Inspection on 09/02/06 for Peddars Way

This inspection was carried out on 9th February 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peddars Way 24/08/09

Peddars Way 18/09/07

Peddars Way 19/09/06

Peddars Way 11/08/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Peddars Way 5a Peddars Court Peddars Way Lowestoft Suffolk NR32 4TT Lead Inspector Jane Offord Unannounced Inspection 9th February 2006 02:00 Peddars Way DS0000024563.V282991.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 Peddars Way DS0000024563.V282991.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. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Peddars Way Address 5a Peddars Court Peddars Way Lowestoft Suffolk NR32 4TT 01502 538746 01502 538746 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 Society of Mentally Handicapped Children and Adults Michael Ullah Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 1 The care home for adults is able to accommodate three young adults in the age range 15-25 years. 2 The home is accommodating one named service user who is 15 years of age, and who will reach the age of 16 on 10.04.2006 3 The above condition no. 2 will cease once the named service user reaches 16 years of age, upon which condition no. 1 above will be amended to reflect an age range of 16-25 years 11th August 2005 Date of last inspection Brief Description of the Service: 5a, Peddars Court is a bungalow built as part of a residential housing development in North Lowestoft. The development has been built in a courtyard style so the bungalow is attached to neighbours on both sides. The home is located close to local shops, amenities and public transport. The service is home to three young people who have significant levels of physical and learning disabilities. The home has its own minibus to transport the young people. The home is run by Mencap, a voluntary agency specialising in services for people with learning disabilities. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday between 14.00 and 17.00. The manager was present and assisted with the inspection process. The three young people returned from their various daytime occupations during the afternoon. One resident’s file was seen and two new staff files were examined. The medication administration records (MAR sheets) were seen and some members of staff were spoken with. Due to the degree of disability of the residents it was not possible for the inspector to gain their views about the service. The week’s menus were looked at and the preparation of the evening meal was seen. The manager gave a tour of the home and explained a number of plans that have been proposed for enlarging one bathroom and altering the use of another room to enable one of the resident’s bedrooms to be made bigger to accommodate the special equipment needed. On the day of inspection the home was clean and tidy. Staff greeted the residents as they returned and offered them drinks and snacks. Help with drinks was offered sensitively. Staff members talked and joked with the residents and the residents responded with smiles and laughter. What the service does well: What has improved since the last inspection? Since the last inspection plans have been drawn up by an architect and occupational therapist (OT) to enlarge one bathroom to give better access for a resident who uses a wheelchair. Agreement has been reached on how the work will be funded and the manager is hoping the work will commence shortly. Work in the second bathroom to upgrade the floor covering was due to start later in the week. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 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. Peddars Way DS0000024563.V282991.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 Peddars Way DS0000024563.V282991.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): 2. People who use this service can expect to have their individual needs assessed and met. EVIDENCE: The three residents have been together in the home for a number of years. It was originally registered as a childrens’ home. Two of the residents are now eighteen and the registration has been varied to allow the residents to remain together in the home with the same staff team. Additional training to help staff make the transition from caring for children to caring for young adults has been undertaken. Peddars Way DS0000024563.V282991.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, 9. People who use this service can expect to have a care plan that reflects their needs and be supported to take risks. EVIDENCE: One resident’s file was examined and contained a lot of detail about the abilities and needs of the resident. Under the assessment section there was information about mobility, fine motor skills, sensory difficulties, sleep pattern, continence and physical difficulties. Other areas assessed included personal hygiene needs, dressing/undressing, cognitive skills, communication (can use some Makaton), safety awareness and domestic skills. Interpersonal relationships and social skills were also addressed. The care plan and objectives were designed to maintain as much independence as possible. Areas covered were to promote communication skills and maintain family contact, to continue education, to maintain current mobility levels, to promote health needs, manage epilepsy and continence, to maintain personal hygiene, discourage self harm and participate in sensory activities with the use of lights, tactile materials and sound. There was evidence that interventions were reviewed but they were not signed. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 10 The file also contained a photographic care plan that showed the resident with family members and recorded their hobbies and some achievements. There were pictures of tasks the resident needed help with and some of the places they enjoyed visiting. There were a number of risk assessments that had been generated for day-today activities such as bathing, being scalded, harming others or self-harming, managing epilepsy and accessing community facilities. There was a behaviour management plan that was developed with the input of a multi disciplinary team to manage the dislocation of the resident’s jaw. There had been evidence that it was a form of self-harm but the team had found that at times the resident’s jaw dislocated spontaneously. The records showed that it had happened twice since the beginning of the year and each time the resident had been treated at the James Paget Hospital. The medical team had proposed that they teach the staff team how to reduce the dislocation to prevent the trips to hospital. The manager had not agreed to that as they felt there was too great a risk to the resident being treated by non-medical staff. Peddars Way DS0000024563.V282991.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): 12, 14, 15, 17. People who use this service can expect to be encouraged to maintain contact with family and friends, to take part in leisure activities of their choice and to receive a well balanced diet. EVIDENCE: The resident’s file that was seen contained details of their family, parents, grand parents and siblings. As recorded in the previous section there were also photographs of family members. There was also a list of family birthdays to be remembered. Staff said they supported residents to get cards and presents. One resident divides their time between their family home and Peddars Court, spending two weeks at a time in either place. Two residents continue in full time education. The third resident has completed their education and is awaiting a day placement. Due to their level of need the staff have not yet identified an appropriate centre. The staff team arranges a rota of activities to keep the resident occupied, such as shopping, swimming or visiting places of interest. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 12 The residents participate in activities they enjoy like horse riding, yoga, swimming and music. The home has a music centre and selection of compact discs with a variety of music on them. The menus were seen and showed a wide choice of dishes. A packed lunch for one resident consisted of a ham sandwich, some fresh fruit, a mousse and a chocolate roll. The meal that was being prepared for the evening was a chicken curry and rice. It smelt and looked appetising. The refrigerator was well stocked and had a good selection of fresh fruit and vegetables. One resident is fed via an enteral tube (PEG feed). Staff have been given training to manage this process and a dietician oversees the nutrition content of the feed. The feed has recently been altered as the resident was gaining too much weight. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 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): 18, 19, 20. People who use this service can expect to have their health needs met, receive appropriate personal support and be protected by the home’s medication administration procedures. EVIDENCE: In the resident’s file that was examined there were details of all the health professionals involved in their care. For example the GP, the occupational therapist (OT), the consultant physician, a psychologist, the social worker and the speech and language therapist (SALT). Visits to the hospital were recorded and in the case of it being because of a jaw dislocation the records showed that the staff spent time reassuring the resident throughout the visit. Staff were observed discreetly assisting a resident to go to the bathroom during the inspection. The fire alarm was tested and the noise distressed one resident but the staff had anticipated that and one staff member stayed beside the resident and offered verbal reassurance until the alarm stopped. The residents were all appropriately dressed for their age wearing jeans or tracksuits and trainers. They all looked clean and cared for. Greetings and gestures between staff and residents were friendly and the residents responded with smiles and laughter. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 14 Each resident has a lockable medication cabinet in their own room. The Medication Administration Record (MAR) charts were inspected and there was no evidence of signature gaps. The appropriate codes were used when a resident was either out or on leave so medication was not dispensed. As required (PRN) medication that had a choice of dose i.e. one tablet or two, had the dose dispensed recorded on the reverse of the MAR sheet to allow an audit trail. Staff spoken with had received training in medication dispensing and special training in giving medication through a PEG tube. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 15 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): 23. People who use this service can expect to be protected from abuse. EVIDENCE: There was evidence in the training files and from previous inspections that all the staff had had training in protection of children from abuse (POCA) but with the change of registration from childrens’ home to young adults’ home the protection of vulnerable adults (POVA) training needs to be accessed. Staff files seen did not have evidence that POVA training had been done. The manager has since confirmed that the MENCAP training that the staff have done actually covers POCA and POVA. This needs to be recorded in the staff training records. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 16 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): 26, 27, 29, 30. People who use this service can expect to live in a clean homely house with specialised equipment to maximise their independence and their own personalised room, however they cannot be assured that the present bathrooms will meet their needs. EVIDENCE: The home on the day of inspection was clean and warm. There were no unpleasant odours noted. Individual bedrooms were personalised with different décor and furnishings and the residents’ own photographs and pictures or posters. Music centres and televisions were evident in the rooms as well as in the communal lounge. The physical disabilities of the residents means that two of them require their own wheelchair and special cushion. One resident has a pressure-relieving mattress on their bed. In one bathroom there is a ceiling track hoist system that allows a resident to be moved from a wheelchair into the special bath. This bathroom is not very large and manoeuvring a wheelchair in there for access to the toilet is extremely difficult. The doorjamb has been badly damaged because of the narrow space. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 17 The manager showed some plans drawn up by an architect and the OT to enlarge the bathroom and change the angle of the door to give easier access. The extension means that a garden shed will need re-siting and one bedroom window for one resident’s room will be lost but there is a second window in that room. The changes will make the task of managing the resident’s personal care far simpler. The second bathroom has a grill over the floor of the shower that is difficult to move and keep clean. The previous inspection identified the problem and a requirement was left to change the flooring to something more suitable. The manager explained that they have had some estimates for the work and the agreement to go ahead with it. They were intending to get the work done in the next week. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 18 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, 36. People who use this service can expect to be supported by staff who are correctly recruited and appropriately trained to meet their needs. EVIDENCE: Two staff files were seen and both contained evidence of a POVA 1st check and an enhanced Criminal Records Bureau (CRB) check done before the staff member commenced work. Each file had documentary identification evidence and two references. Only one file contained an up to date photograph of the member of staff. One Curriculum Vitae (CV) showed a gap in the work history but the manager was able to evidence that that had been satisfactorily explained and recorded. Both files contained evidence of an induction training that had included fire awareness, 1st aid, moving and handling, basic food hygiene, medication administration and POCA training. A folder containing certificates issued for training undertaken showed some staff had had training in infection control, administration of rectal diazepam, NVQ 3 in caring for children and young people and updates for fire, medication administration, 1st aid and moving and handling. Discussion with staff confirmed that they had had the training. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 19 There was documented evidence that regular supervision sessions took place. Notes showed that during supervision training needs were identified. One member of staff confirmed that supervision takes place regularly and they felt able to raise any concerns with their supervisor. They said that the team had recently been very supportive after a bereavement in their family. The team will cover for each other and to support the residents during difficult times. Peddars Way DS0000024563.V282991.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, 42. People who use this service can expect it to be managed by an experienced manager and have their health and safety protected. EVIDENCE: The registered manager has a long history of working with people and children with learning disabilities. They have worked in a variety of residential settings and been in management for ten years. They hold a number of NVQ 4 awards in care and management and are an NVQ assessor. As noted in a previous section of the report staff have undertaken training in moving and handling and fire awareness. The fire alarm was tested during the inspection and recorded. A risk assessment was seen for a member of staff who has a diagnosis of epilepsy with clear instructions about how to manage the situation should they have a seizure at the home. Peddars Way DS0000024563.V282991.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 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 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 3 27 1 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X X X 3 X Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 22 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 2 Standard YA6 YA27 Regulation 15 (2) (c) 23 (2) (a) Requirement The member of staff must sign reviews and changes of a care plan. The plan to extend one bathroom must go ahead to enable one resident to use it in safety. The grille and flooring in the other bathroom must be changed to a covering more suitable. This is a repeat requirement from the last inspection. All staff files must contain a recent photograph of the staff member. This is a repeat requirement from the last inspection. Timescale for action 28/02/06 31/05/06 3 YA27 23 (2) (a) 28/02/06 4 YA34 19(1)(b) (i)Sch.2 09/02/06 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 Refer to Standard YA23 Good Practice Recommendations Training records should record any POVA training done by DS0000024563.V282991.R01.S.doc Version 5.1 Page 23 Peddars Way staff. Peddars Way DS0000024563.V282991.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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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