Inspection on 01/09/06 for Lavender Road (9)

This inspection was carried out on 1st September 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lavender Road (9) 28/09/07

Lavender Road (9) 12/01/06

Lavender Road (9) 17/08/05

Lavender Road (9) 02/03/05

Lavender Road (9) 29/09/04

Lavender Road (9) 02/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Lavender Road (9) Whickham Newcastle upon Tyne NE16 4LR Lead Inspector Liz Simpson Unannounced Inspection 1st September 2006 1.30 Lavender Road (9) DS0000029717.V310259.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 Lavender Road (9) DS0000029717.V310259.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. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lavender Road (9) Address Whickham Newcastle upon Tyne NE16 4LR 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) 0191 4960436 NO FAX None United Response Miss Claudia Jean Beutelspacher Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12th January 2006 Brief Description of the Service: The home can provide personal care for 6 people who have learning and physical disabilities. The home cannot provide nursing care. The home is situated in Whickham and is a large detached bungalow divided into two units, Lavender House and Rowan House all with single bedrooms. It is set within its own extensive grounds with car parking facilities to the front of the house. It is on a bus route, which makes it easy for relatives and friends to visit, and the home has its own transport. There is a variety of community facilities reasonably close by including churches, doctor’s surgeries and a large shopping area in the centre of Whickham. The bungalow is purpose built with all of the necessary facilities, The layout and design of the building provides easy access throughout and bathrooms and toilets are suitably adapted for physically disabled people. All bedrooms have an emergency call system. The weekly cost for care is £1,172.81. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days and was an unannounced inspection. The people who live at Lavender House and Rowan House have complex needs and are not able to verbally express their needs. However staff were able to interpret people’s wishes and ascertain likes and dislikes. The focus of the inspection was to look at the quality of life and services received by people who live in the home. Time was spent chatting to people who live there and talking to a relative, talking with the manager and staff. The inspector also looked at some records including care plans, risk assessments, medication arrangements, activities, staff records, policies and procedures. The visit included a look around the home. Time was also spent sitting down with people and staff during meal preparation and teatime. What the service does well: What has improved since the last inspection? The manager is now registered with the Commission for Social Care Inspection (CSCI). All staff have finished the Adult Protection Training and any new staff are on a list to do this training. 50 of the staff team have an NVQ (National Vocational Qualification) Level 2 in care. The home was asked to update care plans at the last inspection and they have worked hard to do this. But work is still going on to finish every care plan and risk assessment. Rotas are now planned around the needs and wishes of the people who live there, and not the staff. Both lounges have been decorated. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 6 Complaints information is now available and has been circulated to relatives. 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. Lavender Road (9) DS0000029717.V310259.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 Lavender Road (9) DS0000029717.V310259.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to the service. Information is available for service users and relatives which tells them what they can expect from the service and how their needs will be met. Each service user has a written agreement with the home. EVIDENCE: The manager confirmed that information for service users and relatives has been reviewed and updated for September 2006. Information, with pictures, is being written for service users so thy have a better understanding about the service. The inspector received a copy of the service user agreement for one of the service users. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 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): Standards 6 7 8 & 9 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. Most service users’ care plans have enough information to ensure their needs and personal goals are met. EVIDENCE: The manager confirmed some care plans, including risk assessments need to be reviewed and updated. A sample of 3 care plans was looked at. Information includes a pen picture, which gives a summary of a service user’s needs and how a person’s wishes and dignity is respected. This is useful for new and agency staff who don’t know the service user very well. Other information includes a detailed support plan, risk assessments, daily records, kept in a service users room and reviews to ensure needs are met. Risk assessments are more detailed using the framework recommended by the previous inspector. There were separate risk assessments for each risk identified e.g. moving and handling, bathing, personal hygiene and nocturnal seizures. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 10 For another service user relatives are kept in the picture by a regular news letter. There is a wide range of information to guide staff on meeting individual need. To make access easier all record files should show the type of information held and where you would find it. The staff team is enthusiastic and committed to communicate with service users, treat people with courtesy, dignity and respect, consult with service users in all aspects of daily living and encourage them to lead as independent a lifestyle as possible. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 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): Standard 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. All service users attend day services and have a person centred weekly timetable. Recreational and leisure time interests are promoted within the home which can provide a range of activites and occupation for service users. Service users are able to maintain community and family links, which can help to ensure they do not become socially isolated. Service users are involved in the choice of meals, participate with shopping and encouraged to take part with meal preparation. This helps to promote their general health and well being. EVIDENCE: Staff reported that Lavender Road has a good relationship with the neighbours who often bake them cakes. They have had two coffee mornings to help get to know the neighbours. Last year a service user attended an adult education class in Italian Cookery. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 12 Part of the weekly activities programme includes time for each service user to be involved with housework and laundry. Since the last inspection staff rotas have been changed to reflect the needs of service users and to promote individual choice. Teatime meal preparation was observed. Two service users were involved in making the meal. One service user showed me his work book and from the pictures was able to point out his likes and interests. Staff consulted with service users and were patient and encouraging in interpreting wishes. In Rowan House there is a water dispenser machine. Service users are encouraged to use this independently which promotes a healthy lifestyle. Tea was well presented, nutritious and taken in a congenial family style setting. Both Lavender and Rowan Houses have a four week menu with meals being chosen in consultation with service users. The current format is under review to include more digital photographs to make choice better for service users. Both units have a computer but don’t have access to the internet. Access to the internet would improve and diversify activities. Bulk shopping could be done on the internet with fresh food bought from local shops. This would help service users to mix with the local community. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 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): Standard 18, 19 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. Most care plans and risk assessments have been reviewed and detail enough information to guide staff effectively in meeting service users needs. The home maintains close links with the local medical centre and other professionals to make sure service users’ physical and emotional health needs are met. Good procedures are in place for the administration of medicines that help to make sure service users are given their medication safely. EVIDENCE: Staff training records detail moving and handling techniques and safe handling of medication as part of the core training. All staff must complete the medication competency training before they can administer medication. Two service users’ records were looked at which showed that good procedures are in place for safe working practices. The records looked at include a pen picture, called “I can help you” and support plans which also cover risk assessments. These detail information to Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 14 ensure staff provide sensitive and flexible support to maximise service users’ privacy, dignity, independence and control over their lives. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 15 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): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to the service. Information about making a complaint is clear and accessible. This contributes to service users’ and their relatives’ views and concerns being voiced. It also ensures any complaints are dealt with promptly. Appropriate systems are in place to protect vulnerable people against abuse and all staff receive training in this area as part of their core training, so they can identify any signs of abuse and protect service users. Good procedures are in place to effectively handle service users’ monies. EVIDENCE: The manager confirmed that complaints information has been circulated to all relatives. Procedures are in place to ensure complaints are dealt with promptly and appropriately. Staff training records show that all staff, apart from new starters have received training to ensure vulnerable people are protected. As this is part of the core training staff receive, it is included on an ongoing programme. 2 service users’ records were checked. These showed that the home has good procedures in place for the safe handling of service users’ monies and they are protected against any financial abuse. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 16 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): Standards 24 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. The home is clean, comfortably furnished and generally well maintained. EVIDENCE: All rooms apart from the bathrooms have been decorated. The home is waiting for a quote from a local decorator for the bathrooms and this will be completed in the coming weeks. Three rooms were viewed, with the respective service users’ permission. These have recently been decorated and service users consulted about the décor. Furnishings were of a high standard with appropriate equipment and customised to individual tastes. Health and Safety records were checked and the home has appropriate policies and procedures in place to protect the health and safety of service users. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 17 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): Standards 32, 34 and 35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. 50 of the staff team have an NVQ (National Vocational Qualification) level 2 or above. This ensures that service users are supported by qualified staff who can meet service users’ needs. The home operates appropriate recruitment procedures to ensure the protection of service users. EVIDENCE: Individual staff records are kept centrally not at Lavender House. However a staff training log confirmed that 50 of the staff team have NVQ Level 2 or above. Staff spoke positively about training, supervision and management support. Since December 2005 the arrangement of a manager for both units was reported by staff as much better. One member of staff said “I love my work and know the residents well”. Another member of staff said there was “loads of training” but expressed some concern about the use of agency staff who are unfamiliar with the needs of service users. Efforts are made by the manager to use consistent agency staff or relief staff but this is not always possible to cover rotas, at short notice, for staff sickness and any vacant posts. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 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): Standards 37, 39 and 42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service The manager runs the home for the benefit of service users. She has a good understanding of the diverse needs of service users and they are treated as individuals and enabled to make choices. Service users’ health and safety is promoted by a well managed home and robust procedures are in place to safeguard service users’ moies A formal process for consultation with service users and their relatives needs to be further developed to promote and safeguard service users’ rights. EVIDENCE: The manager is the home’s registered manager with the CSCI (Commission for social care inspection. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 19 Staff reported they receive good support and supervision from the manager. The home has a recruitment and employment policy in place. Procedures make sure the health and safety of service users is protected. All staff receive an induction programme which includes core training on moving and handling and POVA (Protection of Vulnerable Adults). The home has an Equality and Diversity Policy. The staff team were observed to treat service users with courtesy, dignity & respect. Service users are treated as individuals, helped to communicate better and encouraged to be as independent as possible. The views of service users and relatives are sought which includes service users and relatives meetings. However this needs to be developed into a formal framework to make sure there is continuous improvement of the service. Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 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 X 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes 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. 2. 3. 4. 5. Standard YA6 YA9 YA20 YA24 YA39 Regulation 15 13 13 (2) 23 24 Requirement Any outstanding care plans must be completed Any outstanding risk assessments must be completed Medicines which are given occasionally must have the dosage recorded on every record Front doors to Lavender House and Rowan House require repainting A formal quality assurance framework must be developed Timescale for action 01/11/06 01/11/06 01/11/06 01/11/06 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA14 YA33 Good Practice Recommendations Provide internet access for both Lavender and Rowan units Staff vacancies should be recruited promptly to avoid the extended use of agency staff Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Lavender Road (9) DS0000029717.V310259.R01.S.doc Version 5.2 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. 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