Inspection on 20/03/07 for White Acres

This inspection was carried out on 20th March 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

White Acres 12/11/09

White Acres 23/07/08

White Acres 28/09/05

White Acres 11/07/05

White Acres 28/10/04

White Acres 22/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 White Acres 15 Leicester Road Shepshed Loughborough Leicestershire LE12 9DF Lead Inspector Mrs Julie Western Key Unannounced Inspection 20th March 2007 09:30 White Acres DS0000001681.V334230.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 White Acres DS0000001681.V334230.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. White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Acres Address 15 Leicester Road Shepshed Loughborough Leicestershire LE12 9DF 01509 502845 01509 502845 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) Prime Life Ltd Miss Emma Hattersley Care Home 12 Category(ies) of Learning disability (12) registration, with number of places White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To be able to admit the named person of category LD/SI as identified in correspondence with the previous registration authority dated 11/05/00. To be able to admit the named person of category LD/ MD as identified in correspondence with the previous registration authority dated 10/08/01. 28th September 2005 Date of last inspection Brief Description of the Service: White Acres is a care home providing personal care and accommodation for up to twelve residents with a Learning Disability; on the day of the inspection the home was fully occupied. The home has twelve single bedrooms, one of which has an en-suite facility. There is a rear garden, which is accessible to all residents. White Acres is part of the Prime Life Group and is situated in Shepshed, Leicestershire, within an residential area and close to local amenities, to which residents have access. There is easy access by private or public transport. There is a limited parking area to the front of the building and on-street parking. Gardens are to the rear and side. Accommodation is provided over two floors with access between the floors being via stairs. Communal areas are provided on the ground floor, with bedrooms located on the ground and first floor. The home’s stated aim is ‘to promote clients’ independence by providing care and support to maintain and develop skills as a forerunner to returning to mainstream society’. White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took into account any previous information held by CSCI including the home’s previous inspection reports, its service history, pre-inspection questionnaires completed by the manager and residents’ questionnaires sent to the home by the Commission prior to the inspection. The site inspection took place over three hours and consisted of case tracking a sample of residents’ records and assessing the care given. Some policies and procedures were examined and some records concerning the safety of the home were also seen. Three residents and two care staff were spoken with. The acting manager, in the absence of the manager, who was on maternity leave, was present throughout the inspection. At the time of the inspection the home confirmed that the weekly fees ranged from £282 - £936, depending on the assessed needs of the resident. Additional charges are made for services such as ladies’ hairdressing. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report is available in the reception area or the manager’s office. What the service does well: What has improved since the last inspection? The lounge has been completely redecorated to include the replacement of the old, worn carpet. Since the last inspection an in-house training mentor has been appointed, who is responsible for co-ordinating staff training. White Acres DS0000001681.V334230.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. White Acres DS0000001681.V334230.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 White Acres DS0000001681.V334230.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): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a range of accessible information about the service they receive. They are involved in an in-depth assessment process. EVIDENCE: The statement of purpose and the service user guide are comprehensive and tell the residents what they can expect from the service. The statement of purpose needs updating to reflect the changing nature of inspections. Assessments prior to admission were in each resident’s care records and showed that residents, their relatives and other professionals were involved and contributed to the care plans. One resident described how he came to the home from living with his mother and visited it several times before making the choice to move in on a permanent basis. Care plans, risk assessments and reviews were signed and showed that residents were involved in these processes. Personal profiles for each resident provided a detailed account of the residents’ personal history and other essential information White Acres DS0000001681.V334230.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): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from good support that enables them to conduct their lives independently and safely. EVIDENCE: The care plans seen contained details about how residents expressed their needs and showed that they were encouraged to make decisions for themselves wherever they were able. Care plans were reviewed regularly and were signed where appropriate. Formal reviews, involving families and professionals involved with the resident, were held six-monthly. Policies and procedures were available for risk management and the values of privacy, dignity and choice. These values were referred to throughout the care plans. Residents were very positive about the staff; one said ‘they help me when I need help’. White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 10 Surveys received from residents showed that they were able to make decisions about what they wanted to do from day to day. On the day of the inspection one resident went into town to bet on a horse; something he enjoyed and did regularly. Throughout the inspection staff were observed communicating with residents with respect and sensitivity and residents demonstrated that they were confident and respectful with staff. White Acres DS0000001681.V334230.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): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have access to a wide range of work and leisure activities. They are fully supported to maintain and develop their independence. The residents benefit from a well balanced diet and they are supported in maintaining a healthy lifestyle. EVIDENCE: Care plans clearly show the preferences of residents, including diet, weekday and weekend activity. Residents also described their wishes and aims in a booklet with pictures entitled ‘Who am I?’ There was evidence in care notes of leisure activity such as coffee mornings, meals out and visits to pubs. On the day of the inspection, some residents were playing darts. There was evidence of in house activity such as videos and books. One resident said she enjoyed the weekly pottery lessons at the home. Two residents attended college two hours weekly and several also attended the local day centre. One resident had a small part time job. White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 12 Residents were encouraged by staff to undertake activities such as shopping, cleaning their rooms and ironing. Residents also accompanied staff on shopping trips to the supermarket. The home had a pet rabbit and residents who wanted to, took turns to clean and feed it. A resident mentioned that this year’s holiday had not been chosen by the residents, but that he would like to return to Mablethorpe, where ten of the residents holidayed last year. Residents held regular meetings. Prime Life provides a mini-coach and some residents described a recent trip to Cadbury’s World. Records demonstrated that menus are planned and based on residents’ dietary needs and preferences. Residents said they enjoyed the food and one said ‘I like helping with the meals here’. There was evidence of fresh fruit and vegetables in the kitchen. White Acres DS0000001681.V334230.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, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Medication procedures need reviewing to ensure that residents’ health care needs are fully met. Residents are given personal care with sensitivity and regard for their privacy and dignity EVIDENCE: Personal and health care needs were clearly recorded in individual care plans. Records showed that two residents used wheelchairs and needed assistance with bathing and showering; other residents needed prompting. Medication records showed that one resident’s medication had not been signed for. A similar omission had been found at the previous inspection. The acting manager said that the medication was given but the staff member had forgotten to sign for it. The previous inspection had also found omissions on the medication administration sheets. The pharmacist last visited in January 06. Following discussions, the acting manager agreed to contact the pharmacist immediately for a visit and to advise regarding medication records. White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 14 There were easy-to-read leaflets on healthy eating, taking care in the sun, weight, alcohol and smoking. Residents and staff spoken with said they had found the leaflet on taking care in the sun particularly useful. One resident administered her own medication and records showed that this had been risk managed appropriately. White Acres DS0000001681.V334230.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; there is a robust adult protection procedure EVIDENCE: Records showed that the home had received no complaints in the last twelve months. There was a clear adult protection procedure, which was linked to the Local Authority procedures. All staff members spoken with had received training on safeguarding adults and were knowledgeable about complaints. One resident said ‘If I don’t like something I go to…[the key worker] or …[the acting manager]. They sort it out for me’. White Acres DS0000001681.V334230.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents live in a safe and generally comfortable environment. Bathrooms however, are dated and one bath is not suitable for the needs of the current residents. EVIDENCE: A tour of the premises showed that the building was generally well maintained internally and the gardens and grounds offered a pleasant place for residents to sit out in good weather. The building is not particularly spacious, with communal and office areas being small. Rooms were very well personalised and well decorated. Environmental improvements have included the redecoration of the lounge and replacement of the carpet. The bath/shower rooms showed signs of age and were institutional in appearance; the tile grouting was discoloured and some tiles were cracked. One bath was too small for the residents to use. White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 17 The corridor carpet outside the kitchen was not properly fitted. The home was clean and tidy and smelled fresh throughout. White Acres DS0000001681.V334230.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, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are in sufficient quantity for them to be able to care for the residents. Staff members are suitably trained, qualified and competent. EVIDENCE: The rota showed that there were sufficient numbers of staff on duty. Additional staff members were available to provide flexibility when needed. Residents and staff spoken with confirmed that there were enough staff members to attend to their needs. The training budget is managed at the Prime Life headquarters and the acting manager said that there were a lot of opportunities for training within the organisation. An in-house training mentor has recently been appointed to oversee the training in the home. The acting manager confirmed that seven staff members had achieved the National vocational Qualification at Level 2 and one staff member had achieved NVQ Level 3. White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 19 The staff member spoken with had recently completed LDAF training, a nationally recognised training programme for working with people with a learning disability. Other recent training included a dementia course for four staff members. Staff spoken with said they had regular supervision and records confirmed this. Staff folders were well maintained. White Acres DS0000001681.V334230.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): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed competently and the staff team are supported in carrying out their respective roles. The views of residents are listened to and they are involved in decisions affecting them. EVIDENCE: The registered Manager is currently on maternity leave and the deputy manager is acting manager during this time. She is currently completing the NVQ at Level 4 in management. She has worked in this home for three years. The acting manager does not have access to a computer and regularly has to take work home. White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 21 The residents have regular meetings, which are recorded. They also work with the day centres they attend and give regular feedback about the home at reviews. The home has a range of policies and procedures e.g. infection control, health and safety, moving and handling, fire safety and Legionella controls. Risk assessments for the environment were seen and individual service user risk assessments were contained in personal files. Residents spoken with were aware of the right and wrong way to perform many activities. White Acres DS0000001681.V334230.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 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 23 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 YA20 Regulation 13[2] Sch3[3](i) Requirement Timescale for action 15/05/07 2 YA24 The registered person must ensure that staff adhere to the correct procedures when distributing medication to residents. 23[2](b,d) The registered person must provide plans for redecorating and upgrading the bath/shower rooms. 15/05/07 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 YA1 YA20 Good Practice Recommendations The statement of purpose should be updated to reflect the changes in frequency of inspections from the Commission. Regular visits should be made by a pharmacist for information and advice on the dispensation of medication. White Acres DS0000001681.V334230.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 White Acres DS0000001681.V334230.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. Re-publishing this information is in breach of the terms of use of that website. 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