Inspection on 07/12/05 for 129 Neale Avenue

This inspection was carried out on 7th December 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

129 Neale Avenue 04/02/09

129 Neale Avenue 07/03/07

129 Neale Avenue 18/01/05

129 Neale Avenue 19/08/04

129 Neale Avenue 17/02/04

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Sense East (Neale Avenue) 129 Neale Avenue Kettering Northants NN16 9HG Lead Inspector Mrs Pat Harte Unannounced Inspection 7th December 2005 11.00 Sense East (Neale Avenue) DS0000044413.V253057.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 Sense East (Neale Avenue) DS0000044413.V253057.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. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sense East (Neale Avenue) Address 129 Neale Avenue Kettering Northants NN16 9HG 01536 415385 01536 415385 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.sense.org.uk Sense East Vacant Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: As part of the Sense East organisation, 129 Neale Avenue, Kettering provides specialised personal care for up to six Residents with profound sensory impairment, learning disability, and physical disability. The property, which is leased from East Lindsay Partnership Housing, trading as Linx Homes, has been extensively renovated by the registered provider, and is well equipped to meet the physical needs of the Residents. 129 Neale Avenue is a two storey building located in a quiet residential street in Kettering, near to the town centre and its amenities. Internally, there are wide corridors and a purpose built lift provides access to the first floor bedroom accommodation. Residents are provided with single bedrooms that have specially designed en suite facilities to cater for their physical needs. There are also two large bedrooms on the ground floor, each with en suite facilities that include specialised baths that can be electrically raised and lowered. The communal facilities include a lounge, dining room and a conservatory area used for activities. There is a large enclosed garden to the rear of the property. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for Service Users and their views of the service provided. Inspection planning took one hour and consisted of a review of the last inspection report and requirements, the Home’s service history including notifications and events. The primary method of inspection used was ‘case tracking’ which involved selecting two Residents records and tracking the care they receive through review of their records and discussions with care staff. On the day of inspection one Resident was at home, all other service users were attending day care or were out pursuing their various activities. Discussions were held with two members of care staff and the Deputy Manager. A partial tour of the premises took place and a selection of records was The Inspection took place from late morning and during the afternoon over a period of three hours and was carried out on an unannounced basis What the service does well: The Home has a very committed staff group. It was clear that they respected and valued their Residents as individuals and relationships were observed to be very good. Visual and auditory aids are used to enable the Residents to communicate, to allow them choice and independence and to seek their views on the service. Residents are provided with a good range of activities and there is additional input from volunteers to enable individual activities on a regular basis. Routines are relaxed and flexible and geared to the individual needs and wishes of the Residents. Staff ensure that Residents Health Care needs are closely monitored with prompt referral made to Medical Professionals where necessary. A good range of equipment is provided to ensure Resident’s safety and meet their physical needs. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 6 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. Sense East (Neale Avenue) DS0000044413.V253057.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 Sense East (Neale Avenue) DS0000044413.V253057.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, 2, 3 & 4 Information is provided to prospective Residents and their Relatives to enable them to make informed choice regarding their placement. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide that outlines what the service can and cannot provide. The information is currently being updated to reflect the management arrangements and will require further adjustment as those arrangements change with the appointment of a new Manager. There have been no new admissions since the last Inspection. However discussions with the Deputy Manager showed that a full assessment of a prospective Resident’s needs would be carried prior to admission in order to ensure that all needs could be fully met. As part of the admissions process the prospective Resident and their family or Representatives would be given opportunities to visit the Home, meet other Residents and staff, view the premises and discuss their needs. There are opportunities for overnight and weekend stays for any new Resident and the admission process would be conducted at the individuals pace. Sense East (Neale Avenue) DS0000044413.V253057.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, 7, 8, & 9 Whilst care plans were found to be detailed not all areas of personal care were fully documented and the organisation of Residents’ care plan information did not provide easy and quick access for staff. EVIDENCE: Two Residents records were inspected. The plans of care included very detailed information on the emotional, physical, communication and spiritual needs of the Residents. Strategies for the management of behaviours were in place. However some care areas, such as hair and nail care, were not documented. Risk assessments had not been updated and recognised risk assessment tools in relation to pressure care and nutritional risks were not utilised. The organisation of the information was discussed with the Acting Manager, following the Inspection. The care plan information was difficult to locate in the Residents’ files and improvements could be made to ensure easy and quick access for staff. It was clear from discussions with staff that they knew their Residents needs well. They were aware of potential risks and routinely monitored areas such as skin conditions. The care provided to the Residents was both holistic and Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 10 good. They were supported and assisted to communicate their wishes and make choices in their daily lives. Discussions with staff and observations of staff/Resident interaction showed that Residents were consulted and involved in the running of their Home. Sense East (Neale Avenue) DS0000044413.V253057.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): 11, 12, 13, 14 & 15 Residents are supported to live fulfilled lives and are provided with a wide range of activities. EVIDENCE: All of the Residents are supported to attend day care to provide stimulation and meaningful activities appropriate to their needs. A wide range of both individual and group activities is provided taking account of Residents individual wishes and preferences. The Home uses the services of Volunteers to support and enhance the activity programme. Residents are supported to pursue individual interests and activities both in the Home and in the community. On the day of Inspection one Resident had been on a Christmas shopping trip. The interaction between her and her carer on their return showed that they had had a very good time and the Resident had been supported and enabled to make her purchases. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 12 Discussions with staff showed that Residents are fully supported to maintain personal and family relationships. The Home has an open visiting policy and Residents are encouraged, where possible, to undertake and enjoys visits and stays with their families. Residents’ religious needs are respected and arrangements are made for them to attend places of worship for example one Residents regularly attends a local mosque. Sense East (Neale Avenue) DS0000044413.V253057.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): 18, 19 & 20 Residents are consulted on the way in which their care is to be provided and their wishes are determined and respected. Not all medication was administered in accordance with the prescription instructions. EVIDENCE: The care plan information and discussions with staff showed that staff provide personal care in ways that are suited to the individual Resident’s wishes and needs. Considerable thought has gone into providing the right equipment to aid staff in carrying through personal care comfortably and safely for those Residents with high physical dependency. Detailed instructions are contained in the Residents care plans outlining individual communication methods used to ensure that Residents are enabled to express their needs and wishes. Health care needs were clearly documented. Records showed that staff responded quickly to any changes and made referrals to the appropriate Medical Professionals. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 14 Medication was safely stored. All incoming medication is checked and recorded and a disposal record was maintained. The administration records were generally in good order. However care must be taken to ensure that there are clear directions for the administration of all prescribed drugs, including creams and gels, and that the administration record is fully maintained. There was an instance where the administration of a prescribed cream was not recorded, a further instance where the discontinuation of a cream had not been clearly recorded and had been given and an instance where there were no clear directions for the administration of a dental gel together with no record of administration. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 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): A system for the recording of complaints, comments and compliments has not been developed and staff were not fully conversant with Protection of Vulnerable Adults procedures. EVIDENCE: It is acknowledge that the Home receives very few complaints however currently there is no system in place to record any comments, compliments or complaints. The importance of this area for development was discussed with the Deputy Manager who agreed that action would be taken to set up a recording system as advised on the last Inspection of 7th July 2005. The Home has copies of the local Adult Protection guidance and reporting procedures and staff induction training includes reference to this area. However neither of the two staff members spoken with were fully conversant with the procedures nor there was recognition that Resident to Resident abuse can occur. The Deputy Manager gave immediate attention to this area and all staff are now to receive further training through the supervision system. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 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): 24, 25, 26, 27, 28, 29 & 30 The home provides a safe comfortable environment, which is maintained to an acceptable standard but some equipment is in need of replacement. EVIDENCE: The premises were in good order, clean, warm, comfortable and well maintained. Standards of domestic and hygiene maintenance were viewed as good throughout the areas of the premises viewed. Care is taken to provide a wide range of equipment to assist staff in meeting their Residents complex care needs. The Acting Manager confirmed that two areas identified as in need of change are under review. In one instance a Resident’s bath is not suited to his needs and in another a Resident’s bed requires replacement. It is acknowledged that there are difficulties in locating the right equipment but every effort should be made to action both areas as quickly as possible. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 17 Specialised equipment includes a padded “box” styled bed with high sides to protect the Resident from falls or injury and a safety gate to protect another Resident from harm should she access the first floor corridor area at night. In both instances it is clear that this equipment is necessary for safety reasons. Discussions were held with the Acting Manager, following the Inspection, and it was agreed that there is a need for clear written protocols to be developed showing the reasons for the use of the equipment and the circumstances or timings for the use. For example the protocol on the use of the gate should clearly indicate that this equipment is only be used as a protection measure over night. It was agreed that the written protocols would be forwarded to the Commission. The garden area would benefit was redesigning to remove the steep access ramp to the lawn area to make access more Resident friendly. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 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): 31, 33 & 36 Sufficient numbers of care staff are deployed to meet the needs of current Residents. EVIDENCE: Staff rotas indicate that minimums of 4 care staff are deployed on daytime shifts and 2 waking night carers provide night care. There is provision to adjust the levels further should the needs of the Residents change. The staff on duty at the time of the Inspection were viewed as very committed and caring. They showed that they were fully committed to the well being of their Residents and to enabling them to live fulfilled lives. Relationships between staff and the one Resident at home were observed to be very good. Discussions with staff showed that they were familiar with the Home’s aims and objectives and the Organisation’s philosophy of care. Staff felt that there was now stability within the staff group, the recruitment programme had been successful, reduced the reliance on the use of Agency staff and provided better continuity and consistency of care for their Residents. It was clear that staff have achieved a Teamwork approach. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 19 Staff stated that they had opportunities for both informal and formal supervision and that the Acting and Deputy Managers were on hand to provide them with support and guidance. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 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, 38 & 42 The Organisation and Acting Manager have ensured that, in the absence of a Registered Manager, the Home continues to be efficiently run in the best interests of the Residents. EVIDENCE: The Organisation has made proper and effective provision for the Management of the Home in the absence of a Registered Manager. The recruitment process for a new Manager is underway and it is anticipated that successful recruitment will be achieved in the near future. It was clear from discussions with staff that both the Acting and Deputy Manager are viewed as an integral part of the staff team. Staff spoken with felt that they were easily accessible to them, were willing to discuss any issues, work alongside them, guide them in practice and provide them with support. Both Managers demonstrated that they knew their Residents well and were in daily contact with them and the staff to achieve a good standard of care and enable their Residents to lead fulfilled lives. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 21 Discussions with the Acting and Deputy Manager showed that they were open to advice and had a commitment to developing the service and addressing any shortfalls. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 22 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 3 3 3 X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 X X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sense East (Neale Avenue) Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 X DS0000044413.V253057.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA6YA17 Regulation 12 (1)(a) Requirement Nutritional and pressure risk assessments of Residents must be undertaken to make certain the nutritional and skin care plans are in accordance with their assessed needs. (Outstanding requirement timescale of 10/03/05 & extended timescale of 30/09/05) Clear directions must be obtained for the all prescribed medication. Medication must be administered in accordance with the prescription instructions and a record maintained. Timescale for action 30/01/06 2 YA20 13(2)&17 (1a) 10/01/05 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 2 Refer to Standard YA1 YA6 Good Practice Recommendations The review of the Home’s Statement of Purpose should be finalised and a copy of the updated Statement forwarded to the Commission Consideration should be given to reviewing and reordering DS0000044413.V253057.R01.S.doc Version 5.0 Page 24 Sense East (Neale Avenue) 3 YA22 all care plan information to provide quick and easy access for staff and to ensure all needs are fully reflected. A record of all complaints and compliments should be developed with a review of the record evidenced on a 3 monthly basis. Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Sense East (Neale Avenue) DS0000044413.V253057.R01.S.doc Version 5.0 Page 26 - 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!