Latest Inspection
This is the latest available inspection report for this service, carried out on 7th May 2009. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
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.
For extracts, read the latest CQC inspection for Limetree Avenue Care Home.
Annual service review
Name of Service: Limetree Avenue Care Home The quality rating for this care home is: The rating was made on: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Rebecca Shewan Date of this annual service review: 2 1 0 5 2 0 0 9 Annual Service Review Page 1 of 7 Information about the service
Address of service: 23 Limetree Avenue Retford Nottinghamshire DN22 7BB 01777708725 F/P01777708725 Telephone number: Fax number: Email address: Provider web address:
www.mencap.org.uk Royal Mencap Society Name of registered provider(s): Conditions of registration: Category(ies) : learning disability Number of places (if applicable): Under 65 Over 65 6 0 Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: Sarah Louise Hall has become the Registered Manager Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service 23 Limetree Avenue is a 3-storey, semi-detached house in a quiet, residential street within quarter of a mile of Retford town centre, near shops, pubs, and cinema and leisure facilities. The home caters for six male and female residents with learning disabilities. It was established in 1991 and five of the residents have been there since that time. The latest addition arrived in 1996; no one has been admitted since. Five of the current residents attend local authority day care services for some part of the week. All residents have their own personalised decorated bedrooms, with a communal lounge, dining room and kitchen. There is a bathroom and a shower room; there are toilets on each floor. One ground floor bedroom is en-suite. There is a small well maintained garden. On the second floor there is a sleep-in room for staff and an office where records, documents, policies and procedures are kept. Annual Service Review Page 2 of 7 Detailed information was not provided about fees, but the manager stated these are dependent on individual assessed needs. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: The previous annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations. What other people have told us about the service. What has this told us about the service? The last report was positive. Requirement and Recommendations for good practice were made relating to the Appointed Manager must submit an application for Registration with CSCI (Commission for Social Care) and undertake the Registered Managers Award promptly to ensure that she is compliant with Regulation 8. There is no policy in place for continence promotion, which needs to be addressed. The Appointed Manager has subsequently applied for registration and is now the homes Registered Manager. The homes previous inspection report and notifications received provided evidence that the home has good processes in place for assessing potential new service users, with services being offered to only those service users whose needs can be met. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. The key principle of the home is that people using the service are in control of their lives and they direct the service. Staff are fully committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible. Care plans are developed with, and owned by the person using the service. It is based on a full and up to date holistic assessment. It includes reference to equality and diversity and clearly addresses any needs identified in the six strands of diversity, which are gender (including gender identity), age, sexual orientation, race, religion or belief, and disability. The plan is person centred and focuses on the individuals strengths and personal preferences. The plan is written with Annual Service Review Page 4 of 7 the individual, or their representative. The service knows and records the preferred communication style of the individual, and will use new and innovative methods that enable the person to fully participate. The service has a can do attitude and risks are managed positively to help people using the service lead the life they want. Any limitations on freedom, choice or facilities are always in the persons best interests. People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individuals expectations. Central to the homes aims and objectives is the promotion of the individuals right to live an ordinary and meaningful life, appropriate to their peer group, in both the home and the community, and to enjoy all the rights and responsibilities of citizenship. The service understands and actively promotes the importance of respecting the human rights of people using the service, with fairness, equality, dignity, respect and autonomy all being seen as central to the care and support being provided. The home seeks the views of residents and considers their varied interests when planning the routines of daily living and arranging activities both in the home and the community. Routines are very flexible and residents can make choices in major areas of their life. Residents are enabled to exercise choice and control over their lives and are encouraged to maintain contact with family and friends. There is a wide variety of food to choose from and drinks and snacks are available throughout the day. Residents are offered a good provision of health care and personal support by the home. People living in the home are encouraged to manage their own healthcare including visual, hearing, oral and continence care. Staff are trained and competent in health care matters particularly in the care of individuals who remain immobile for long periods of time. All care is administered in way that protects residents privacy and dignity. Individual plans clearly record peoples personal and healthcare needs and detail how they will be delivered. Staff ensure that care is person led, personal support is flexible, consistent, and is able to meet the changing needs of the residents. Aids and equipment are provided to encourage maximum independence for people using services. The home has developed efficient medication policy, procedure and practice guidance. The home has good procedures in place for the monitoring and recording of all drugs administered and those entering and leaving the home. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse, and have their rights protected. The ethos of the home is that it welcomes complaints and suggestions about the service, uses these positively and learns from them. People who use the service are supplied with a complaints procedure that they can understand. This procedure is available in a variety of formats that may include large print, other languages, Braille, audio and pictures. Individuals and their representatives have a clear understanding of how to make a complaint and when they will get a final response. The home has an open culture where individuals feel safe and supported to share any concerns in relation to their protection and safety. Policies and procedures regarding safeguarding adults are available to staff and give them clear guidance about what action should be taken. All staff working within the home are fully trained in safeguarding adults and know how to respond in the event of an alert. Individual staff are also trained to respond appropriately to physical and verbal aggression and fully understand the use of physical intervention as a last resort. Annual Service Review Page 5 of 7 The home provides accommodation for service users that is safe, hygienic and odour free, whilst infection control and Health & Safety procedures are adhered to at all times. The living environment is appropriate for the particular lifestyle and needs of the residents and is homely. Residents are encouraged to see the home as their own. It is a very well maintained, attractive home and has very good access to community facilities and services. It is fully accessible throughout to people with physical disabilities, adaptations and specialist equipment are designed to fit within the homely environment. The management has a proactive infection control policy and they work closely with their own staff and external specialists to ensure that infections are minimised. The home has good staffing levels in order to provide safe and appropriate care. The staff team have the necessary skills and experience to the meet the needs of current residents. The service has a highly developed recruitment procedure that has the needs of people who use the service at its core. The service is highly selective, with the recruitment of the right person for the job being more important to the filling of a vacancy. People who use the service are involved in the recruitment of staff and receive training and support to do this. The home has an Equal Opportunities policy in place and is an equal opportunities employer. The management of the home believes in promoting an equal and diverse culture among staff and residents. The service ensures that all staff within its organisation receives relevant training, that is targeted and focused on improving outcomes for residents. Staff have the skills to communicate effectively with all residents. The management and administration of the home is based on openness and respect, residents therefore experience the benefits of a home that is well managed and administrated. The Registered Manager has been in post for nearly three years and has the necessary skills, experience and qualifications to uphold her registration. The home works to a clear health and safety policy. Safeguarding is given high priority and the home provides a range of policies and guidance to underpin good practice. A formal quality monitoring system is in place, with clearly defined processes for gaining feedback from service users and stakeholders, meeting compliances, monthly monitoring visits and annual reviews of the service. What are we going to do as a result of this annual service review? We are not going to change our inspection plan, and will do a key inspection by 6th May 2010. However we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 6 of 7 Reader Information
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