Inspection on 06/02/06 for The Limes

This inspection was carried out on 6th February 2006.

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

Other inspections for this house

The Limes 16/07/07

The Limes 12/12/06

The Limes 04/05/05

The Limes 26/08/04

The Limes 16/04/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 The Limes 39 Queens Road Donnington Telford Shropshire TF2 8DA Lead Inspector Keith Salmon Unannounced Inspection 6th February 2006 11:00 The Limes DS0000020568.V275946.R01.S.doc Version 5.1 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 The Limes DS0000020568.V275946.R01.S.doc Version 5.1 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. The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Limes Address 39 Queens Road Donnington Telford Shropshire TF2 8DA 01952 402295 01952 410779westview 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) prOKare Ltd. Mrs Amanda Michelle Crawford Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: The Limes care home provides personal care and accommodation to six adults with a mental disorder. It is owned by PrOKare Ltd and was first registered in July 2001. Situated in a residential area of Donnington the Home is within easy walking distance of local amenities, i.e. shops, public houses, transport, and in close proximity to Telford Town Centre. The Home is a detached two-storey property with communal sitting and dining areas, six bedrooms offering single occupancy, including three bedrooms on the ground floor benefiting from en suite facilities. The property is well maintained, with décor and furnishings providing a warm, homely and comfortable ambience. The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection commenced at 11.00, lasted 3.5 hours, and was undertaken by one Inspector. This Report is a product of a review of progress relating to ‘Requirements’ cited at the previous Inspection, held in May 2005, of care related documentation, including staff recruitment/deployment records, plus a range of documents/records reflecting the general operation of the Home, together with observations made during a tour of the Home, and discussions with Residents, the Community Services Manager (Sarah Kate Spencer) other members of Staff members. High standards of direct care provision, are provided in a friendly, homely, and open atmosphere. Although, at the time of this Inspection, The Limes was without a Registered Manager, the overall day-to-day management, and some elements of strategic management, are clearly satisfactory. What the service does well: What has improved since the last inspection? Staff personal/employment files are now stored on-site and will always be available when a suitably senior manager is present (it is expected this will certainly be so at ‘Announced’ Inspections). The position of Home Manager has now been filled with the successful candidate taking up appointment on 15 February 2006. The Limes DS0000020568.V275946.R01.S.doc Version 5.1 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 Limes DS0000020568.V275946.R01.S.doc Version 5.1 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 The Limes DS0000020568.V275946.R01.S.doc Version 5.1 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): 1,4,5. Prior to taking up residency all prospective Residents are enabled to reach an informed choice, and to fully understand the service they may expect to receive. Processes to ensure appropriate, and thorough, assessment of care needs and aspirations are effectively applied prior to admission. Each Resident is issued with an individual Statement of Terms and Conditions. EVIDENCE: A review of documentation demonstrated the Home has a Statement of Purpose and User Guide, both of which are easy to read and contain content, which meet the requirements of the Standard. Residents confirmed they had visited the Home prior to admission. Residents are provided with an individually appropriate Statement of Terms and Conditions detailing the accommodation and services to be provided by the Home. The Limes DS0000020568.V275946.R01.S.doc Version 5.1 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): These Standards were not fully assessed. EVIDENCE: The Limes DS0000020568.V275946.R01.S.doc Version 5.1 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): 11,17. Residents have opportunities for personal development, which are specifically, and effectively, matched to identified care needs. Residents are fully involved in the planning, and provision, of a varied and healthy diet. EVIDENCE: Discussion with the Community Services Manager and one particular member of Care Staff, together with observation of menus, highlighted a particularly noteworthy practice, in which the staff member leads Residents in the planning and developing of a ‘healthy living’ menu, together with the purchase of food and meals preparation. The menu has a four-week cycle, which continues to evolve with input from regularly held Residents’ meetings. In addition, those Residents with an interest in cooking are enabled, with support where necessary, to prepare meals for all the Residents. The Inspector considers the Home’s Staff are to be commended for their efforts and commitment to this area of care. The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 11 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 care needs of Residents are identified and appropriate care provided. Storage, administration and disposal of medicines are in accordance with accepted good practice. EVIDENCE: Review of Residents Care Plans showed evidence of input from visiting clinical professionals. Inspection of the medicine storage provision, and medicine administration records, demonstrated the Home’s practices meet current legislation and the guidelines of the Royal Pharmaceutical Society. The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 12 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. Residents are able to directly influence the conduct of their own care and matters relating to the general running of the Home. Systems, including ready access to information relating to advocacy services and the Home’s Complaints Procedure, are in place for the protection of those living at the Home and Staff are clearly aware of their role in protecting Residents from abuse. EVIDENCE: Examination of documentation, and discussions with Residents and Staff, provided evidence of regular Residents’ meetings which are minuted and supported by Staff. A clear and concise Complaints Procedure is displayed, which includes reference to the Commission for Social Care Inspection as the regulatory body, together with contact details. Policies relating to the protection of Residents from abuse were observed to be in place and readily accessible, these included, ‘Whistle Blowing’, ‘Abuse Awareness,’ and ‘Adult Protection’. Staff training files indicated that Staff had received training in respect of these Policies. The Home maintains a system for the recording of complaints, with none having been lodged since the previous Inspection. The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 13 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): 24,25,26,28. The Home’s bedrooms, lounge/sitting and dining areas offer a comfortable ‘domestic’ ambience, with furnishings being in good order. Bedrooms are decorated and furnished to the Residents’ wishes, personal taste and choice. EVIDENCE: Review of related documentation confirmed all necessary maintenance contracts are in place, with all areas clearly benefiting from regular refurbishment/redecoration as required. The garden provides a safe environment, is easily accessible to Service Users at all times of year, and provides opportunity for Residents to be involved in its maintenance. Residents are clearly encouraged to personalise bedrooms with their own possessions. The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 14 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): 31,32,33,34,35,36. Staff numbers on duty, and skill-mix were sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The commitment of the Home to providing training for Care Staff, and to continuing supervision and support, is good. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staff numbers, and skill-mix, enable a service provision, which meets the care needs of Service Users. Several Requirements were made at the previous Inspection, all of which stemmed from Staff employment records not being available on-site. This has now been rectified, and all of the Requirements fully met as a review of these files demonstrated the Home is in full compliance with the Standard and Schedule 2 of the Regulations. Staff are subject to a thorough and relevant orientation/ induction programme with evidence of on- going training. The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 15 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): 37,38,39,42,43. Although West View has been without a Registered Manager in post for some months, the overall day-to-day management and some elements of strategic management, are satisfactory. The management of staff, in particular the delegation of management tasks, is forward thinking with any related implications having been carefully thought through. The views of Residents, relating to the quality of care provided by the Home, are actively sought and influence the operation of the Home. The Home’s management actively pursues the establishment of a ‘Quality Assurance’ culture. Health and Safety Policies/Procedures/Practices were satisfactory. EVIDENCE: Good staff management/development practice is seen in individual Staff members having delegated responsibility for specific ‘management’ tasks e.g. COSSH, shopping (with Residents), gardens/grounds, medicines. Particularly noteworthy is the responsibility undertaken by a staff member in leading Residents in the planning and development of a ‘healthy living menu, together with the purchase of food and meals preparation. The enthusiasm The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 16 and innovation seen in this project is commendable. Notwithstanding the current good management practice, it is generally accepted that to ensure long-term good practice, the presence of a ‘Registered Manager’ is necessary. The Inspector was informed the position of Home Manager has now been filled, with the successful candidate taking up appointment on 15 February 2006. Evidence was seen of programmed meetings between Residents and their allocated ‘Key Worker’, plus ‘whole house’ meetings where a wide range of operational and ‘community’ issues are discussed, with many topics generated by the Residents. There is also a monthly ‘quality audit’ by a senior PrOKare Manager, which addresses mainly operational areas with the results presented, in graph form, for staff information. COSHH requirements were satisfactory, with maintenance and servicing of equipment regularly undertaken and appropriately documented. Records are maintained for hot water supply to baths, and water tested during the Inspection was found to be within the required temperature limits. The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 17 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 3 2 X 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 X STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 X 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 2 3 3 X X 3 3 The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 18 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 YA37 Regulation 9-(1)(2) Requirement The new Manager must apply to to the CSCI for approval to be Registered Manager. Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 The Limes DS0000020568.V275946.R01.S.doc Version 5.1 Page 20 - 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. 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