Inspection on 28/07/05 for 25 Old Mill Park

This inspection was carried out on 28th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

25 Old Mill Park 15/01/08

25 Old Mill Park 22/05/06

25 Old Mill Park 30/01/06

25 Old Mill Park 19/03/05

25 Old Mill Park 18/10/04

25 Old Mill Park 22/03/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 25 Old Mill Park Louth Lincolnshire LN11 0NY Lead Inspector Sue Hayward Unannounced 28 July 2005 08:45 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 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 Stationary 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. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service 25 Old Mill Park Address Louth Lincolnshire LN11 0NY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01507 608052 Sense East Care home only 6 Category(ies) of LD Learning Disability (6) registration, with number SI Sensory Impairment (0) of places 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 19/03/05 Brief Description of the Service: 25 Old Mill park is one of a number of homes within the county that is operated by SENSE East. It is registered to provide care and accommodation for up to six service users between the ages of eighteen to sixty-four years who have been affected by a dual sensory impairment (deaf/blindness) caused by rubella and who also have a moderate or severe learning disability. The home is located in the market town of Louth, which has a range of services and facilities. It is a domestic style house providing six single bedrooms for service users, one on the ground floor. There are stairs but no lift facility so service users at this home who are accommodated on the first floor need to be able to manage stairs. There is a lounge, dining room, kitchen and sensory/activity room on the ground floor. The home was fully occupied and there have been no new admissions since the last inspection. Transport for residents is provided in the form of a minibus. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced starting at 08: 45 and took place over 5 hours. It was carried out by one inspector as the first of two statutory inspections for 2005/6. The main method of inspection used was “case tracking”. This involved selecting three service users records and tracking the care they receive through their records and discussion with three staff on duty. In view of the communication needs of service users the inspector was only able to speak with one service user on a general basis and therefore also relied on observations made of staff carrying out their work with service users. A sample of other regulatory records and policies and procedures were also checked. What the service does well: What has improved since the last inspection? The Statement of purpose, which gives information about the home, has been reviewed since the last inspection. A monitored dosage system of medicine administration has been introduced and some staff have had training about this. This offers further safeguards to staff and service users. There is an on-going programme of redecoration and residents are enabled to be involved with this as much as possible. A bedroom has been redecorated 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 6 since the last inspection and bedroom door locks have been changed in all but one instance. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 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 standard(s) 1, 2 and 5 The procedures in place for the introduction and assessment of people to the service ensure care needs can be met. Terms and conditions do not contain sufficient information about fees charged to ensure residents are fully informed. EVIDENCE: There have been no new admissions to this home since the last inspection and most service users have been at the home for a number of years. All three files checked contained detailed assessment information and care plans. Assessment information demonstrated the involvement of other professionals such as social workers. The organisation also employs a behavioural therapist and records were available which demonstrated the individual guidelines that have been developed for service users. Since the last inspection the statement of purpose, which gives information about the home has been reviewed. This information can be made available in other forms such as widget and symbol. The service user guide in symbol form needs to be updated with Old Mill Park’s details as it currently shows those of another home within the organisation. All records checked contained information about service users terms and conditions of occupancy at the home. Information about fees charged was 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 9 available but was not included in the terms and conditions information kept on service users files. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 and 10 Care plans contain sufficient information to ensure the care needs of service users are met. People who use the service are enabled as much as possible to make decisions about preferred routines and independence is promoted EVIDENCE: All files of service users inspected on this occasion contained detailed information about service users’ needs and how they are met and were being stored securely. Risk assessments were also in place. There was photographic information of activities contained on files and it was noted that some information was in symbol form. There was evidence, which demonstrated that reviews are held on a twice-yearly basis and at least one of these relatives and other professionals are invited to attend. Observations and discussion with staff indicated that they had a good knowledge of the needs of residents, such as their individual communication needs. Staff gave examples of how residents are given choices such as being able to touch and feel different textures of fabrics if they have little sight. One staff member confirmed that service users choose their own clothes when shopping and also had the opportunity to choose decorations and soft 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 11 furnishings for their rooms. Residents also have opportunities to pursue holidays of their choice, which are based on their individual preferences. During discussion with staff it was apparent that service users have opportunities to be involved in a range of activities to promote their independence as well as social and leisure activities. Assessments detailed areas of risk, which had been identified in relation to individuals as well as the home environment. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, and 16 The home provides a range of activities and leisure interests both within the home and community, which service users can participate in. These are based on the preferences of service users who are encouraged to make choices about their preferred lifestyles and routines. Transport provided does not fully meet the needs of service users. EVIDENCE: Discussion with staff and records checked demonstrated that service users have a variety of opportunities to take part in a range of activities, educational and leisure interests. During the inspection a service user was noticed to be listening to music. He said that he enjoyed this and a staff member was fully aware that this was one of his interests. During discussions with staff members examples were given on some of the activities that service users participate in such as horse riding, sailing, 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 13 aromatherapy and yoga. Service users were getting ready at the time of the visit to attend a resource centre, which has links with a local college. Examples were given of service users undertaking educational and work related opportunities e.g. one was doing a stable management course. Service users holidays are planned to take into consideration their differing needs and preferences for example some are going to Butlins, some to a cottage in Norfolk, one for a long weekend and days out at a theme park and one a sailing holiday. Service users are enabled to be as independent as possible such as participating in household tasks and food shopping. Examples were given of some community events that they had participated in which included a tabletop sale at the local library. Service users can attend Church services if they wish. The home has its own mini-bus, which service users contribute to however staff said that it was unusable at present due to a mechanical problem. An alternative vehicle has been provided however staff comments indicated that this did not meet the needs of the service users as it did not have enough seats to accommodate all residents or the facilities to secure wheelchairs. It is acknowledged that staff confirmed that the organisation where in the process of trying to address this issue. Staff communicated well with service users and were attentive to their needs. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 20 This home supports service users to be as independent as possible and make choices about their lifestyles. Service users are protected by the homes procedures for administering medicines. EVIDENCE: The organisation has policies and procedures for the receipt, recording, administration and disposal of medication. The procedure for administering medication was observed on the day of the visit. It is the policy of the home that this is carried out by two people. Whilst service users are not able to administer their own medication it was noticed that they are assisted to be as involved as possible, for example a service user was helped to apply creams and lotions. Staff wore disposable gloves whilst carrying out this procedure and medicines are securely stored. Discussion with staff indicated that they had had training from a local pharmacy in relation to the monitored dosage system of dispensing medication, which has been introduced since the last inspection. The manager and deputy were in the process of completing additional modular training covering further aspects about this, which is to be cascaded to staff. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 15 Staff were attentive to residents needs and supported them appropriately. Records included information about the needs and preferences of service users and staff had a good knowledge of these. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Residents are protected by the procedures and systems in place for dealing with complaints and allegations of abuse. EVIDENCE: The complaints procedure is contained in the statement of purpose and a copy was in each bedroom. Records of complaints are kept. One complaint has been raised since the last inspection, which is in the process of being addressed. There is a comprehensive policy relating to adult abuse and it was noticed that the updated Lincolnshire County Council policy on adult protection procedures was on the notice board in the office along with the General Social Care Councils code of practice for staff. There have been no Protection of Vulnerable Adults issues raised since the last inspection. Staff demonstrated that they were aware of what to do should either a complaint or an adult protection issue be raised. As service users have communication difficulties staff rely on their knowledge of and observations of service users to determine whether they are satisfied with the service. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26 and 30 The home provides a well-maintained and comfortable environment for service users. Further attention is needed to ensure that the entrance hall floor and carpet is repaired/replaced to ensure that any potential risks posed to service users are reduced. EVIDENCE: The property, which is of a domestic style, provides a clean, comfortable and tidy home for service users. Bedrooms were furnished according to service users needs and reflected their individual tastes and interests. Staff comments indicated that service users are enabled to choose items to decorate and furnish their rooms. The property is generally well maintained and locks have been changed to all rooms with the exception of one since the last inspection. Further work remains outstanding to the hall carpet and some repairs are needed to the floor. This matter has been reported to the housing association as they have some responsibilities for the upkeep of this. It was understood that this work would be completed within the next two months. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 18 The exterior and gardens were not seen on this occasion but discussion with staff indicated that the repainting of the garden furniture was to be a project that service users were to participate in. The fire brigade and environmental health officers inspect the premises periodically. The last reports were viewed. The fire officer’s report of 24/02/02 was satisfactory. The Environmental Health Officer last visited the home 13/07/04. Staff were aware of infection control procedures and stocks of gloves were seen for staff to use. Laundry facilities were not seen on this occasion. These were inspected at the time of the last inspection of 19/03/05 and were satisfactory. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 35 Staff have training to ensure that they have the necessary skills and knowledge to care for service users safely however staffing levels must be reviewed to ensure that there are sufficient staff on duty to fully meet needs at all times. EVIDENCE: At the time the inspection commenced two staff were on duty. Staff spoken to said that generally there are three staff on duty during the day however it was not always possible to maintain this level, for reasons such as staff illness. Staff were of the opinion that on the occasions when there are only two staff on duty the home is able to meet service users basic needs but there are occasions when their quality of life is affected. For example a comment was made that staff were unable to give one service user enough one to one support to assist his development. Another comment was made that when there is only two staff on duty service users choice in relation to social and leisure activities is limited. Duty rotas checked also confirmed that there were occasions when only two staff were on duty during the day. The home does use agency staff and tries to ensure that the same staff are used each time to ensure consistency. The last inspection report of 19/03/05 commented that a ratio of one staff member to two service users was necessary. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 20 Staff confirmed that they have training opportunities, which includes regular updates in some matters and more specialised training in others. The deputy manager confirmed that there are currently 7 staff in the process of working towards a National Vocational Qualification (NVQ) award at either level II, III and IV. Records demonstrated that manual handling training had occurred on 07/01/05, adult abuse training in November 2004, crisis prevention intervention training and first aid training in March 2005. All staff have induction training on employment. This includes covering seven modules of training over a period of time. Staff had a good knowledge of service users needs and comments demonstrated their commitment to ensuring service users have a good quality of life. 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41 and 42 There are a range of policies and procedures and record keeping systems in place to ensure the safety and welfare of service users. EVIDENCE: The organisation has a range of policies and procedures and a sample were viewed on this occasion including the homes procedure for raising concerns and complaints and adult abuse procedure, medication policy, risk assessment and “whistle-blowing”. All were satisfactory. A number of records required by law were also inspected and were being generally well maintained with the exception that staff files checked did not contain recent photos. The home is generally well maintained and there were no obvious safety issues noticed. Risk assessments of the environment and matters relating to individuals had been completed, as had a fire risk assessment of the home, which are reviewed on an annual basis. Fire records checked demonstrated that fire alarms are tested weekly and tests of the emergency lighting generally monthly. There is a record in place to record any accidents should 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 22 they occur. Staff confirmed that training they have includes health and safety matters such as first aid, manual handling, basic food hygiene and fire drill. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 x x x 3 Standard No 25 Old Mill Park Standard No 31 32 Score x 3 Version 1.20 Page 23 C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc 11 12 13 14 15 16 17 x 3 2 3 x 3 x 33 34 35 36 2 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x 2 3 x 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 24 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 5 Regulation 5 (1)(b) Requirement Service users terms and conditions/contracts must be reviewed to include the fees charged. Suitable arrangements must be made for transporting service users. The registered person must make repairs to the carpet and floor in the entrance hall. This requirement is outstanding from the inspection of 19th March 2005 however it could be demonstrated that it is in the process of being addessed. A further timescale has been given for completion. Locks to bedroom doors must work in an emergency. This matter has been adressed since the last inspection in all but one instance. Staffing levels must be reviewed to ensure that they are in sufficient numbers to fully meet service users needs at all times. Staff records must include a recent photoraph. Timescale for action 25th October 2005 25th September 2005 25th September 2005 2. 3. 13 24 16 (m) & 12 (1)(a) 23 (2) (b) 4. 26 23 (2) 31st August 2005 5. 33 18 (1) 25th September 2005 25th September 2005 6. 41 17 (1) & schedule 2 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 25 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 Good Practice Recommendations 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 26 Commission for Social Care Inspection Unity House, The Point Weaver Road off Whisby Road Lincoln, LN6 3QN 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 25 Old Mill Park C53-C04 S2310 25OldMillPark V239456 250705 Stage 4.doc Version 1.20 Page 27 - 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. 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