Inspection on 12/01/06 for Lavender Road (9)

This inspection was carried out on 12th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10 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) 01/09/06

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 Mrs Eileen Hulse Unannounced Inspection 12th January 2006 01:30 Lavender Road (9) DS0000029717.V263241.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 Lavender Road (9) DS0000029717.V263241.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. Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 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 Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 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 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. Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 12th January 2006 by one inspector (Eileen Hulse), it was un-announced and was carried out as part of the annual inspection programme. It took 7hrs to complete that included 2hrs to prepare for the inspection. The focus of the inspection was to gain insight into the quality of life and services received by service users who live in the home. Time was spent chatting to service users, talking with the Manager and staff who were on duty and observing the rapport between service users and staff, inspecting some records including care plans, risk assessments, medication arrangements, a sample of staff training files, quality assurance systems, complaint and POVA policies and procedures and a tour was made of the premises. Service users living in the home have complex needs and communication difficulties and therefore, they are not able to verbally express how they feel about the service. No relatives visited the home at the time of the inspection so their views of the home could not be obtained at this time. Staff were positive about the home and comments they made included: • • • ‘I have done loads of training, moving & handling, first aid and health and safety’ ‘I enjoy working in the home’ ‘We do get support from the Manager’ What the service does well: What has improved since the last inspection? The prospective Manager has made an application to the Commission for Social Care Inspection to be registered as the Manager of the service. A date has been arranged to carry this out. Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 Page 6 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.V263241.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 Lavender Road (9) DS0000029717.V263241.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 inspected at this time. EVIDENCE: Lavender Road (9) DS0000029717.V263241.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 and 9 The care plans have deteriorated and do not include sufficient information to ensure the care needs of service users are met on a day to day basis or to ensure that staff have the guidance and information they need to meet all of the care needs. Risk assessments do not give the detail that is needed to ensure that risks are minimised and service users are kept safe. EVIDENCE: A sample of care plans were examined and varying levels of information are included within them particularly in areas regarding personal care needs. In one care plan, it stated the need to maintain a good standard of personal hygiene, but it was not explained how this could be achieved, another entry stated that staff were to offer baths but again, it did not state how often or how service users could respond to this request. Some of the information is out of date, one service user’s financial care plan has not been reviewed or updated since October 1999. However, the skills of the staff team enable staff to communicate with the service users and this was evident through observation during the inspection. Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 Page 10 Risk assessments included within the care plans have not been updated or reviewed since April 2004. The recorded details of the risk assessments do not describe the risk or state how the risk can be minimised and do not give any direction for staff should a situation arise. Lavender Road (9) DS0000029717.V263241.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): 16 and 17 The daily routines and staffing levels do not always promote individual choice and allow service users the freedom of movement within their own home and therefore, the rights of service users are not always respected. Menus inspected appear to have a good and varied selection of well balanced meals that are chosen from the likes and dislikes of service users. This ensures that service users are offered a healthy diet. EVIDENCE: During discussions with the Manager and a member of staff on duty, they stated that restrictions would not be imposed on service users without prior consultation and only then on the basis of an assessment towards the aim of minimising a risk to personal safety. However, it was observed that due to staff going off duty, service users had to be moved to another area of the home where there was a remaining member of staff on duty. All the service users are involved in the weekly grocery shopping. There is a five week menu, which is chosen with service users present and discussed at service users meetings. Due to their limited communication skills most people Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 Page 12 are unable to offer their own suggestions for the menu, but staff have a good knowledge and understanding of people’s likes and dislikes. If service users don’t like a dish they would simply leave it and an alternative would be prepared. Lavender Road (9) DS0000029717.V263241.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 and 20 The staff team have been trained in the use of the specialist equipment used within the home. However, moving and handling techniques are not detailed within the service users individual plans of care, therefore, this does not promote safe working practice for both service users and staff. Good procedures are in place on the administration of medicines that helps to make sure service users are given their medication safely. EVIDENCE: Staff stated they had received training on moving and handling techniques and this was evidenced within the staff training records. However, some of the service users living in Lavender Road have severe physical disabilities and cannot move without the assistance of staff, the individual plans of care do not give any guidance to staff and do not detail how to move people safely. Lockable space is provided in all service users bedrooms, however, service users living in the home are unable to manage their own medication. The home has a monitored dosage system in use for medication that is maintained by a leading pharmaceutical company. Although the staff team have received medication awareness training from the pharmacy of the company only the Manager or senior support workers administer medication to Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 Page 14 the service users. Records inspected evidenced that good recording systems are used when ordering, administering and returning unused medication back to the pharmacy. Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 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): 22 and 23 Each service user has a complaints procedure within their personal files but this information is out of date and of little help should a service user or their representative wish to make a complaint about the service provided. Appropriate systems are in place to protect vulnerable people against abuse and some of the staff have received training in this area so that they can identify any signs of abuse and therefore protect the service users. EVIDENCE: The complaints policy and procedure has not been reviewed since 2002 and contains old information that is no longer in use. Information within the complaints policy states the name of a former Manager as being in charge of the service, the name of the complaints manager of Gateshead Council who is no longer employed there and it does not give any details of the Commission for Social Care Inspection should the complaint not be dealt with to their satisfaction. The policy does include timescales in which the complaint will be investigated. Some of the staff team have received Protection of Vulnerable Adults Training and arrangements should be made for the remaining staff team to access this training. Records evidenced that a suspected incidents of abuse is currently being investigated. In discussions with staff they stated they felt confident they could recognise or suspect if an abuse situation was taking place and would know what to do about it. Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 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): 24 The home is clean, nicely furnished and generally well maintained. However, the two lounges are in need of re-decoration to ensure that a high standard is maintained and that services users live in a comfortable environment. EVIDENCE: Wallpaper has been chosen to have the two lounges decorated and this will be completed in the coming weeks. Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 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): 32 and 35 Although some of the staff team have an NVQ qualification the home has not achieved 50 of the team to have a care qualification. This does not ensure that service users are supported by qualified staff who can meet their assessed needs at all times. EVIDENCE: The home have only four members of staff qualified to NVQ Level 2 and therefore do not meet the standard. However, the Manager is aware of the need to have 50 of care staff trained and dates are to be identified for the remaining staff to undertake an NVQ qualification. Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 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, 39 and 42 The home must have a Manager in place that has been registered with the Commission for Social Care Inspection. This requirement has been outstanding for some time and must now be addressed urgently. The home has no formal quality assurance system in place. EVIDENCE: The home cannot measure the quality of the service provided as they do not have a quality monitoring system in place. However, Staff have received mandatory training and a number of short courses to ensure the health, safety and welfare of service users, and of everyone coming into the home. Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 Page 19 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 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X 2 X x 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lavender Road (9) Score 2 X 3 x Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 3 x DS0000029717.V263241.R01.S.doc Version 5.0 Page 20 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 Standard YA6 Regulation 15 Requirement Care plans must include sufficient information to ensure care needs are met. Risk assessments must be completed with good information that will guide staff effectively Timescale for action 01/04/06 2 YA9 13 01/04/06 3 YA16 12 Routines must be centred around the needs/wishes of service 26/01/06 users and not the staffing rota Care plans do not detail moving and handling procedures for complex needs of service users Complaints information available to service users and their relatives must give up to date information All staff must receive Adult protection training (Previous timescale of 01 Nov 2005 not met) Both lounges require redecoration (Previous timescale of 01 Dec 2005 not met) 01/04/06 4 YA18 12 5 YA22 22 01/04/06 6 YA23 13 01/04/06 7 YA24 23 01/04/06 Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 Page 21 8 YA32 YA37 18 8 50 of the staff team must achieve a care qualification. The prospective Manager must be registered with CSCI (Previous timescale of 01 Nov 2005 not met) The home must implement a quality assurance system (Previous timescale of 01 Nov 2005 not met) 26/01/06 9 YA39 10 24 31/03/06 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lavender Road (9) DS0000029717.V263241.R01.S.doc Version 5.0 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.V263241.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!