This inspection was carried out on 17th June 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
104 Tennyson Road 104 Tennyson Road Luton Bedfordshire LU1 3RP Lead Inspector
Katrina Derbyshire Unannounced 17th June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service 104 Tennyson Road Address Luton Bedfordshire LU1 3RP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01582 418858 Mr Geoffrey Plane Mr Gerard Kempson Miss Deborah Newman CRH Care Home 8 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (8) of places 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th March 2005 Brief Description of the Service: 104 Tennyson Road is a care home which is registered for a maximum of eight adults with mental health needs. The accommodation consists of a three storey house with eight single bedrooms. The office is on the ground floor. It also has sleeping in facilities for staff (including ensuite facilities). The lounge, dining room and the kitchen are also located on the ground floor. The laundry room is located at the back of the house and accessed via the kitchen. There is a small parking space at the front and a garden at the back. The rear garden is secluded and has some shrubs, trees, flowerbeds and a small patio area with a barbeque. The home is situated approximately one kilometre from the shopping centre of Luton. A bus stop is located within walking distance of the home. There is a regular bus service to the town centre.
104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 17th June 2005. The manager Mr. Kempson was present during most of the inspection. During the inspection many of the areas within the home were visited and the inspector spent time with many of the residents’ in the lounge area of the home and garden. The care of three residents’ was examined in depth by looking at their records and interviewing the residents’ and staff who look after them. Observations of care practice and communication between the residents’ was also made at the inspection. What the service does well: What has improved since the last inspection?
The way the home writes their care plans has changed. There is now more information in them. The information is clear and makes sure that the residents’ receive the support that they need. The home has also worked with residents’ to look at the risks they may face on a day-to-day basis, for example leaving the home on their own. They have explained how the residents’ can remain as safe as possible, without taking away any of their rights as individuals. More training for the staff at the home has also taken place since the last inspection. Staff had recently attended training on how to protect vulnerable people and how they would know if any abuse of residents’ happened, and how they would report this so something could be done. 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 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. 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 5. The pre admission information available to residents’ is sufficient for them to make an informed decision about whether to move into the home. EVIDENCE: The statement of purpose had changed since the last inspection and now included the required information; this was supported by the homes admission procedure, which gave clear guidance to the staff. However although all the information that should be in the service user guide was available in the home, for example the most recent inspection report, complaints procedure and residents’ views of the home this was not kept together as a guide for the residents’ and the home needs to change this. Assessments had now been undertaken on all residents’. Each individual care file seen contained a document. This document had recently been completed and had assessed the physical, social, emotional and psychological needs of the residents. Contracts to outline the rights and responsibilities of residents were also in place and explained for example the notice period needed if a resident was to move out of the home. However residents or their representatives must sign these contracts to evidence that they are in agreement with their terms of residency and then dated.
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The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 & 9 Progress has been made on improving the care planning processes in the home to ensure the needs of residents are identified and met. These changes have improved the standards of care received by the residents. EVIDENCE: Individual plans are available for residents and the changes made since the last inspection have resulted in the health, personal and social care needs being planned for. Discussion with staff confirmed that residents are involved in their care planning and residents also spoke of their involvement. The way in which the home approached risk taking for the residents had also changed. The risks that residents wished to take in their lives were supported by the staff team. Several residents spoke of going out on their own and how important this was for them. Plans were in place to support and encourage residents in their individual pursuits and if restrictions were in place the reason and consultation with the resident was documented. Decision-making is managed informally due to the small number of residents living at the home. Residents and staff spoke of meeting together to discuss social activities for example.
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The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 & 17 Information about the local community available to residents is sufficient for them to make personal decisions on how they each integrate with the local community. Meals are nutritious and balanced and offer a varied diet for residents. EVIDENCE: All residents through discussion spoke of their knowledge in relation to the local pubs, shops, cinema and churches. Care records and residents supported the fact that all local facilities were used by the residents if they wanted to, for example one resident liked to attend church several times a week and this was supported by the homes staff team. Several residents’ used local transport, which they were knowledgeable of and the times and types of transport available to them. Meals and snacks are available throughout the day. Residents have access to a fridge, which contains a variety of drinks and there are tea and coffee making
104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 11 facilities in the dining area of the home. The menu kept in the home was observed to be followed by the home and residents’ spoke of their opportunity to assist with meal preparation and selection on occasions. A good amount of stock was in place and one resident said “ the food is very nice, l always like it”. 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 The way in which the medication at the home is managed is satisfactory in promoting good health. EVIDENCE: Within the individual care records of the residents was documentation from a variety of health care professionals to show the type and frequency of heath services accessed by the resident. Residents spoke of meetings that they attended where a family member and/or social worker could join them. Decisions about the support they received would be discussed and the home would arrange appointments for them if they needed to see other professionals. The management of the home spoke of the procedures in place to ensure that residents could always receive care from outside agencies and that staff would support each resident in attending appointments. Medication is stored in a locked cabinet, as there are currently no controlled medication within the home the current storage facilities are satisfactory. Medication charts are kept for each resident and staff sign each time a medication is administered. Staff confirmed that they had received training in the administration of medication and it was observed that safe and appropriate practice was followed during a medication round at teatime. 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23. Adult protection training has improved since the last inspection however the internal guidance at the home is not sufficient to ensure the residents are being protected at all times. EVIDENCE: Since the last inspection staff have attended training in protecting vulnerable adults. Certificates of attendance were kept in the home and staff confirmed that they had received this training. The homes policy did detail the types of abuse and how staff could possibly recognise the abuse of a vulnerable adult. However the reporting procedures in the event of any suspicion or allegation of abuse was not clear and did not reflect the local guidance on how an allegation or suspicion of abuse should be managed. A requirement has been made in relation to this area so that both management and staff know how and when to report abuse and their role in any subsequent investigation. 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 28. The general maintenance of the environment and furnishings in some areas of the home is not of a good standard, although this does not place the residents at risk it does not create a pleasing and pleasant environment to live in. EVIDENCE: The front entrance to the home needed to be weeded and tidied. The carpet in the main lounge was being cleaned, but other areas in the home had stained carpets and burns caused by discarded cigarettes. Staff confirmed that new curtain poles had been fitted in residents’ bedrooms, however the majority of curtains were hanging off and the poles were bending with the weight of the curtains. The dining area of the home was clean and had recently been decorated, the furnishings in this area were of a good standard, and many of the residents were seen to use this area and the tea and coffee making facilities that it provided. The rear garden was tidy and garden furniture was in place for the use of residents, the residents use this area regularly and many spoke of their enjoyment of the outside area. 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 34. The procedures for the recruitment of staff are not robust and do not offer protection to the people living in the home. EVIDENCE: Staff files of those team members recently appointed to the home did not contain all the required information needed to evidence that the home had undertaken all the necessary recruitment checks to ensure the protection of residents. Criminal Records Bureau checks had not been received prior to the appointment of one member of staff and another member of staff had commenced at the home prior to the receipt of a second reference. The number of staff on duty had increased since the previous inspection and two staff were now on duty until 20.00, staff confirmed that this increase had recently been introduced. Residents conversed with the staff in an easy manner and appeared relaxed in their company. One resident said of the staff “ they are always very kind, they help me and they know what they are doing”. Staff spoke of regular staff meetings and notes from these meetings are kept, the care of residents and the general day to day running of the home is discussed at these meetings so that all staff share the same goals.
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The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 & 42. The manager is clear in his vision for the home, which he has communicated to the residents and staff. EVIDENCE: The manager has been employed at the home for several years and spoke of his plans for improving the care to residents and how he plans to achieve this. Staff confirmed that through staff meetings improvements and changes in practice had been discussed and that they were then given the opportunity to put their ideas forward for improvement. One staff member stated “ there has been a recent improvement, we are working well as a staff team and this is making it better for the resident’s”. Many of the resident’s spoke of how “approachable” the manager was and that they found him “ very easy to talk to”. Residents are able to smoke in their bedrooms and this has always been the case at the home. However a risk assessment needs to be undertaken in
104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 17 relation to this. Several of the bedroom carpets had extensive burns in the carpets and bedding due to discarded or dropped cigarettes. During the night there is only one member of staff on duty who ‘sleeps in’, this is a high risk to everyone in the home and action will need to be taken by the home to reduce any risk to everyone in the home. 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 18 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 x x 2 Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x x 3 x x Standard No 11 12 13 14 15 16 17 x x 3 x x x 3 Standard No 31 32 33 34 35 36 Score x x 3 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
104 Tennyson Road Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 1 x I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 19 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 YA5 Regulation 5,17 Requirement Timescale for action 31/10/05. 2. YA23 3. YA24 Residents contracts must be signed and dated. (Previous requirement timescale of 20/04/05 not met.) 12(1),13 The homes protection of 31/10/05. (6) vulnerable adults policy must include how and to whom the reporting of alleged abuse should be made. (Previous requirement timescale of 20/04/05 not met.) 12(1)(a),2 The front of the home must be 31/10/05. 3(1)(a),23 weeded and made presentable to (2)(b&c). create a homely enviornment. 12(1)(a),2 3(1)(a),23 (2)(b&c). 12(1)(a),2 3(1)(a),23 (2)(b&c). 19 Curtains must be secured so that they do not hang off the curtain poles. The replacement of bedroom carpets must occur for thoes with heavy stains and burns. Two references and all other information as stated in schedule 2 must be obtained prior to the employment of staff. (Previous requirement timescale of 19/04/05 not met.) The home must undertake a risk assessment relating to the smoking in residents bedrooms and reduce the risk of fire in the home. 31/10/05. 15/12/05. 31/10/05. 4. 5. 6. YA24 YA24 YA34 7. YA42 12(1),13( 4),23(4). 31/10/05. 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 20 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 YA1 Good Practice Recommendations All matters listed within schedule one should be kept together so that the statement of purpose and service user guide are easily accessible. 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Clifton House 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 104 Tennyson Road I51 S14977 104 Tennyson Rd V213116 170605 Stage 4.doc Version 1.30 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!
