Inspection on 29/06/07 for Ten Acre Respite

This inspection was carried out on 29th June 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ten Acre Respite 26/01/06

Ten Acre Respite 15/09/05

Ten Acre Respite 01/12/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

Whitwood Hall

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

CARE HOME ADULTS 18-65 Ten Acre Respite 89 Ten Acre Road Kimberworth Park Rotherham S61 3RW Lead Inspector Mrs Christine Rolt Key Unannounced Inspection 29th June 2007 09:40 Ten Acre Respite DS0000060441.V320014.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 Ten Acre Respite DS0000060441.V320014.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. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ten Acre Respite Address 89 Ten Acre Road Kimberworth Park Rotherham S61 3RW 01709 375355 01709 740525 NONE londonroad@tiscali.co.uk Milbury Care Services Limited 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) Gillian Mulhearn Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: Ten Acre Respite is a care home providing a respite care service for up to four adults with learning and physical disabilities and nursing needs. Service users who access the service have multiple complex needs. Ten Acre Respite is owned by Milbury Care Services. The home is located in the Kimberworth area of Rotherham, close to public transport and local shops. Ten Acre Respite is a modern single storey building with spacious accommodation. All bedrooms are single with en-suite lavatories. There is level access to the garden areas outside and the home has a small car park. The Statement of Purpose, Service User Guide and latest CSCI inspection report were all displayed in the entrance. Referral to this service is via Rotherham Primary Care Trust who block book the beds for nursing care therefore no fees are involved. The registered manager supplied this information during the site visit. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 09:40 am to 14:55 pm on 29th June 2007. The registered manager provided assistance throughout the day. This is a home for respite care for four people. At the time of this site visit, three people had been resident within the home but one person had already left, one was in the process of leaving and the third person was leaving within the hour. Therefore only one resident was seen. Opportunity was taken to speak to the parents of two residents and a member of staff. Two people were tracked throughout the day to ensure that all their needs were being met. Their care plans were read, a sample of records was examined and an inspection of the building was carried out. The inspector wishes to thank the resident, relatives, the staff and the registered manager for their assistance and co-operation. What the service does well: What has improved since the last inspection? A requirement in the last inspection report regarding secondary dispensing of medication had been dealt with. This was caused because parents were sending in sufficient tablets for the length of residents’ stays at the home. The manager informed parents that they must send in medication in the original packaging and secondary dispensed medication would not be accepted. Parents had complied. The loose handrail had been made safe. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 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 Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents only moved into the home after their needs had been assessed and been assured that the home could meet their needs. EVIDENCE: Files contained full needs assessments and relatives said that they had been fully involved in meetings to discuss residents needs. A member of staff said that she and another member of staff assessed prospective residents in their own environments and involved the prospective resident, their family, health professionals and other professionals to ensure that they gained as much information as possible about the prospective resident’s needs. Care plans showed that assessments were reviewed before each visit to the home to ensure that information about the resident was up to date. Relatives said that there was good communication with the home. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ assessed and changing needs and their methods of communication were reflected in their care plans to ensure that their needs and wishes were met. EVIDENCE: Residents had their own care plans and two of these were checked. These provided detailed information of residents’ individual physical, health, social and emotional needs, risk assessments, likes, dislikes and wishes and how these were being met. Where residents had little or no verbal skills, files contained information of gestures and signs used by residents to ensure that staff were aware of what each gesture meant. Files also contained lists of residents’ likes. Assessments and care plans were reviewed before each visit to ensure that information was up to date. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 10 Each resident also had a keepsake box which contained items that they liked. Staff were observed to treat the resident with respect and dignity and also observed to offer the resident a choice. Relatives said that residents were very happy in the home and enjoyed their visits. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents were able to participate in activities and leisure activities both inside and outside the home. Their rights were respected and choices were offered. EVIDENCE: The home is on a housing estate and many of the residents live locally. Residents who attended day centres during the week could continue to do so if transport was provided. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 12 Routines within the home were flexible. The home had an activity area with a good supply of games and craft materials. The manager said that they also provided baking and painting activities. A member of staff gave examples of activities that she did with residents including counting games, reading to residents, musical games and drawing. The home also had a wide selection of videos and books. The manager said that residents were taken out shopping and to a local pub for lunch and a member of staff confirmed this. Relatives said that they were kept well informed. A member of staff said that if a relative phoned, she held the phone to the resident’s ear so that they could hear their parent’s voice. The home also used daily diaries, which residents took home with them to inform parents of how residents had spent their time in the home, and these were brought into the home on the residents’ next visits to inform staff of any changing needs or points of interest. The manager said that meals were based around residents’ likes and dislikes and two options were always on offer. If a resident indicated that they did not want either of the meals on offer, then staff offered other foods until they found something that the resident wanted. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents received the personal support they preferred and their physical, emotional and heath needs were met. EVIDENCE: Residents received the help and support they needed and there was good information in their care plans of how their physical, emotional, health and social needs and wishes were met. A keyworker system was in place and a named nurse also supported each resident. The manager said that families tended to contact the named nurse to discuss residents’ physical and health needs. The key workers dealt with residents day to day routines and social needs. Both files checked contained detailed information of residents’ health needs. The information was specific to each resident and included a range of monitoring charts and templates to ensure that each resident’s needs were monitored and recorded. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 14 The manager said that because of residents’ profound needs, none of the residents were capable of self-medicating. The previous requirement about secondary dispensing had been addressed after the last inspection. The manager said that she had written to all parents and explained that only medication in original packages from the pharmacy would be accepted. Because medication had gone home with residents on their discharge, there was no medication on site to check against residents’ records. However, files provided good information of medication. This included details of what each resident’s medication was used for, its side effects, precautions of use, its appearance, how to be given and when, the strength and dosage. Some medication had handwritten amendments. The manager was strongly advised to obtain a second signature to verify that the amendments were correct. Medication that required refrigeration was kept in a locked medication refrigerator. An external thermometer displayed the temperature. No record was kept of this. The manager said that she would ensure that this was done. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents were protected from abuse and the home’s complaint procedure ensured that residents and their representatives had the means to complain. EVIDENCE: The complaints procedure and complaints book were displayed in the entrance to the home. The manager said that there had been no complaints and a member of staff confirmed this. The two relatives who were spoken to during the site visit said that they had no concerns, had never needed to complain and considered the home to be good. They were confident that any concerns would be addressed. The manager said all staff attended adult protection training within the first year of employment. Those who had not already attended were waiting to go on this training, which was arranged by the company. There were no adult protection issues with this home. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was clean, comfortable, spacious and safe. EVIDENCE: The home was clean and tidy. There were no offensive odours. Private and communal areas provided sufficient space to accommodate residents in wheelchairs. All four bedrooms had en-suite lavatories. Bedrooms were themed and were individually decorated and furnished. Beds were adjustable. The home had a good range of adaptations to ensure that residents were not put at risk. Residents had a choice of an adapted bath or a walk in shower. There was an enclosed, private garden area that incorporated a patio area with seating. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 17 The manager confirmed that the loose handrail had been repaired and was now safe. There was also a previous requirement for the wiring to be made safe in the sensory room. The manager explained that the sensory room was not practical or suitable for residents’ use. It was a small room and did not allow manoeuvrability of the hoist. This room was now used for the storage of residents’ files. The laundry room was clean and tidy and the washing machine had a sluicing facility. Relatives said that the environment was good, “No steps, so a good environment”. They considered that the home was clean and that clothing was laundered to a satisfactory standard. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recruitment procedures, staff training and staff skills ensured that residents were supported and protected by competent and qualified staff. EVIDENCE: There was a registered nurse and a support worker on duty during this site visit. The registered manager was informed of the inspection and chose to attend and provided assistance. The support worker said that she enjoyed her job and was clear of what her duties were. She said that she received a great deal of support, had monthly supervision sessions and that staff were encouraged to share their ideas for improvements, which were implemented if considered viable. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 19 Training needs were met, she said that she had undertaken induction training to a recognised standard when she commenced and her training file showed that within the previous 12 months she had undertaken skills training for a variety of subjects that helped her with her job. These included communication skills, epilepsy training, diabetes, eating and drinking awareness, and courses specifically for working with people with learning disabilities. She was able to give examples of how this training helped her in her work. In addition to this she had also undertaken all the mandatory health and safety training. She was currently waiting to start NVQ Level 2 in care. Two staff recruitment files were checked. All documentation was in place with the exception of full copies of Criminal Records Bureau disclosures. Only the top half of the form was available, therefore POVA and Offences could not be checked. The manager said that this was how she received the information from head office and that if there were offences then these would be risk assessed by head office. The need for the full document to be available for inspection was discussed with the manager. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home’s quality monitoring ensured that systems were in place, views were sought and staff were trained to provide a well run home that promoted and protected residents. EVIDENCE: The registered manager was a registered learning disabilities nurse and had also attained the Registered Managers Award. Audits of the environment and systems within the home were carried out monthly and reports of monthly visits by the registered provider were available. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 21 The manager said that the home held regular coffee mornings for residents and their families. A member of staff said that there was good communication with residents’ families and relatives confirmed this. In addition to this an annual questionnaire was sent to relatives, social workers, physiotherapists, day centre staff, speech therapists and the epilepsy liaison service to seek their views of the service provided. Certificates for the maintenance and servicing of systems and equipment within the home were up to date with the exception of the Fire Detection and Alarm System Periodic Testing Certificate dated 7th April 2004. The manager said that the system had been tested and serviced in December 2006 but the certificate was at the head office. The need for the certificate to be available for checking on site was discussed with the manager. Fire checks and Emergency lighting were checked weekly and fire drills took place every two months and residents were included. Staff had fire awareness lectures annually and these were supplemented by video instructions every three months. Staff training was ongoing. Staff received all mandatory health and safety training and skills training to ensure that residents’ health and welfare needs were met. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 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 4 33 X 34 2 35 3 36 X 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 4 X 3 X X 2 X Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 YA34 Regulation 19 Requirement Timescale for action 26/08/07 2. YA42 23 Full information on Criminal Record Bureau disclosures must be available for checking during CSCI inspections Certificates to verify that 26/08/07 equipment and systems have been serviced within the required timescales must be available within the home i.e. Fire Detection and Alarm System Periodic Testing Certificate 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 YA20 YA20 Good Practice Recommendations It is strongly recommended that countersignatures be obtained when handwritten amendments are made to medication. The temperature of the medication refrigerator should be monitored and recorded daily. Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Ten Acre Respite DS0000060441.V320014.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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