Inspection on 28/10/05 for Tennyson Road, 104

This inspection was carried out on 28th October 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tennyson Road, 104 19/11/08

Tennyson Road, 104 28/12/07

Tennyson Road, 104 20/04/07

Tennyson Road, 104 27/11/06

Tennyson Road, 104 17/06/05

Tennyson Road, 104 12/03/05

Tennyson Road, 104 14/09/04

Tennyson Road, 104 06/03/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Tennyson Road, 104 Luton LU1 3RP Lead Inspector Georgia Chimbani Unannounced Inspection 28th October 2005 10:00 Tennyson Road, 104 DS0000014977.V263088.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 Tennyson Road, 104 DS0000014977.V263088.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. Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tennyson Road, 104 Address Luton LU1 3RP 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 418858 Mr Geoffrey Plane Miss Deborah Newman Mr Gerard Kempson Care Home 8 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (8) of places Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17 June 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. Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Present at this unannounced inspection was a member of staff Ms Bernadette Hwata. The deputy manager Ms Jane Bebbington arrived in the home after the inspection had commenced. The inspector was informed that the manager was off sick. The inspection was 3 hours and 30 minutes in duration. As part of the inspection process the inspector interviewed 4 service users. Feedback indicated that although generally they were happy with the care provided at the home there were some areas of concern. These have been addressed in this report. 7 requirements were made at the last inspection. 2 requirements were met, 5 were not met however at they time of the inspection they were within the timescales set at the previous inspection. The inspection was carried out three days before the timescales expired however based on evidence available it is the inspector’s opinion that compliance is unlikely to be achieved by 31/10/05. remain outstanding are restated. Requirements still within the timescales relate to service user contracts, replacement of carpets and repair of curtains, staff files and fire risk assessments. The registered persons are urged to give priority to outstanding requirements to avoid the possibility of enforcement action by the CSCI. A further 9 requirements are made following this inspection bringing the total number of requirements following this inspection to 13. What the service does well: What has improved since the last inspection? Work has been carried out to the front of the house to make it more presentable. Carpets have been replaced in some but not all service user rooms. The adult protection procedure has been reviewed to include clear procedures on reporting abuse. Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 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. Tennyson Road, 104 DS0000014977.V263088.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 Tennyson Road, 104 DS0000014977.V263088.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): A variation application must be submitted for a named service user to ensure that their needs can be met by the home. The home must have written confirmation that service users are aware of their contractual responsibilities. EVIDENCE: The home is registered for service users between the ages of 18 and 65 however one service user was noted to be over the age of 65. The manager advised that this service user has been living at the home for over 20 years. The registered persons must submit a variation application to the CSCI for a service user over the age of 65. At the previous inspection a requirement was made for service user contracts to be signed and dated. The inspector examined two contracts. One had not been signed by either the service user or a representative of the home. The second contract had been signed and dated by the service user but not by a representative of the home. This requirement is restated for the third time. The registered persons are required to ensure compliance with this requirement to avoid the possibility of enforcement action. Tennyson Road, 104 DS0000014977.V263088.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): EVIDENCE: Standards 6, 7 and 9 are key standards that must be inspected at least once during a 12-month period. These standards were assessed and met at the last inspection and have therefore not been assessed at this inspection. Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, 16 and 17 The home is run in a way that encourages service users to independent and to take responsibility for their every day lives. The home must ensure there are sufficient quantities of food stocks to meet the dietary needs of service users. EVIDENCE: A discussion with the deputy manager revealed that service users are not interested in education or employment. One service user started computer classes but lost interest and stopped attending. Some service users attend daycentres. A service user with low motivation has regular sessions with the key worker to try and find activities that will improve their motivation to take part in social activities. Service users lead an independent life at the home. This was confirmed during the inspection as the inspector observed service users waking up at times that suited them and eating a breakfast of their choice at a time that suited them. Service users hold a key to their bedroom and the front door. They are also responsible for their own laundry with assistance offered by staff if required. The inspector noted that service users are encouraged help with duties such as laying the table, emptying ashtrays or Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 11 unloading the dishwasher. A rota of when individual service users were expected to carry out these duties was seen. Interviews with service users confirmed that they are able to maintain links with their friends and family. One service user told the inspector that they occasionally go out for a drink with their sister. Another service user was observed receiving a visit from their family. The home stores fresh and frozen food in a cabin in the garden. An inspection of the fridge and freezer revealed that there were sufficient quantities of food. Interviews with some service users revealed mixed feelings about the food provided by the home. Two service users described the food as “alright” while another said the food was sometime not cooked properly. Another service user said breakfast was usually bread and butter with jam and cereal however the milk was often delivered late therefore it was not always possible to have cereal for breakfast. The inspector has observed on arrival at the home at 10am that several bottles of milk and two loaves of bread had been delivered and were placed outside the front door. The registered persons must ensure that arrangements are made to ensure that there are sufficient supplies of food in the home to meet the needs of service users at all times. Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 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 the following standard(s): 18 Service users are satisfied with the level personal support offered by staff. EVIDENCE: The manager informed the inspector that all service users living at the home were able to manage their personal care with no assistance from staff however sometimes staff had to prompt some service users to take a bath or change their clothes. This was confirmed through discussions with some service users. Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 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 the following standard(s): 22 and 23 Incomplete complaints records cast doubt on the home’s ability to effectively deal with complaints within the correct timescales. The revised adult protection policy ensures that staff are aware of the procedures to be followed to safeguard service users. EVIDENCE: The home’s complaints record was seen and it showed that 5 complaints have been received in the last 12 months. Most complaints were by neighbours regarding the level of noise at the home. The complaints records did not indicate the action taken to resolve the complaint and the date. This is required. At the previous inspection a requirement was made for the adult protection policy to include procedures on the action to be taken and by whom in the event of an allegation of abuse being made. The inspector was shown the revised adult protection policy and confirmed that this requirement was met. Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 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 the following standard(s): 24 and 30 The home does not currently provide a consistently clean, safe and comfortable living environment for all service users. EVIDENCE: At the previous inspection three requirements were made relating to maintenance of the home. The requirement relating to the up keep of the front garden was met however requirements relating to the replacement of bedroom carpets and securing of curtains were still outstanding. The manager informed the inspector that carpets had been replaced in three service user rooms but work in other bedrooms was still outstanding. Curtains were still not secured in a service user’s room and another bedroom had no curtains at all. The carpet in the lounge, hallways and some service user rooms were very dirty and need to be cleaned or replaced. The standard of hygiene in the home was unacceptable. The curtains in a service user’s room were stained with cigarette smoke and need to be cleaned or replaced. The flooring for the toilet on the ground floor requires replacement as the sealing has worn away and poses a risk to infection control. The foot-stool in the lounge requires cleaning. The small fridge in the kitchen used for storing milk and food purchased by service users had food stains and spillages and was required cleaning. The taps in a service user’s room on the top floor were caked with lime scale. This needs to Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 15 be removed. The registered persons must ensure the areas detailed above are addressed. Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 16 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): 32, 34 and 35 The home has clearly invested in staff training however the level of staff competencies and skills must be maintained through up to date training. Recruitment practices in the home have improved but there must be consistent checks for all staff to protect service users. EVIDENCE: Training certificates for staff were displayed on the wall at the entrance to the home. Documentation displayed indicated that staff had received a variety of training over the last couple of years, however some training needed to be updated. For example documentation seen indicated that a member of staff had last received training in food hygiene and manual handling in 2001 and 2002 respectively. The manager informed the inspector that two members of staff were due to attend training in food hygiene the following week. Training and development plans for staff were not available. The registered persons must ensure that a training and development plan is available for all staff working in the home. All staff must have up to date training in the core areas of food hygiene, moving and handling, first aid, infection control, fire safety and adult protection. At the previous inspection a requirement was made for information detailed under schedule one of the Care Homes Regulations 2001 to be obtained prior to the employment of staff. Two staff files were examined. Both files contained documentation such as Criminal Records Bureau checks, recent photographs Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 17 and evidence of eligibility to work. One file did not contain proof of identity and another did not contain a statement as to their physical and mental fitness. Both files contained two references however where staff had previously worked in a position involving work with vulnerable children or adults, no written confirmation was available regarding their reason for leaving this job. The registered persons must ensure that proof of identity and a statement as to their physical and mental fitness is available for all staff working in the home. Where staff have previously worked in a position involving work with vulnerable children or adults written confirmation must be available as to their reason for leaving. Tennyson Road, 104 DS0000014977.V263088.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): 37, 39 and 42 The home is well run but a quality assurance system must be implemented to ensure that the views of service users and stakeholders are sought and acted upon. Risk assessments must be carried out to ensure that service user’s rights to smoke do not compromise their safety. EVIDENCE: The registered manager was off sick during the time of the inspection however the deputy manager who was covering for the manager was available. The deputy manager has worked at the home approximately 3 to 4 years and during discussions with the inspector showed knowledge of the service and the needs of service users. The deputy manager’s name was also included on the staff rota and this ensured that both staff and service users were aware of the times when the manager was available. There was no evidence that a quality assurance exercise had been carried out in the home recently. A discussion with the deputy manager revealed that that was being dealt with by the manager however in their absence they were unsure as to what progress had Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 19 been made in this area. The registered persons must ensure that a quality assurance system is implemented. This must seek the views of service users, their relatives and other professionals. A report of the findings and any recommendations must be compiled and made available to the CSCI. At the previous inspection a requirement was made for the home to undertake a risk assessment relating to smoking in bedrooms to reduce the risk of fire. The deputy manager showed the inspector a risk assessment format that had been formulated for this purpose however it was still to be implemented. The deputy manger told the inspector that while some service users were smoking in the designated smoking areas, some were disregarding the new rules. The registered persons must ensure that this risk assessment is carried out. This requirement is restated. Tennyson Road, 104 DS0000014977.V263088.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 X 2 X 1 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 1 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 2 x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tennyson Road, 104 Score 3 X X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000014977.V263088.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA3 Timescale for action 12(1), 14 The registered persons must 28/01/06 submit a variation application to the CSCI for a service user over the age of 65. 5 Service user contracts must 31/10/05 be signed and dated by the service user and a representative of the home. [Previous timescale of 20/4/05 not met] This requirement remains within the timescales set at the previous inspection. 16(2)(i) The registered persons must 30/11/05 ensure that arrangements are made to ensure that there are sufficient supplies of food in the home to meet the needs of service users at all times. 22 The registered persons must 28/01/06 ensure that the record of complaints clearly states the action taken to resolve a complaint, by whom and the date. 16(2)(c)23(2)(d) The registered persons must 31/10/05 ensure that curtains are DS0000014977.V263088.R01.S.doc Version 5.0 Page 22 Regulation Requirement 2 YA5 3 YA17 4 YA22 5 YA24 Tennyson Road, 104 6 YA24 23(2)(d) 7 YA24 23(2)(d) 8 YA30 23(2)(d) 9 YA32 18(1)(c)(i) 10 YA35 17(2) Sch4 para 6(f) provided in a named service user’s room. Curtains throughout the home must be secured so that they do not hang off the curtain poles. This requirement remains within the timescales set at the previous inspection. The registered persons must ensure that the carpet in the lounge and hallways are cleaned or replaced. The registered persons must ensure that bedroom carpets with heavy stains and burns are replaced. This requirement remains within the timscales set at the previous inspection. The registered persons must ensure that the home is kept clean and hygienic. Particular attention must be paid to replacement of the flooring in the ground floor toilet and removal of lime scale on the taps in a service user’s room as well as cleaning of a service user’s curtains, the footstool in the lounge and the fridge in the kitchen. The registered persons must ensure that All staff must have up to date training in the core areas of food hygiene, moving and handling, first aid, infection control, fire safety and adult protection. The registered persons must ensure that a training and development plan is available for all staff working in the home. 28/01/05 15/12/05 28/12/05 28/01/06 28/01/06 Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 23 11 YA34 19 Sch 2 12 YA39 24 13 YA42 12(1)13(4)23(4) The registered persons must 31/10/05 ensure that proof of identity and a statement as to their physical and mental fitness is available for all staff working in the home. Where staff have previously worked in a position involving work with vulnerable children or adults written confirmation must be available as to their reason for leaving. [Previous timescale of 31/10/05 not met] This requirement remains within the timscales set at the previous inspection. The registered persons must 28/01/05 ensure that a quality assurance system is implemented. This must seek the views of service users, their relatives and other professionals. A report of the findings and any recommendations must be compiled and made available to the CSCI. The home must undertake a 31/10/05 risk assessment relating to the smoking in residents bedrooms and reduce the risk of fire in the home. This requirement remains within the timscales set at the previous inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 24 No. Refer to Standard Good Practice Recommendations Tennyson Road, 104 DS0000014977.V263088.R01.S.doc Version 5.0 Page 25 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. 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