Inspection on 05/04/06 for Lee Road (9-11)

This inspection was carried out on 5th April 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 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) 25/06/07

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 Nichola Cahill Unannounced Inspection 11th April 2006 09:30 DS0000023052.V287644.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 DS0000023052.V287644.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. DS0000023052.V287644.R01.S.doc Version 5.1 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 Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (0) of places DS0000023052.V287644.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: 9-11 Lee Road is registered for the care of 6 service users with a learning disability. The building is leased from the council and is managed by MENCAP. It is situated on a busy 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 GP surgeries, shops, pubs, a library and leisure facilities. Information regarding the service is available through public inspection reports and the homes statement of purpose and service users guide. The current fees for services received by the home are between £400 and £450. This information was received on 5th April 2006, however, is due to be reviewed imminently. DS0000023052.V287644.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the annual Key inspection visit carried out on 5th April 2006 by Nicky Cahill (inspector) and Gill Gentles (inspector). The inspection consisted of time spent with service users, staff and the management to discuss the service provided and to confirm findings, care planning, individual lifestyles and the day-to-day running of the home. Direct observations of care delivery were experienced throughout the visit. A tour of the building was carried out. Documents were viewed for case tracking purposes. What the service does well: What has improved since the last inspection? The service provides information to service users to ensure that they can make an informed choice regarding where they live and their needs and aspirations. Service users care plans and enabling plans have been updated and reflect current and ongoing needs. Service users are supported in airing concerns and complaints. Staff are fully informed regarding awareness and protection of adults from abuse. Some areas of the home are well decorated and provide a suitable environment for the service users. Staffing numbers are appropriate; recruitment and training records were in order. DS0000023052.V287644.R01.S.doc Version 5.1 Page 6 Service users are supported in a reasonably well run home which takes into account individual wishes and feelings and protects health and safety of service users, staff and visitors to the home. 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. DS0000023052.V287644.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 DS0000023052.V287644.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 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The service provides information to service users to ensure that they can make an informed choice regarding where they live and their needs and aspirations, however, this information is not suited to the needs of all service users presently residing in the home thus does not enable them to be fully informed of the services provided. A pre-admission policy and procedure is in place, this will allow the home to ensure that service users are placed appropriately. EVIDENCE: Service users have all received a copy of the up-dated service users guide and statement of purpose. This was evident through discussions with service users and staff and the viewing of both documents. The statement of purpose requires some small amendments to be made. The service users guide is in a written format with accompanying pictures, however, the document is lengthy and not entirely suited to individual needs. A recommendation has been made for improvement in this area. The home has had one service user vacancy for some months. At the time of the inspection visit no new assessments had been carried out. A copy of the Service user selection and assessment policy was in place. It was confirmed by the manager that this policy would be followed in the event of a referral Service users have all received a copy of the up-dated service users guide and DS0000023052.V287644.R01.S.doc Version 5.1 Page 9 statement of purpose. This was evident through discussions with service users and staff and the viewing of both documents. The statement of purpose requires some small amendments to be made. The service users guide is in a written format with accompanying pictures, however, the document is lengthy and not entirely suited to individual needs. A recommendation has been made for improvement in this area. The home has had one service user vacancy for some months. At the time of the inspection visit no new assessments had been carried out. A copy of the Service user selection and assessment policy was in place. It was confirmed by the manager that this policy would be followed in the event of a referral being received. DS0000023052.V287644.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users care plans and enabling plans have been updated and reflect current and ongoing needs, however, further documented information will ensure that individual needs will be fully met. Confidential information is stored appropriately, thus protecting the privacy of service users. Service users are assisted in making decisions, there for their choices and aspirations are respected. EVIDENCE: It is acknowledged that care staff had worked hard to meet the requirements previously made with regard to the poor care plans in place. Care plans had been updated and reviewed since the last inspection visit. Care plans reflected the current and ongoing needs of service users, however, some information was still to be completed. Service user risk assessments had been transferred to enabling plans; these were detailed and had been signed off by the service user and care staff. Further enabling plans should be developed to cover all areas identified for each service user. DS0000023052.V287644.R01.S.doc Version 5.1 Page 11 Person Centred Planning had begun for some service users; however, it was recommended that the home concentrate on the completion of the care plan updates required. Evidence was gathered from viewing two care plans; discussions with care staff and service users and case tracking from other documentation within the home. A recommendation for improvement has been made in this area. Care plans were kept in a lockable facility within the homes office. Those service users with a person centred plan had a place of safe keeping within their bedrooms. Evidence was gathered from observations; discussions with service users and confirmation by care staff. Decision making for service users was evident within service user meeting minutes, care plans viewed and discussions with service users and staff. DS0000023052.V287644.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are fully supported in making decsions regarding their individual lifestyle preferences and there for have the opportunites to retain their independence. EVIDENCE: Service users are offered support to ensure that they are assisted in making choices regarding their education, community links, relationships, leisure activities and other aspects of individual lifestyle choices. Evidence was gathered through care plan documentation, discussions with service users and care staff and from observations throughout the inspection visit. Service users had made positive choices regarding their individual involvement in Gateway club. Several different activities had been planned for the Easter weekend, these were to include a meal at a local pub and making Easter bonnets. One service user had been supported in attending a football match with the Wycombe Wanderers. DS0000023052.V287644.R01.S.doc Version 5.1 Page 13 A balanced diet is offered to all service users and will take into account their individual dietary requirements and preferences. This was confirmed through observation, discussions and documentary evidence. DS0000023052.V287644.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users care plans and enabling plans have been updated and reflect current and ongoing health needs. The homes registration does not reflect the current service user group. This does not ensure that the home is fully equipped to meet the needs of the service user group. Current medication practices not condusive with the organisations policies and procedures. Therefore the safety of service users is comprimised. EVIDENCE: The systems in place for the safe handling and administration of medications were viewed. The home has insuffient measures in place to measure stock control. Creams and lotions are not dated on opening. Medication records contain gaps in recording. There is no consent from the GP for the administration of homely remedies. Current practices in place do not reflect the organisations policies and procedures. It was confirmed with the manager that a team meeting will be planned to discuss issues raised. Of the two staff files viewed, one had training in safe handling of medications. A requirement has been made for improvement in this area. Care plan documentation had been updated to ensure that all health care needs were identified and service users were being supported in accessing DS0000023052.V287644.R01.S.doc Version 5.1 Page 15 external rescourses. It was evident from works carried out that the home had recognised the physical frailty of one service user. Health care needs were discussed with care staff and it was confirmed that appropaite support is offered. From observations, disucssions with care staff and documentary evidence it was clear that the current service user group have increased needs due to the ageing process. It was confirmed by the service manager that discussions are taking place within the organisation to ensure that all service users are apporpaitely placed and that the home may fully meet their individual needs. The homes categories of registration do not presently reflect the service user group residing in the home. A requirement has been made for improvement in this area. All care staff are due to attend a dementia awareness course as this is an identified need for a number of service users. DS0000023052.V287644.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported in airing concerns and complaints. Staff are fully informed regarding awareness and protection of adults from abuse. Service users are protected by the systems in place. EVIDENCE: Service users have a copy of the homes and organisations complaints procedure. This was evident through observation, disucssions with staff and documetnation in place. All staff have been issued with a copy of the homes whistle blowing policy. Awareness of abuse had been discussed during team meetings. All staff have training this area. Evidence was gathered through discussions with staff, viewing team meeting minutes and from the action plan submitted following the last inspection visit to the home. DS0000023052.V287644.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Some areas of the home are well decorated and provide a suitable environment for the service users. However, further works need to be carried out in order to make the home suitable to meet the needs of all service users. EVIDENCE: The home has made marked progress since the last inspection visit in improving the overall environment for service users. All bedroom areas had been decorated in accordance with the service users wishes. It was confirmed by the homes manager and the decorator on site that works would continue until all communal areas were completely refurbished, with the exception of the kitchen area. Grab rails had been fitted to aid the physical frailty of one service user. The refurbishment of the kitchen area was discussed as a concern. It was confimred that this area was not due to be changed at present. However, it was noted that it is no longer suitable for the needs of service users and presents with some health and safety concerns. A requirement has been made for improvement in this area. DS0000023052.V287644.R01.S.doc Version 5.1 Page 18 Evidence was gathered from discussions with service users, staff and the homes decorator, service user meeting minutes and through observations. DS0000023052.V287644.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staffing numbers are appropriate; recruitment and training records were in order. Service users are supported by an adequate number of staff who have been appropriately recruited and trained. EVIDENCE: Discussions with staff, observations made and the viewing of staffing rotas would confirm that staffing has been increased in order to fully meet the needs of the current service user group. Two personel files were viewed. All documetnation required was in order. Training records showed that mandatory training had been carried out. DS0000023052.V287644.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are supported in a reasonably well run home which takes into account individual wishes and feelings and protects health and safety of service users, staff and visitors to the home. EVIDENCE: The overall management of the home has improved since the last inspection visit and progress has been made to ensure that the home is moving forward. All requirements made during the previous inspection visits have been or are in the process of being met. Evidence was gathered through discussions with the manager, staff and the service manager, the viewing of documentation and observation of current practices. It was confirmed that the acting manager, Jerry Hearn, would now be registered with The Commission following his recent interview. It was DS0000023052.V287644.R01.S.doc Version 5.1 Page 21 discussed that the manager attends some management courses to further enhance his skills in the day-to-day running of the home. The home facilitates regular service user meetings, staff meetings and one to ones with staff, by the manager, and for service users, via their key worker. This was confirmed through discussions with service users, staff and the viewing of documentation. At the time of the inspection visit the service manager and manager were meeting to discuss the future plans for the home. Once completed this plan will be forwarded to The Commission. It was also confirmed that the organisations annual quality audit would be completed shortly, a copy of this would also be forwarded to The Commission. Health and safety was discussed and documents viewed to ensure that safe systems were in place to protect service users, staff and visitors to the home. Observations throughout the home have highlighted the health and safety issues within the kitchen area. This has been discussed previously. DS0000023052.V287644.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 2 x 3 X 2 X X 2 X DS0000023052.V287644.R01.S.doc Version 5.1 Page 23 no Are there any outstanding requirements from the last inspection? 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 20 Regulation 13 Requirement It is a requirement that the practices in place for the safe handling and administration of medications are reflective of the organisations policies and procedures. It is a requirement that the home ensures that the categories of registration for the home are reviewed to reflect the current service user group. It is a requirement that the kitchen area be refurnished and re-decorated. Timescale for action 31/05/06 2 18 12 30/06/06 3 30 23 30/06/06 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 2 Refer to Standard 1 6 Good Practice Recommendations It is recommended that the service users guide be tailored to the individual needs of the current service user group. It is recommended that further works be carried out to the care plans and enabling plans to include more in depth information. DS0000023052.V287644.R01.S.doc Version 5.1 Page 24 3 37 It is recommended that the manager attend further management courses. DS0000023052.V287644.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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. 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