Inspection on 23/03/07 for St Luke`s Close (6)

This inspection was carried out on 23rd March 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Luke`s Close (6) 07/12/05

St Luke`s Close (6) 11/02/05

St Luke`s Close (6) 10/08/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 St Luke`s Close (6) Ambury Road Huntingdon Cambridgeshire PE29 1JT Lead Inspector Jacqui Barry Key Unannounced Inspection 23rd March 2007 11:15 St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Luke`s Close (6) Address Ambury Road Huntingdon Cambridgeshire PE29 1JT 01480 456941 F/P 01480 451883 annika.short@cambridgeshire.gov.uk www.cambridgeshire.gov.uk Cambridgeshire County Council 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) Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Only 2 rooms measuring 14.5 square metres to be used for wheelchair dependent service users No service user will be accommodated for more than 6 months at any one time 7th December 2005 Date of last inspection Brief Description of the Service: 6 St. Luke’s Close is a local authority respite care home for up to 6 adults with a learning disabilities. Service users may also have a physical disability. Although the usual pattern of visits is for planned short stays, the home also takes people in an emergency and may accommodate them for up to six months. 6 St. Luke’s Close is a short walk from Huntingdon town centre which has a range of shops and leisure facilities. The home is a single storey bungalow, with a large entrance hall, lounge, dining-room/kitchen, laundry room, six single bedrooms, a large assisted bathroom, a large assisted shower room and two offices. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 27th March 2007, over approximately four hours. Time was spent looking at records, two service user files, talking with staff and the manager. There was also a tour of the building. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. Prospective service user’s needs had been fully assessed prior to admission. Service users must not be accommodated for more an 6 months in accordance with the home’s condition of registration, unless a variation is applied for and approved by the CSCI in advance. EVIDENCE: One pre-admission assessment was seen for a service user who had moved into the home 11 months earlier. The assessment provided a full and comprehensive picture about the service user’s needs and need for support. The home had a condition of registration that service users must not be accommodated for more than 6 months. This had been breached due to a lack of other suitable accommodation being sought for the service user. New accommodation had been identified for the service user, who was due to move on in mid April 2007. The manager was informed of the seriousness of breaching conditions of registration and that further advice would be sought. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users were supported to make decisions, which promoted their independence. EVIDENCE: The service user plans inspected set out how individual requirements would be met on a day-to-day basis. There was good evidence to support that specialist services were accessed where needed and family contact was promoted. One member of staff spoken with described how services users were involved in making decisions about their lives through regular and informal consultation. Service users were also able to choose what to eat and how to spend their time. There were detailed risk assessments recorded to support service users to be as independent as possible. Staff spoken with had a clear understanding of St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 9 their responsibilities to protect service users and support their independence and development. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users were encouraged to follow their own lifestyle with appropriate daily routines and activities to suit their abilities. EVIDENCE: Inspection of records demonstrated that a reasonable range of appropriate activities and opportunities were provided for. As a respite service, the home was less involved in organising day-time activities than a permanent resource. Care was however provided to some service users on a longer-term basis and those user’s needs were well provided for. Good use was made of local amenities including visits to organised clubs, shopping and use of leisure resources. Staff spoken with described the range of activities within the home. Support was evidently being provided for one service user living in the home on a longer-term to maintain family contact. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 11 The daily routines in the home were observed during the inspection and were relaxed. Staff were friendly and caring and demonstrated clear understanding of service user’s needs. Personal care and support was offered discreetly and staff were respectful during their work. One member of staff spoken with described how service users were encouraged to take responsibility over aspects of their lives. Service users were involved in meal preparation in line with their interests and abilities, with support from staff. Menus indicated a varied and well-balanced diet was provided. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service user’s physical and emotional needs were met through support and care planning arrangements and good medication administration practices. EVIDENCE: Individual daily routines and care plans highlighted clear information about how service users preferred to be supported in all areas of their lives. Staff observed during the inspection worked flexibly and sensitively with a service user who had moved into the home in an emergency situation. The home held responsibility for the storage and safe administration of all medication. Records showed that service users attend appointments with health professionals in or away from the home as appropriate. It was also evident that the home was accessing support from other professionals including an occupational therapist. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users were listened to and protected from harm. EVIDENCE: It was positive that learn that service users had felt safe enough to access the home’s complaint’s procedure. There was good written evidence detailing what complaints had been about and of the action taken to address problems. One member of staff spoken with had received training in adult protection and the other knew what to do in the event of an allegation or suspicion of abuse. Guidance on the protection of vulnerable adults was available in the home. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The environment was clean and well-maintained. EVIDENCE: The home was immaculately clean and tidy on the day of the inspection. At the last inspection a statutory requirement was made in respect of a badly stained bedroom carpet. On this occasion, the carpet had been replaced, meeting the statutory requirement. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. The frequency of staff supervision must be improved, as should the information contained on staff recruitment files. EVIDENCE: One member of staff spoken with reported regular supervision from her linemanager. The other member of staff worked on a relief basis, but undertook regular duties. This member of staff had not received adequate formal supervision and this was discussed with the manager. Three staff recruitment files were inspected. One contained all of the relevant checks, although there was no photographic identification on the second file. The third file seen contained no information, although the manager stated that this member of staff had not yet started in post. At the last inspection, a statutory requirement was made in respect of staff recruitment references being checked thoroughly. On this occasion, references seen were found to be satisfactory, meeting the previous requirement. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 16 Both members of staff spoken with had received training to support them to work with service users with learning difficulties. One member of staff had not yet received training in the protection of vulnerable adults, but was confident in describing how she would report concerns. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Systems were in place to ensure the safety and well-being of service users. EVIDENCE: A new manager was appointed in November 2006. The manager had substantial experience of working with adults with learning difficulties and was aware that she needed to apply to the CSCI to become the registered manager. At the previous inspection, a statutory requirement was made in respect of rotas including the surname of all members of staff. Rotas seen detailed staff’s full names, meeting the requirement. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 18 There was a satisfactory system in place to monitor the operation of the home and records connected to health and safety were in good order. St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 20 NO 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 YA1 Regulation 4 Requirement The Registered Person must ensure that conditions to the home’s registration are not breached. The Registered Person must ensure that all of the information detailed in Schedule 2, is provided on all staff recruitment files. The Registered Person must ensure that staff receive adequate supervision. Timescale for action 27/03/07 2 YA34 19, Schedule 2 18 31/05/07 3 YA36 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 St Luke`s Close (6) DS0000032579.V318306.R01.S.doc Version 5.2 Page 22 - 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!