CARE HOME ADULTS 18-65
Littleover Lane Residential Care Home 44 & 44a Littleover Lane Littleover Derby Derbyshire DE23 6JG Lead Inspector
Claire Williams Unannounced Inspection 19th October 2005 09:30 Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Littleover Lane Residential Care Home Address 44 & 44a Littleover Lane Littleover Derby Derbyshire DE23 6JG 01332 270154 01332 270154 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) Royal Mencap (Housing & Support Services) Vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: Littleover Lane is owned by Mencap. The accommodation comprises of two houses, which provide personal care for up to 9 service users with a learning disability, aged between 18 and 65 years of age. Five service users occupy house number 44, and four service users live at house number 44a. Both houses have been furbished to reflect the style of a family home. Both houses have an accessible garden, which is segregated with a garden fence and a gate separating the patio areas. Each house is run independently, in accordance with service user needs. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 9.30am. The visit lasted 6 hours, and was the second inspection of the home this year. The inspector checked the previous requirements and recommendations made in the previous inspection report, and checked the key areas that were required to be assessed in a 12-month period. She examined care files and associated documents, and spent time speaking with staff members. A tour of both houses was undertaken and the health and safety records and checks of the building were examined. Time was spent observing service user and staff interaction. The Manager was on duty and assisted the inspector with the inspection. What the service does well: What has improved since the last inspection?
The manager has been successful in being appointed the permanent manager for the home. The Statement of Purpose has been updated to reflect this new appointment. Some new staff have now commenced on their induction, which will improve on the short staffing, that the home has been experiencing. The staff are now consulting the service users and involving them in the development of their care plan. The home has purchased a medication fridge ensuring that medication is stored appropriately. The communication processes between the home and service users families has now improved, and regular contact maintained. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The service users have access to updated information detailing the facilities and services available at the home. EVIDENCE: The acting manager has been successful in being appointed as the permanent manager. The Statement of Purpose and Service user guide have been reviewed and amended to include this information, and additional information as required by the Care Homes Regulation 2001. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, and 7 Individual care plans are in place enabling the staff team to meet service users needs. EVIDENCE: All service users have an individual care plan in place covering a variety of topics but including aspects of personal and health care specific to the individuals. The staff team are still transferring some of the old care plans into the new format and different files are at different stages in this process. The inspector examined one file on this occasion, and the staff member is still updating this file. The inspector spoke with the service user who confirmed that he is involved in the development of his plan and consulted about its contents. The service user also confirmed that he is consulted on a daily basis about aspects involved in the running of the house. The organisation responsible for the home – “Mencap” carried out an internal service review. Part of the review involved the examination of service users files. The review highlighted recommendations concerning the documentation; which included the need for evidence of the consultations held with service users and the recording of changes in care and updating risk assessments. The
Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 10 manager and the staff team are in the process of addressing these recommendations. The manager has implemented an action plan record in response to the requirement made in the previous inspection report. This action plan is a tool to use for recording the identified changes following reviews, with agreed timescales for the staff to action and update the service users care plan. The staff team are currently becoming familiar with the record and its purpose. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, and 17 Dietary needs of the service users are catered for, but the food provided is not a varied selection of food to meet service users tastes and choices. EVIDENCE: The service users are encouraged to maintain contact with their families, friends and their representatives. Those service users that are unable to verbalise independently rely on the staff team to maintain this contact. In response the previous inspection report regular contact is now maintained and recorded for a specific service user and their family at agreed timescales. The inspector examined the kitchen areas in both houses and the documentation concerning the planning and provision of meals. Both houses would benefit from the kitchen areas being upgraded, as the kitchens units look worn. The fridge temperatures in both houses were being monitored and the records completed. The staff team support the service users to undertake the food shopping, which is based on individual preferences. The staff team do not devise menus with the service users, and the choice of food is either chosen by individual service users or by the staff if service users are unable to verbalise their
Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 12 choice. On examination of the records of the food provided to service users the inspector noticed that there was some repetitiveness in the food given in both houses. On discussion with some staff they felt that different staff members had different cooking skills therefore the food choices were sometimes based on what “staff members can cook” rather than a varied nutritional meal for the service users. The records for the meals taken and the fridge temperatures are currently displayed on the fridges in both houses, rather than being filed away in keeping with providing a homely environment. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The staff team are not ensuring that medication is stored appropriately placing service users at risk. EVIDENCE: In response to the previous inspection report the manager purchased a medication fridge for the storage of insulin and medication. However there was no evidence at the time of the inspection to support that the temperature of the medication fridge was being monitored and recorded. Therefore the medication is being stored without any safe systems in place to ensure the temperature is within the recommended limits for that medication. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed on this occasion as they were assessed during the previous inspection visit. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 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, and 30 Improvements to the environment in both houses are required in order to provide a homely and safe living environment for service users to enjoy. EVIDENCE: Both houses are furnished to reflect a homely style. However the furniture and decoration is beginning to look worn in both houses, which creates a poor first impression of the homes. These issues and the need for remedial action to be taken have not been addressed following the requirements made in the previous inspection report. Therefore the requirements and the work outstanding have been repeated in this report. The following areas require attention; • The kitchen in house 44 has broken units and surfaces look worn • The toilet area in house 44 has an odour and pipe work looks dirty. • The carpet in house 44a looks loose and is rippled. An immediate requirement was issued in order to address this potential trip hazard. • The kitchen and surfaces in house 44a looks worn. • Several pieces of furniture in both houses look worn, as the paintwork is badly chipped. • Several carpets look stained and worn in both houses • A redecoration and renewal programme is not in place.
Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 16 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, 35, and 36 A qualified staff team, with a mixture of skills and experiences, supports the service users. Staff morale is low among some of the staff team resulting in some staff turnover and sickness. EVIDENCE: The inspector examined two staff files and the training matrix. The records confirmed that the staff team have attended all of the mandatory training courses as required by the regulations. Majority of the staff team have completed a National Vocational qualification (NVQ) at level 2 or above. Therefore the home have successful achieved the training standard of having at least 50 of its workforce trained to this level by December 2005. There was no evidence in the staff files to support that appraisals are undertaken, and although supervision records were evident in the files, these were out of date. The inspector spoke with the staff members on duty, and a mixture of feedback was given. Although one staff member felt that the communication processes were ok within the home, another staff member felt that they were deteriorating and that staff morale was low. This feedback was given to the manager and a teambuilding exercise was recommended in order to ensure that all of the staff team work together in accordance with the aims and objectives of the home, and to improve the staff morale amongst the team.
Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 17 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, 38, 39, and 42 The home regularly reviews aspects of its performance through a good programme of self-review, and consultations, which include seeking the views of service users, and relatives. Service users now benefit from having a permanent manager to run the home. EVIDENCE: The acting manager has been successful in being appointed as the permanent manager of the home, and she is currently completing an application to apply for registration with the Commission for Social Care Inspection. As briefly stated in the previous section the inspector received mixed feedback from the staff spoken to about working at the home. Some staff members felt that the manager was supportive, approachable and provided leadership but some staff felt that this could be improved upon. The Manager is currently completing a Registered Manager’s course (NVQ4) and is experienced in working with this service user group. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 18 The organisation and the home have effective quality assurance mechanisms in place. As stated Mencap have undertaken an internal audit/review of the service and have sent a comprehensive report with recommendations to be addressed. The service users, relatives and other stakeholders have been sent questionnaires earlier in the year in order to obtain their feedback on the services provided. A representative from the organisation regularly undertakes visits to the home in accordance with the requirements of regulation 26. However due to sickness a visit was not undertaken for September. The inspector checked some of the health and safety systems in place at the home. The staff team had received updated Fire training and the night staff receive this twice a year. All electrical appliances have been PAT tested in September 2005. The gas and electrical installations certificates were up to date. The Fire Officer visited in September 2005 and no recommendations were made. The inspector checked the file for the routine checks of the fire systems and emergency lighting and these were out of date. The checks on the water temperatures and checks required to prevent legionella were also out of date. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score X x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X x Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x X X X X 2 LIFESTYLES Standard No Score 11 x 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X X 3 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X 2 x Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 20 YES 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 YA17 Regulation 16 (2) (i) Requirement The Registered Persons must ensure that service users have suitable, wholesome, and nutritious food, which is varied and properly prepared in accordance with service users preferences. The Registered Persons must ensure that the temperature of the medication fridge is recorded and monitored. The areas damaged by the removal of the alarm must be redecorated. (Requirement repeated from last report) The units in the kitchen in house 44 must be repaired or replaced (Requirement repeated from last report) The toilet in House 44 must be redecorated. (Requirement repeated from last report) The carpet in the dinning area of house 44a must be repaired and replaced. (Imediate requirement issued) The kitchen surfaces in house 44a must be replaced or repaired (Requirement repeated from last report)
DS0000001985.V257531.R01.S.doc Timescale for action 01/02/06 2 YA20 13 (2) 01/12/05 3 YA24 23 (2) (b) 01/03/06 4 YA24 23 (2) (b) 01/03/06 5 6 YA24 YA24 23 (2) (b) 23 (2) (b) 01/03/06 08/11/05 7 YA24 23 (2) (b) 01/03/06 Littleover Lane Residential Care Home Version 5.0 Page 21 8 YA24 23 (2) (b) 9 YA24 23 (2) 10 YA24 23 (2) 11 12 13 YA24 YA36 YA42 23 (2) 18 (2) 23 (4) (v) The furniture that is worn in both houses must be repaired or replaced. (Requirement repeated from last report) (b) The carpets in both houses that are stained and worn must be replaced. (Requirement repeated from last report) (b) A programme of decoration and refurbishment must be developed. (Requirement repeated from last report) (b) The bathroom in house 44a must have the seal replaced around the bath/shower area. The Registered Persons must ensure that all staff are appropriately supervised. ( c) The Registered Persons must ensure that Fire equipment and systems are checked at suitable intervals and that the records are maintained. 01/03/06 01/03/06 01/03/06 01/02/06 01/02/06 01/12/05 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 Refer to Standard YA6 Good Practice Recommendations The Registered Persons should ensure that all of the service users files, care plans and risk assessments are updated on the new format and are relevant to the service users current needs and aspirations The staff team should ensure that they check the records of the previous meals provided for the service users to ensure that they have some variation to their diet. The staff team should file the records for the meals provided and the fridge temperatures in a drawer rather than displaying them in the kitchen areas. The Registered Persons should ensure that both houses are clean, hygienic and free from odours. The manager should supervise all staff at least six times per year.
DS0000001985.V257531.R01.S.doc Version 5.0 Page 22 2 3 4 5 YA15 YA15 YA30 YA36 Littleover Lane Residential Care Home 6 7 8 YA36 YA38YA32 YA42 The Registered Persons should ensure that all staff members receive an annual appraisal The Registered Persons should consider some team building excercises to improve the communication proceses, and to improve staff morale. The Registered Provider should ensure that checks are undertaken to prevent legionella, and that the records are maintained. Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Littleover Lane Residential Care Home DS0000001985.V257531.R01.S.doc Version 5.0 Page 24 - 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!
