CARE HOME ADULTS 18-65
Limetree Avenue Care Home 23 Limetree Avenue Retford Nottingham DN22 7BB Lead Inspector
Richard Ramsden Unannounced Inspection 25th January 2006 11:35 Limetree Avenue Care Home DS0000008709.V280880.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 Limetree Avenue Care Home DS0000008709.V280880.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. Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Limetree Avenue Care Home Address 23 Limetree Avenue Retford Nottingham DN22 7BB 01777 708 725 01777 708 725 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 Miss Kathleen Markham Antcliffe Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30/11/05 Brief Description of the Service: 23 Limetree Avenue is a three-storey, semi-detached house in a quiet, residential street within a quarter of a mile of Retford town centre, where there are shops, public houses and other leisure facilities. The home can accommodate six male and female residents’ with learning disabilities. It was established in 1991 and five of the current residents have lived there since that time. All residents have their own personalised bedrooms; there is a communal lounge, dining room and kitchen. The home has a bathroom and separate shower room and there are toilets located on each floor. One ground floor bedroom has ensuite facilities. On the second floor there is a sleeping in room for staff and an office where records, policies and procedures are kept. Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced inspection over one day, it took approximately 4 hours. It included the inspection of care and other records, a discussion with two residents, three support workers and the homes manager. A partial tour of the building was also completed. What the service does well: What has improved since the last inspection?
Since the last inspection a waking member of night staff has been employed each night to ensure that the home is sufficiently staff to meet all the residents 24-hour needs.
Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 6 Risk assessments have been amended to include details of the action to be taken by staff to avert or reduce the risks to the residents. Previously one of the resident’s bedroom doors was being wedged open and this could have presented a risk in the event of fire. A door closure has now been fitted which will automatically close the door if the homes fire alarms are activated. 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. Limetree Avenue Care Home DS0000008709.V280880.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 Limetree Avenue Care Home DS0000008709.V280880.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): X None of these standards were assessed as part of this inspection. EVIDENCE: Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8,9. The individual care plans contain sufficient information to ensure that staff are always aware of what support and assistance each resident requires. Residents are consulted on, and participate in all aspects of life within the home. Appropriate risk assessments support residents as part of an independent lifestyle. EVIDENCE: Two residents care plans were viewed as part of this inspection. The care plans contained detailed information identifying what assistance and support each resident requires. The care plans were being reviewed each month and had been updated where necessary. The residents spoken with confirmed that they had been involved in planning and reviewing their care plans. (This is good practice). The manager was reminded that where possible residents or their representatives should sign to confirm that they have been involved in the review process. One resident had attended a fracture clinic on the day of this inspection her care plan was amended during the inspection, to reflect her change the needs. (This is good practice).
Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 10 Residents confirmed that they are asked on a regular basis for their views on the way in which the home is run. A house meeting is held each week and residents are encouraged to voice their opinions. The minutes of the house meetings were checked as part of this inspection. A new process has recently been implemented which should work well when everyone becomes used to the new user-friendly format. The risk assessments viewed as part of this inspection contained appropriate information and had been reviewed on a regular basis. Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 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): 14. Appropriate leisure activities are provided. EVIDENCE: The individual care plans viewed as part of this inspection detailed resident’s interests and leisure pursuits. The manager stated that the information in this section of the care plan identifies the regular activities that each person participates in, however it does not necessarily reflect all the varied social activities provided. The two residents spoken with said that they enjoy going shopping with staff and one person said that they had been out for lunch on the day of this inspection. One person said that they had enjoyed attending a lot of outings and activities over the Christmas period. The inspector recommended that the homes records should accurately reflect the level of social activities provided. Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20. Resident’s health care needs are being met. The home provides a safe system for the Administration of medication. EVIDENCE: The records viewed as part of this inspection showed that resident’s health care needs are being appropriately met. The residents spoken with said that the staff always offer assistance if they need to see a doctor. The homes medication system was checked and found to be satisfactory. All of the staff that administers medication has received appropriate training. The medication administration records had been appropriately signed and the record of receipt and disposal of medication were well maintained. The manager stated that none of the current residents are assessed as safe to administer their own medication. She is aware that a risk assessment would need to be completed with any residents who administer their own medication. The inspector confirmed that it is acceptable that the medication keys be kept in a locked cupboard when the medication is not being administered to the resident for whom it is prescribed. The medication keys must be kept safe at all times.
Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 13 Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): X None of these standards were assessed as part of this inspection. EVIDENCE: Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,30. 23 Limetree Avenue provides a comfortable safe environment. The residents spoken with were very satisfied with their individual bedrooms. At the time of inspection the home was appropriately clean and hygienic. The cupboard in the laundry where cleaning products are stored must be kept locked, as it could present a health and safety hazard to residents. EVIDENCE: The home has been maintained to a good standard, the furnishings are domestic in character and help to create a homely environment. The two residents bedrooms viewed as part of this inspection had been individually decorated and contained many personal items. (This is good practice). The residents spoken with said that they are very happy with their bedrooms and confirmed that they can use them at any time. At the last inspection a requirement was made that staff must seek advice about the practice of wedging open a residents bedroom door. An automatic door closure, which will respond when the fire alarms are activated, has now been fitted to this door. Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 16 All of the areas of the home viewed as part of this inspection were appropriately clean and tidy. The laundry is small with domestic sized equipment, which meets the needs of the residents. It was noted that the cupboard where cleaning materials are stored was unlocked and unattended at the time of this inspection. This cupboard must be kept locked at all times when not being used by staff as it could present a health and safety risk to the residents. Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 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): 33. An effective staff team supports the residents. However there was no staff in the building when the Inspector arrived to complete the inspection and there was no information how the staff could be contacted. EVIDENCE: The rota for the week of this inspection showed that adequate staffing levels are being provided to meet the assessed needs of the residents. At the last inspection an immediate requirement was made that a waking member of night staff must be provided each night as one resident was assessed as requiring assistance throughout a 24-hour period. The home now provides one member of waking staff and a person sleeping in on the premises each night. When the inspector arrived at the home there were no staff on the premises. The inspector telephoned the home that there were no details explaining how members of staff could be contacted. When the staff returned to the home they confirmed that the telephone answering machine should have given details of how to contact the manager who could return to the home if there was an emergency. The manager must ensure that this procedure is fully operational at all times.
Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 18 The telephone answering machine was fully functional by the time the inspection had been completed. Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 19 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): 38,39. The management of the home creates an open, positive and inclusive atmosphere. The home has an effective quality assurance system. EVIDENCE: The manager operates an open door policy that encourages residents and staff to voice their opinions about the way in which the home is run. The residents and staff spoken with during the inspection stated that the manager is very approachable and that they believe they could discuss any issues with her. The home has an effective quality assurance system. A user-friendly residents questionnaire is completed each year. The residents’ responses are compiled into one document, which is made publicly available. (This is considered good practice). Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 20 It is recommended that the quality assurance system also seek the views of family, advocates and stakeholders in the community e.g. GP’s chiropodists and other professionals. Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 21 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 2 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X X 3 3 X X X X Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA33 Regulation 18 Requirement It is required that when there are no staff on the premises a telephone message must identify a member of staff who can be contacted to return to the home should the need arise. This system must be fully operational at all times. It is required that the cupboard in which cleaning materials are stored is kept locked at all times when not being used by staff. Timescale for action 25/01/06 2. YA30 13 (4) 25/01/06 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 YA14 YA39 Good Practice Recommendations It is recommended that the home keeps and accurate record of all the activities and entertainment which is available for the residents. It is recommended that the home Quality Assurance System seek the views of family, advocates and stakeholders in the community. Limetree Avenue Care Home DS0000008709.V280880.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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