CARE HOME ADULTS 18-65
Limetree Avenue Care Home 23 Limetree Avenue Retford Nottingham DN22 7BB Lead Inspector
Judith Avill Key Unannounced Inspection 30th May 2006 04:30 Limetree Avenue Care Home DS0000008709.V298350.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 Limetree Avenue Care Home DS0000008709.V298350.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. Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 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.V298350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: 23 Limetree Avenue is a 3-storey, semi-detached house in a quiet, residential street within quarter of a mile of Retford town centre, near shops, pubs, and cinema and leisure facilities. The home caters for six male and female residents with learning disabilities. It was established in 1991 and five of the residents have been there since that time. The latest addition arrived in 1996; no one has been admitted since. Five of the current residents attend local authority day care services for some part of the week. All residents have their own personalised decorated bedrooms, with a communal lounge, dining room and kitchen. There is a bathroom and a shower room; there are toilets on each floor. One ground floor bedroom is ensuite. There is a small well - maintained garden. On the second floor there is a sleepin room for staff and an office where records, documents, policies and procedures are kept. Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over early one evening, it took approximately 3 and a half hours. The inspection included inspection of care and other records, a discussion with 3 residents the manager and one member of staff and a tour of the building including viewing 2 resident’s bedrooms with their permission. What the service does well: 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.
Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 6 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.V298350.R01.S.doc Version 5.2 Page 7 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 good. The statement and purpose and service user guide need to be reorganised. Prospective residents would have a full assessment prior to admission to the home. EVIDENCE: The Statement of Purpose and service user guide seen were not comprehensive. It is recommended that the documents be reorganised in line with legislation and national minimum standards. Details of a recent community care assessment were seen on one residents plan. The manager reported that prospective residents would have a full a assessment prior to admission. Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 8 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 9 and 10 Quality in this outcome area is good. Each resident has a comprehensive person centred plan (PCP). Each plan contained specific details of personal social and health support needs and ‘how’ staffs provide services to individual residents. EVIDENCE: Three plans were viewed during the inspection. Details of individual choices, preferences were recorded. Records of resident’s involvement were seen and reviews were maintained up to date. The plans were provided in different formats to meet individual residents abilities. Clear risk assessments were seen for individuals as appropriate and amended to meet the changes as needed. Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 9 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 and 17 Quality in this outcome area is good. Individual leisure activities are recorded EVIDENCE: The manager and staff reported that the record of all of the activities and entertainment of individual residents is being developed. The PCP’s seen did not reflect the activities and entertainment planned for individual residents as discussed with residents and staff. This recommendation was issued at the last inspection. Individual residents commented on planned outings and the involvement of staff. Interaction observed between residents and staff was appropriate and respectful. Residents are offered a key to their room and staffs only enter with resident’s permission. The meal being prepared at the commencement of the inspection smelt appetising and residents commented that they had enjoyed it. Staff reported that meals are planned with residents at the beginning of each week and adjusted if required. Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 10 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): 18,19and 20 Quality in this outcome area is good. Residents are supported in the way need and they require. The medication policy needs to reflect the practice of the home. EVIDENCE: The person centred plans reflect the needs and wishes of the residents to meet heir physical and emotional heath needs, Files viewed indicated responses and actions to be taken by staff to support individuals. The home uses the Mencap medication policy. Staffs spoken with were aware of the process s for receipt, storage administration and disposal of medication. The procedure needs to reflect the practice of the home. Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 11 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. Residents said they are listened to and feel safe at the home. EVIDENCE: The residents spoken with said they feel able to talk to the staff and say if they are not happy. No records of complaints have been recorded since the last inspection. The Home uses the Mencap policies and procedures for responding to allegations/suspicions of abuse and neglect. Staff’s spoken with were aware of action to be taken in the event of an allegation or suspicion of abuse. Individual finance records are maintained, however no record of resident’s personal allowances were recorded on the most recent form used at the home. Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 12 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 good. The home is clean and well maintained. EVIDENCE: Three residents bedrooms were seen on the day of inspection. The rooms were well-personalised and met individual needs and tastes. The ground floor bedroom has an ensuite toilet and walk in shower to accommodate with wheelchair access. A portable ramp is in place for access to the garden and front door. Furnishings and fittings are of good quality. The home is safe bright and cheerful and provides sufficient light and ventilation. The home has sufficient bathing and toilet facilities for the number of residents accommodated. The home was clean and well maintained on the day of inspection. Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 13 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): 32,34, 35 and 36 Quality in this outcome area is good. A competent and qualified staff team supports the residents. EVIDENCE: The staffing rota provided showed that the staffing levels met the needs of the residents. However the home has a manager and no other senior staff at the time of inspection. The manager provides care and support for residents on shift as well as managing staff and the home. It is recommended that consideration be given to enabling the manager to have more administrative time for managerial tasks and monitoring. Support staffs attend induction and foundation training within the first 6 months of employment. Records of training are well documented. Staff spoken with confirmed the recruitment policies and procedures are followed. The homes recruitment practices meet legislation and National Minimum Standards. All staff receives regular supervision. Staffs are spoken with commented on the support from colleagues and the manager. Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 14 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, 42 and 43 Quality in this outcome area is good. The home is well run and residents benefit from the homes policies and procedures. EVIDENCE: The home uses the Mencap policies and procedures. A member of staff spoken with was aware of the policies and procures and practices at the home. The manager encourages staff to voice their opinions about the way the home is run. From observations made by the inspector during the inspection residents offered opinions and comments about the home. The manager and staff commented that a change to the quality assurance system is ongoing. Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 15 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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 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 3 3 Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 16 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 YA23 Regulation 17 (2) Schedule 4 9 (a) (b) 13 (2) Requirement The registered person must ensure that residents personal allowances are recorded Timescale for action 30/05/06 2 YA20 The registered person must 06/07/06 ensure that the medication policy reflects the practices of the home 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 YA1 YA33 Good Practice Recommendations The statement of purpose and service user guide are reorganised to meet the legislation and national minimum standards Consideration is given to providing the manager with more hours for administrative and managerial tasks and duties Limetree Avenue Care Home DS0000008709.V298350.R01.S.doc Version 5.2 Page 17 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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