove College for LDAF training for a new member of staff is being organised. The registered manager and another senior member of staff completed their NVQ4 Registered Managers Award on 9th November 2005. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 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): 37, 38, 39, 40, 41, 42, 43 The Larches is well managed and structures support the delivery of good care. Health and safety matters are addressed to reduce the risks to people in the home. However, fire safety checks and training must be improved to meet legal requirements. EVIDENCE: The home is well managed and works to promote staff skills, experience and training. Seniors are encouraged to participate in inspection work; understanding and awareness of the role, through exchange visits to the sister home in Kidderminster. The senior staff member on duty at time of the inspection supported and facilitated the inspection of the home. The home has developed a quality monitoring system between The Larches and its sister home Sunnycroft, whereby monthly inspections are conducted by the other home. Senior staff are encouraged to be involved in this process to ensure the quality and standard of care provided is maintained. The senior Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 19 staff member stated that there is also a service users council, which contributes to the monitoring process. The homes policies and procedures were checked. These policies and procedures are informative and clear for staff to follow. Fire records were examined. The fire safety checks file needs to be updated and re-organised. There are gaps in the records of fire safety checks. There is evidence of good practice in that annual fire risk assessments are completed. However, quarterly staff fire training must be completed as per requirements. An immediate requirement notice was left with the home to ensure this is completed as soon as possible or at the latest by 17th April 2006, and that CSCI are notified. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 3 3 3 3 3 2 3 Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 21 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. 1. Standard YA42 Regulation 23 Requirement Fire safety checks must be carried out at the frequency advised by the Hereford and Worcester Fire Authority. Fire safety training must be carried out at the frequency advised by the Hereford and Worcester Fire Authority. Timescale for action 30/04/06 2. YA42 23 17/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations The home’s policy for reporting medication errors should include notification to CSCI. Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Larches, The DS0000018488.V287126.R01.S.doc Version 5.1 Page 23 - 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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