Inspection on 29/09/05 for Strangers Way, 72 to 74

This inspection was carried out on 29th September 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Strangers Way, 72 to 74 15/03/07

Strangers Way, 72 to 74 23/02/06

Strangers Way, 72 to 74 24/01/05

Strangers Way, 72 to 74 20/09/04

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 Strangers Way, 72/74 Luton LU4 9ND Lead Inspector Mrs Linda Lilley Unannounced Inspection 29th September 2005 14:00 Strangers Way, 72/74 DS0000014974.V254068.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 Strangers Way, 72/74 DS0000014974.V254068.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. Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Strangers Way, 72/74 Address Luton LU4 9ND 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) 01582 505013 Aldwyck Housing Association Post Vacant Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2005 Brief Description of the Service: 72-74 Strangers Way provides accommodation to six people with learning or physical disabilities. It is situated on the corner of a main road in the Leagrave area of Luton. The home was created from two semi-detached three-bedroom houses. These were converted to provide two separate units (no 72 and 74): one with four bedrooms plus normal communal facilities and the other with two bedrooms, bathroom, kitchen and lounge. The units can only be accessed from the outside. The smaller unit (no 74) is intended for two service users who are able to live more independently and require a smaller staff input. The staff on duty work across both units. Night staff are based in no 72. There is off-road parking for three vehicles and the garden at the back of the house provides an attractive leisure space for all six service users. There is a good bus service along the main road and the railway station is about a mile from the home. Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place in the afternoon and evening of September 29th 2005. This visit followed a three hour period of review and preparation that included reviewing previous reports, reviewing information from other stakeholders, and documentation received in support of the process and preparing an inspection plan. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting two Service Users and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. Six Service Users, six members of staff and one visitor were spoken to during the inspection visit. A partial tour of the premises was also completed and a review of the documentation and records required to be kept in a care home was also undertaken. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. What the service does well: There is an open and happy atmosphere in the home, with staff interacting with Service Users in an appropriate and caring way that encouraged and respected their independence. There is a very good clear and consistent care planning system being implemented that provides staff with the information they need to satisfactorily meet the needs of the Service Users. There is a robust system in place to ensure the safe management and administration of medicines for the Service Users. Strangers Way, 72/74 DS0000014974.V254068.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. Strangers Way, 72/74 DS0000014974.V254068.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 Strangers Way, 72/74 DS0000014974.V254068.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): 2. 5. Individual Service users needs are assessed to ensure the home has the capacity to meet these. The Service Users contract is incomplete and may result in confusion regarding the terms and conditions of the contract for the Service User. EVIDENCE: The Service Users files seen contained appropriate information including, social and family history and determination of the Service Users personal lifestyle preferences and wishes regarding the care to be provided. Evidence was seen of risk assessment being incorporated into the Service Users assessment and of these being discussed with the Service User. The Service Users contracts seen did not specify the room to be occupied by the Service User, nor did they did not contain a date (in the space for the date on the first page), indicating when the contract had begun. Strangers Way, 72/74 DS0000014974.V254068.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): 6.7.8.9.10. There is a very good clear and consistent new care planning system in place that provides staff with the information they need to satisfactorily meet the needs of the Service Users. The Service Users are involved in the decisions made about their care and are supported to take appropriate risks, thus increasing their independence. The staff has a good understanding of the issue of confidentiality, this provides assurance to Service Users and their families The system for Service User consultation is informal and irregular, therefore they do not always perceive they have an opportunity to effect how the home is run. EVIDENCE: Within the two care plans reviewed, there was comprehensive and detailed information relating to all aspects of care. Particular difficulties were highlighted and there was good guidance for staff on specific intervention, for example how to recognize triggers of aggressions and how to diffuse potential arising behaviours. Care plans are signed by Service Users and they contained pictures to enhance understanding as well as being written in the first person to encourage ownership by the Service User. Risk assessments are undertaken and the outcomes contain clear guidance for Service Users and staff related to each element of the plan of care. Staff spoken to could discuss why confidentiality is important, and that this was covered in the in house Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 10 training. A policy relating to Confidentiality was seen. There are no records of any regular formal meetings with Service Users, and Service Users spoken to were unsure of whether these meetings took place. Strangers Way, 72/74 DS0000014974.V254068.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): 11.12.13.14.15.16.17. Social activities, leisure activities, educational opportunities and the daily routine within the home are managed well and provide a variety of opportunities for Service Users to maintain appropriate and fulfilling lifestyles. Dietary needs of the Service Users are well catered for with a balanced and varied selection of foods available that meets the Service Users tastes and choices. Service Users rights and responsibilities in terms of having the option having their own room/front door keys had not been investigated. This may reduce individual choices and responsibilities regarding privacy. EVIDENCE: Five Service Users were spoken to commented on the activities they take part in, this included, attending day centres, shopping, attending cookery class, attending drama classes, going bowling and attending church events. Discussion with the Manager indicated that finding appropriate activities for Service Users to help with their personal development was a priority in the home. Telephone conversations with external organisations providing classes were observed. Individual Service Users rooms contained their personal leisure items such as music centres and television. During the afternoon of the inspection some Service Users returned from a lunchtime outing to a restaurant. Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 12 Service Users were seen to be involved in setting the table, helping with preparing/serving the evening meal and assisting with the washing up. Service Users spoken to indicated they planned the menu using pictures in cookery books for help. The weekly menu seen and the meal being prepared during the inspection were nutritious and well balanced. The staff in the home indicated they did try to educate and encourage Service Users with healthy eating choices. There are many photographs in the home of Service Users on holidays or taking part in a variety of activities. Family members and friends are welcomed into the home, one visitor was spoken to and he indicated he was always welcome and was a regular visitor. There are photographs of family members taking part in the activities in the home. Currently Service Uses have not been offered a key or locking device to their bedroom and no risk assessments have been completed with regard to this. Strangers Way, 72/74 DS0000014974.V254068.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): 19.20. The health needs of the Service Users are well met, enabling Service Users health to be monitored and prompt referral to appropriate services to be made. The systems for administration of medicines are good with clear and comprehensive arrangements in place to ensure Service Users medication needs are met. EVIDENCE: Within the two Service Users documentation reviewed there was evidence of good assessment of the Service Users needs, with prompt referral to a specialist if required. For example one Service User required medical advice and intervention for a stomach complaint. Care plans contained records of support provided for Service Users to access visits to a range of healthcare professionals. The staff could describe the procedures and policies in place to ensure effective record keeping with regard to effective administration of medicines. Medicine Administration Records seen were accurate and up to date. The recent introduction of typed administration sheets, by the pharmacist, is an example of good practice. The Service Users medicine profile is clearly highlighted within the individual plan and their General Practitioners name is also noted on their Medicine Administration Record. Staff spoken to said they had recently undertaken an in-house training day on the administration of medicines and an update on the medicines used in the treatment of epilepsy. Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22.23. The system for Service User consultation is informal and irregular, therefore they do not always perceive they have an opportunity to effect how the home is run. Staff and Service Users had good knowledge of the complaints procedure and adult protection issues. Their knowledge and understanding of these helps protect Service Users from abuse. EVIDENCE: There were appropriate policies and procedures relating to the protection of vulnerable adult and how to deal with complaints, in place and the staff confirmed that these were covered through the in- house induction training. The complaints process was displayed on the wall in a variety of places in the home and contained pictures to enhance Service User understanding. Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24.27 30. The standard of décor in the home is generally clean and comfortable, although a little worn in places. This provides a homely environment. There is evidence of ongoing maintenance and future planning for further decoration and improvements to meet the individual needs of the Service Users. Overall the home provides a safe environment, however the windows in two of the upstairs bedrooms open fully and could place the Service User at risk of harm. The Service Users in number 72 do not have a bathroom that meets their individual needs. EVIDENCE: Tour of the communal areas in the premises highlighted they are safe, comfortable, and clean. Visits to Service Users room highlighted the large windows in two of the upstairs bedrooms opened fully, one of which opened onto a roof. There where no window restrictors in place and no risk assessments completed that demonstrated they are not required. This was highlighted in the previous inspection. Service Users rooms contained many personal items and an appropriate range of furnishings. Discussion with the Manager indicated liaison with external agencies had resulted in range of possibilities being considered to improve the environment for the needs of Service Users arising from sensory disability, physical disability, and increasing frailty due to age. Service Users living in number 72 said they go to number 74 if they would like a shower, as their bathroom does not have this facility. Staff Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 16 confirmed this. There are however on going plans to convert the bathroom in number 72 to incorporate a shower. A recent flood in 72 had resulted in slight damage to the kitchen ceiling; this was due for repair within 7 days. Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 17 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 Staff roles and responsibilities in relation to the shift leader role, are not clearly written or available within the home. This could result in staff being unsure of their responsibilities and confusion for the Service Users. EVIDENCE: The Manger indicated the home nominates a shift leader and a key holder, (sometimes this is one in the same person, sometimes it is not). There is no indication on the rota as to who is taking these roles on a daily or shift basis and there are no written guidelines outlining the roles and responsibilities of the nominated individual within these roles. This was a requirement from the previous inspection. Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 18 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): 38 39 42 Since the last inspection the appointment of a new Manager and Deputy Manager has resulted in a clearer leadership and management approaches in the home. Service Users views are obtained in relation to decisions affecting their own lives but they are no regular meetings to enable Service Users to affect the way in which the home is run. The Health and Safety of the Service Users and staff was generally well protected, with the exception of the possible need for a risk assessment regarding window restrictors in the upstairs bedrooms. EVIDENCE: Staff spoken to confirmed that that the manager’s style was open, positive and inclusive. This was observed as staff readily approached the Manager for advice and the discussions that took place between the Manager and Deputy highlighted the process of running the home are open and transparent There was no evidence of Service Users meetings, however Service Users were involved in decisions relating to their individual lives There was a comprehensive Mencap policy and procedures relating to health and safety. There were good systems in place to ensure safety, including ongoing monitoring and there was training and updating training relating to Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 19 health and safety. A review of the documentation completed and talking to Service Users and Staff indicated a recent flood resulting in the fire alarm being activated and Service Users being evacuated had been handled appropriately. Record of the required maintenance checks on the electrical systems on the home have been carried out, There were no window restrictors on first floor windows and no risk assessments relating to the lack of window restrictors. Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 20 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 x 3 x x 2 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 2 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 x x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score 2 x x x x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Strangers Way, 72/74 Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 2 x x 2 x DS0000014974.V254068.R01.S.doc Version 5.0 Page 21 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 YA31 Regulation 18 Requirement Timescale for action 15/11/05 2 YA42YA24 13 3 YA8 12 4 YA16 4 The Registered Manager must ensure that there is always an identified named shift leader on duty and written guidance on the shift leaders responsibilities. This will ensure they are identified and fully aware of their responsibilities. The Registered Manager must 15/11/05 ensure that window restrictors are in place on the first floor bedroom windows unless it can be demonstrated through a risk assessment that they are not required. The Registered Manager must 30/12/05 introduce a robust system for Service User consultation, to ensure they have an opportunity to effect how the home is run. . The Registered Manager must 30/12/05 ensure Service Users have been offered a key or locking device, (that can be overridden) to their bedroom unless it can be demonstrated through a risk assessment that this is not appropriate. Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 22 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 YA5 Good Practice Recommendations The Service Users contracts should specify the room to be occupied by the Service User, and contain a date indicating when the contract had begun. This will prevent any confusion for the Service User. The Service Users in house number 72 should have a bathroom that meets their individual needs, and should not have to go to house number 74 to use the shower. 2 YA27 Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Strangers Way, 72/74 DS0000014974.V254068.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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