Inspection on 25/06/07 for Lee Road (9-11)

This inspection was carried out on 25th June 2007.

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 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

Lee Road (9-11) 27/02/09

Lee Road (9-11) 05/04/06

Lee Road (9-11) 16/01/06

Lee Road (9-11) 29/07/05

Lee Road (9-11) 17/03/05

Lee Road (9-11) 12/08/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Lee Road (9-11) Southcourt Aylesbury Bucks HP21 8JF Lead Inspector Chris Schwarz Unannounced Inspection 25th June 2007 12:45 Lee Road (9-11) DS0000023052.V339393.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 Lee Road (9-11) DS0000023052.V339393.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. Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lee Road (9-11) Address Southcourt Aylesbury Bucks HP21 8JF 01296 483997 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) www.mencap.org.uk Royal Mencap Society Jeremy Hearn Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (0) of places Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two services users over the age of 65 That the two places registered for service users over the age of 65 are for service users named within the application for variation of registration approved 11 August 2006. 7th November 2006 Date of last inspection Brief Description of the Service: 9-11 Lee Road is registered for the care of six service users with learning disabilities. The building is leased from the council and is managed by Mencap. It is situated on an estate in the heart of Aylesbury and is a short bus ride away from the town centre. All bedrooms are single with one providing en-suite facilities. There is a lounge and a dining area that are adequately sized for the numbers of service users for which the home is registered. A homely domestic environment is provided. A large, reasonably well maintained garden is available for the enjoyment of service users and visitors to the home. The home has ramped access with grab rails to the front and rear. The home has easy access to community facilities, including doctors’ surgeries, shops, pubs, a library and leisure facilities. Information regarding the service is available through the home’s Statement of Purpose and Service Users’ Guide. Fees for the service ranged from £435.81 to £470.46 per week. Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was conducted over the course of a day and covered all of the key National Minimum Standards for younger adults. Prior to the visit, a questionnaire was sent to the manager for completion alongside comment cards for distribution to service users, relatives and visiting professionals. No replies were received by the time the inspection took place. Information received by the Commission about the service since the last inspection was taken into account. The inspection consisted of discussion with the manager and other staff, opportunities to meet with service users, examination of some of the home’s required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Feedback on the inspection findings was given to the manager at the end of the inspection. The manager, staff and service users are thanked for their co-operation and hospitality during this unannounced visit. What the service does well: Prospective service users are usually assessed prior to admission and given opportunity to visit the home beforehand to ensure it meets their needs. Effective and detailed care plans are in place which adequately document service users’ needs and how these are to be met, within a risk assessment framework. Activities are available to service users to provide them with stimulation and contact with family, friends and the community is supported to maintain social links. Food is well prepared and presented attractively to make sure that nutritional needs are met. The health and personal care needs of people living at the home are well met, promoting health and well-being and ensuring that they receive medication in a safe and consistent manner. Procedures are in place to ensure complaints and adult protection are effectively managed to listen to views of people who live at the home and reducing the risk of harm to them. Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 6 The home is clean, well decorated and maintained, promoting a positive environment for the people who live there. The home provides staff cover to meet needs and undertakes thorough recruitment procedures, coupled with effective training to ensure staff have the right skills and competencies to support the people who live there. The management and administration of the home promote continuity and quality of care for the people who live there and ensure that risk is safely managed to reduce the likelihood of injury or harm. 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. Lee Road (9-11) DS0000023052.V339393.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 Lee Road (9-11) DS0000023052.V339393.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): 1,2. Quality in this outcome area is good. Prospective service users are usually assessed prior to admission and given opportunity to visit the home beforehand to ensure it meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A Statement of Purpose was in place at the home, outlining the aims and objectives of the service and the range of needs that the home is able to meet. A Service Users Guide was also in place and was in the process of being revised. The manager was then intending to look at different formats, which could be used to make the guide accessible and meaningful to each person at Lee Road. A new service user had been admitted to the home in April this year. The admission was arranged under emergency circumstances removing opportunity for the manager to assess the person and follow the usual process of inviting a prospective service user to look around and visit on a number of occasions before any decision is made. The manager explained that the service user had been accommodated elsewhere within Mencap services and knew service users at the home already therefore the transition was smoother and up-to-date information on care needs and the reasons for the admission were easily communicated. The service user was met during the course of the inspection and seemed settled at the home with staff able to meet his needs. A Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 9 keyworker had been allocated and a revised care plan was underway on the computer and new risk assessments for him were to be discussed the day after the inspection as part of the team meeting agenda. The care manual at the home contained an admissions process for managers to follow under usual circumstances and a copy of the assessment tool was seen and found to be a comprehensive document. Referrals would ordinarily be made by care managers from the local authority team for people with learning disabilities. Lee Road (9-11) DS0000023052.V339393.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): 6,7,9. Quality in this outcome area is good. Effective and detailed care plans are in place which adequately document service users’ needs and how these are to be met, within a risk assessment framework. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four of the five service users at the home had a detailed care plan in place, which outlined their needs with risk assessments in place to promote daily living. There was evidence of regular reviewing of information to make sure that details were current and copies of local authority placement review notes. For the newest service user, a partially completed care plan had been produced with fresh risk assessments planned to be written the same week as the inspection. The home was managing service users’ money with building society accounts in place and individual floats of cash for each person kept secure on the premises. A sample of tins and records was examined and found to be in good Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 11 order with receipts kept to explain expenditure and tins tallying with recorded balances. Service user meetings were being held at the home fairly regularly with records kept to note discussions and provided evidence of decision making and consultation with the people who live at the home. Service users were seen to move freely around the building and help with setting the table, clearing away after the evening meal and making their own drinks. Service users said they had chosen the paint colours for their rooms which were redecorated last year. Lee Road (9-11) DS0000023052.V339393.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): 12, 13, 15, 16, 17. Quality in this outcome area is good. Activities are available to service users to provide them with stimulation and contact with family, friends and the community is supported to maintain social links. Food is well prepared and presented attractively to make sure that nutritional needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user had day service placements Monday to Friday with a home day. One person who was having her home day on the day of the inspection said she had been into town with a member of staff to go shopping and have lunch out and chose to watch The Sound of Music on video/DVD afterwards. All service users were looking forward to going to Gateway Club in the evening and had got ready well in advance. A couple of the service users said they go to church occasionally which they also enjoyed. One service user showed his communication book which contained photographs and text of his placement at Thrift Farm in Milton Keynes. Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 13 There was evidence from looking at receipts of financial transactions of service users making use of taxis to get around, eating out occasionally, going to venues such as the zoo and concerts and having aromatherapy massage. Service users had recently returned from a holiday in Devon which they said they had enjoyed. One person had been supported to put together a photograph album which she showed to the inspector. Service users are able to see friends and family at the home. There was no feedback from comment cards to gain visitors’ perspectives. A menu was displayed on the notice board in the kitchen and showed a service user’s choice for each day. A freshly prepared egg and ham salad was served for tea with egg wraps for those who were not keen on salad. Dietician advice was being followed to help those service users who needed support with their nutritional requirements. One person proudly said she had lost weight and felt better for it. Lee Road (9-11) DS0000023052.V339393.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): 18, 19, 20. Quality in this outcome area is good. The health and personal care needs of people living at the home are well met, promoting health and well-being and ensuring that they receive medication in a safe and consistent manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans contained information about the type of support that service users require and areas where they are independent. Checklists were in place to make sure that toothbrush mugs, razors and hearing aids, for example, were kept clean and in good order. All service users were ambulant and therefore no one needed hoisting to assist with daily living tasks. Where one person had some mobility issues his downstairs bedroom had an en-suite shower with a seat. Service users had been supported to look their best and wear jewellery if they wished. Spectacles were clean and male service users had been supported to shave. Records of health care appointments were being well maintained and showed involvement of various professionals such as the dietician, a speech and language therapist, input from the audiology department and staff at Manor Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 15 House Hospital. Dental and doctors appointments were also noted and service users were seeing a podiatrist where necessary. The home was using a monitored dose system of medication administration with medicines kept secure on the premises. No controlled drugs were being used at the time of this inspection. Records of medication administration were in good order with signatures alongside prescribed dose times and a photograph of the service user was to hand for easy identification. Date of opening had been written on tubes of creams and the medication file contained lists of medicines that service users were taking. Staff had completed training on safe administration of medicines. Lee Road (9-11) DS0000023052.V339393.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): 22, 23. Quality in this outcome area is good. Procedures are in place to ensure complaints and adult protection are effectively managed to listen to views of people who live at the home and reducing the risk of harm to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Adult protection, whistle blowing and complaints procedures were in place at the home. The only point raised was that both the complaints and adult protection policies refer to the regulatory body as the National Care Standards Commission and not the Commission for Social Care Inspection. This could cause confusion for staff or other persons and amendments should be made. There had not been any complaints at the home and the Commission had not been contacted with any areas of concern by service users or their representatives. There had not been any adult protection issues at the home. A copy of the local authority multi-agency guidelines was available in the office. Staff had received training in adult protection within the past twelve months. Aylesbury Vale Advocates now have involvement at the home and visit once a month to speak with service users individually and assist with any matters. Lee Road (9-11) DS0000023052.V339393.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): 24, 30. Quality in this outcome area is good. The home is clean, well decorated and maintained, promoting a positive environment for the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is indistinguishable as a care home and is located amongst a housing estate close to Stoke Mandeville Hospital and Aylesbury town centre. Accommodation is on two floors with one downstairs en-suite room and five upstairs rooms. Each is a single room and varied in size; some are quite small but had been personalised and decorated to individual tastes. All areas of the home had been kept clean and redecoration had taken place within the past year. A new cooker had been purchased for the kitchen and apart from damage where a leak had come through the ceiling in the kitchen, the premises looked reasonably maintained and homely. There was a possibility of the landlord refurbishing the kitchen. Toilets and bathrooms had working locks and toilet roll, soap and towels were in place. There is a large enclosed garden at the back with seating areas. Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 18 Service users were looking forward to a barbeque being held at the end of the week. The lounge and dining room were a good size with comfortable seating. Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 19 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): 32, 34, 35. Quality in this outcome area is good. The home provides staff cover to meet needs and undertakes thorough recruitment procedures, coupled with effective training to ensure staff have the right skills and competencies to support the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a couple of staff vacancies – one post was filled subject to clearances and another was being advertised. The rota was being covered with assistance from Mencap recruited and trained relief staff. Rotas appeared to provide sufficient cover to meet the current range of care needs at the home. The staff induction booklet was looked at and found to be a comprehensive document covering care practices and requiring the member of staff to demonstrate knowledge in different areas, such as adult protection and confidentiality. After the induction and mandatory training courses have been completed, staff would then start working with service users. A foundation course is undertaken, also comprehensive and requiring demonstration of skill, which helps prepare staff for National Vocational Qualification level 2. None of the staff had achieved National Vocational Qualifications but were working towards them. Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 20 Staff were respectful toward service users and gentle in their interaction with them. No concerns or issues about staff were raised by service users when asked. Staff recruitment files were examined and found to contain all required documents and clearances. Training records showed that mandatory training was mostly up-to-date with any expired courses due to be updated in the coming months. Regular staff meetings were being held and minutes showed that these included discussion of practice, review of service users’ needs and update on policies and national issues. Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 21 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): 37,39,42. Quality in this outcome area is good. The management and administration of the home promote continuity and quality of care for the people who live there and ensure that risk is safely managed to reduce the likelihood of injury or harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a registered manager who is experienced in working with people with learning disabilities and is undertaking National Vocational Qualification level 4/Registered Managers Award. There has been regular monitoring of quality of service provision by the provider with reports available in the office. A quality assurance audit had taken place towards the end of the year although the report was not available. A continuous improvement plan was in place. Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 22 There was good regard for health and safety with staff training on safety topics up-to-date or booked to be refreshed. Fire safety precautions were being well managed and the home had a current gas safety certificate in place. Regular visual checks were being made of electrical appliances and temperature checks were being made routinely of the hot water tank, fridge and freezers and hot and cold water at outlets. First aid boxes were being checked to make sure that supplies were well stocked. Cleaning products were locked away to prevent accidental injury. No obvious hazards were observed during the course of the inspection. Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 23 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 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 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 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 3 x x 3 x Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 24 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 Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Lee Road (9-11) DS0000023052.V339393.R01.S.doc Version 5.2 Page 26 - 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!