Inspection on 28/09/05 for White Acres

This inspection was carried out on 28th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

White Acres 12/11/09

White Acres 23/07/08

White Acres 20/03/07

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 Linda Clarke Unannounced 11 July 2005, 1:30pm th 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. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service White Acres Address 15 Leicester Road Shepshed Loughborough Leicestershire LE12 9DF 01509 502845 01509 502845 None Prime Life Limited 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) Miss Emma Hattersley Care Home 12 Category(ies) of Learning disability (12) registration, with number of places White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: To be able to admit the named person of category LD/SI (sensory impairment) 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. Date of last inspection 28th October 2004. Brief Description of the Service: White Acres is a care home providing personal care and accommodation for twelve residents with a Learning Disability. White Acres has twelve single bedrooms, one of which has an en-suite facility. The home has a rear garden, which is accessible to all residents. White Acres is part of the Prime Life Group and is situated in Shepshed, Leicestershire. White Acres is located within an residential area, close to local amenties, to which residents have access. The home is easily accesible by private or public transport. Accommodation is provided over two floors with acess between the floors being via stairs. Communal areas are provided on the ground floor, with bedrooms located on the ground and first floor. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took place between 1.30pm and 5.15pm. Opportunity was taken to look around parts of the home, talk with residents, view records and policies which included viewing the care plans of three residents residing at the home. Information within relative comment cards has been incorporated into the Inspection Report, one having been completed by a relative and the second by a Social Service, Review Officer. The Residential Manager along with staff facilitated the Inspection. What the service does well: What has improved since the last inspection? What they could do better: The health and welfare of residents would be promoted, if staff responsible for the administration of medication, followed the policies and procedures of Prime Life Limited. Residents and staff would benefit from staff undertaking level 3 National Vocational Training in Promoting Independence as this reflects the working role which staff have been employed to undertake. The residents would benefit from the lounge and dining area being redecorated and a new carpet provided, as this would provide a more homely environment for residents to relax in. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 6 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. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 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 White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 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) 2 Individual’s needs are assessed prior to admission. EVIDENCE: The admission process is adequate in that social care professionals carry out assessments of individuals, as part of the referral process. The files of three residents residing at White Acres were viewed and found to contain an assessment of need. It was noted that a resident has been admitted to the home, in a category to which the home is not registered, this situation will need to be resolved by the Responsible Individual and the Registered Manager. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, 9 and 10. Individual plans of care are in place ensuring that individuals receive the care they need. EVIDENCE: The Inspector viewed three resident care plans; all were detailed and contained information as to how an individual’s care is to be delivered, which includes the decisions made by residents and the level of support they require, including the level of support if any is required for the management of resident finances. Risk assessments are in place, identifying areas of risk consistent with the promotion of independence. The Inspector spoke with residents, who were able to state their views as to the level of support they require. Records also include a detailed life history, which enables staff to support residents upon admission to White Acres. Records are kept of significant daily events affecting residents, which includes contact with medical professionals, relatives and friends and social and recreational pursuits. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 10 The relative completing a questionnaire provided positive responses to all questions, and made an additional comment: “My sister has lived at White Acres for eight years, she is generally happy, and supported to be as independent as possible, despite changes to the staff team.” The Social Service Review Officer, within her comment card made positive responses to all questions, and made an additional comment: “Staff are approachable and happy to receive constructive concerns.” White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17. Resident’s social, leisure and recreational needs are met. EVIDENCE: The care plans of residents were viewed; activities, recreational and leisure activities were incorporated. The Inspector spoke to two residents who stated that they were going into Loughborough that evening, accessing public transport, as they were going for a glass of wine at a wine bar. A group of residents spoke about the fete that had taken place at White Acres the previous weekend, residents had been actively involved in the fete, taking responsibility for various stalls, and the residents confirmed that the proceeds of the fete were to go towards the holiday planned for Butlins at Skegness in September. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 12 Residents access various day care pursuits through day care centres and colleges, whilst some remain at home during the day. One resident spoken to stated that on a voluntary basis she supports a local toddlers group, and also works part time as a cleaner based at a local industrial estate. The care plan of one resident viewed by the Inspector evidenced that the resident has a part time job at the local Co-op. Residents have contact with relatives and friends, and are supported by care staff and medical professionals with their personal relationships as appropriate and as requested by the resident themselves. White Acres residents and staff have published a newsletter, which has been circulated to relatives; the Registered Manager stated that she’d had positive responses from the newsletter, which would now become a regular feature of the home. In addition to excursions supported by staff, Prime Life Limited provides a mini-coach, which enables residents at White Acres to access local resources and leisure pursuits, twice a month. Excursions to local parks, zoos, public houses and a boat trip have recently taken place. On the evening of the Inspection, residents for their evening meal had a choice of pork chops or fish cakes, with mashed potatoes and fresh vegetables, for desert residents had a slice of cake. Residents during the meal were relaxed, some choosing to eat their meal outside, relaxing in the sun. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20. Residents are looked after well in respect of their health and personal care needs. Medication procedures are not in all circumstances being managed appropriately. EVIDENCE: Care plans of resident’s detail the support individuals require, including their emotional needs, which are also included within the life history information, this is obtained prior to admission. The medication records of three residents were viewed, one residents administration records had not been signed on two occasions over an eight day period, and the counting of tablets indicated, that one tablet had not been administered. The care plan of one resident viewed detailed that the resident administered their own medication a risk assessment incorporated the risks to themselves and others, which is regularly reviewed. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 14 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) 22 and 23. Complaints are handled objectively and residents are confident that their concerns would be listened to, taken seriously and acted upon. EVIDENCE: Prime Life has a detailed complaints procedure, outlining the process of complaints, how they will be handled including the timescale. White Acres nor the Commission for Social Care Inspection has received any complaints since the last Inspection. The one comment card received by the Inspector from a relative indicated that they had never made a complaint, but were aware of the complaints procedure. The Registered Manager and staff are aware of the Department of Health’s guidance on the protection of vulnerable adults; staff undertaking National Vocational Training supports this. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 15 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, 25, 26, 28 and 30. The décor of the home is of a good standard providing a comfortable and safe environment. EVIDENCE: White Acres provides a lounge and dining room on the ground floor, the lounge giving access to the garden and patio area. The décor of the lounge and dining room is looking worn, and the carpet is heavily stained. The Registered Manager confirmed that the carpet has been regularly cleaned; however the stains remain. The redecoration and the replacement of the carpet would provide a relaxing and attractive area for residents to relax. The bedrooms of two resident’s were viewed, the Inspector was accompanied by the resident, one resident had cleaned his room that day, and was spending his time listening to music and painting, whilst the other resident, was very proud of her room, saying she liked it very much, and appreciated that she had an en-suite facility. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 and 35. Staff at White Acres are trained and supported, and employed in sufficient numbers to meet the needs of residents. EVIDENCE: On duty on the afternoon of the Inspection, were two members of staff and the Registered Manager. Records of a member of staff recently recruited were viewed, and found to contain all the relevant information to promote and safeguard residents. Training records evidenced that staff since the last Inspection have received training in moving and handling, health and safety, fire awareness and NAPPI (Non Abusive Psychological and Physical Intervention). The home employs eleven members of care staff, of which two have attained a level 2 National Vocational Qualification in Care, five members of staff are undertaking LDAF (Learning Disability Award Framework) training which is specifically aimed at staff providing care to adults with a Learning Disability. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 17 A member of staff spoken to stated that although she has attained a level 2 National Vocational Qualification, she finds the LDAF training more appropriate, as its specific to her working role. Residents and staff would benefit from staff undertaking a National Vocational Qualification at level 3 in Promoting Independence as opposed to level 2 Care, and this award reflects the role of staff in supporting residents to achieve their potential. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 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 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, 39 and 43. The Registered Manager offers a clear sense of leadership, which reflects on the day-to-day delivery of care practices of residents and running of the home. EVIDENCE: The Registered Manager offers a clear sense of leadership through staff meetings, and day-to-day contact with residents, resident relatives and staff. A Director of Prime Life, who visits the home, supports the Registered Manager. The newsletter produced by the residents and staff of White Acres, gives relatives and friends of residents an opportunity to receive information and to comment upon it. The maintenance team employed by Prime Life Limited manages the maintenance of the home; whilst staff receive training is issues pertaining to health and safety. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 19 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 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 4 3 4 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 3 4 3 3 4 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 White Acres Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x x x 3 C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 20 No 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 20 Regulation 13(2) Requirement The Registered Person to ensure that policies and procedures for the adminsitration of medication are adopted by all staff consistently. Timescale for action Immediate and ongoing 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 24 32 Good Practice Recommendations It is recommended the lounge and dining area be redeocrated and the carpet replaced. It is recommended that staff undertake National Vocational Qualification training at level 3 in Promoting Independence. White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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 White Acres C51 C01 S1681 White Acres V237745 110705 Stage 4.doc Version 1.40 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. 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