Inspection on 16/05/07 for 1 & 2 The Hedgerows

This inspection was carried out on 16th May 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 & 2 The Hedgerows 01/11/05

1 & 2 The Hedgerows 09/06/05

1 & 2 The Hedgerows 08/10/04

1 & 2 The Hedgerows 01/07/04

1 & 2 The Hedgerows 25/03/04

Similar services:

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Southfields

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1 & 2 The Hedgerows Station Road Staplehurst Kent TN12 0QQ Lead Inspector Justine Williams Key Unannounced Inspection 16 & 21st May 2007 09:30 th 1 & 2 The Hedgerows DS0000037839.V340139.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 1 & 2 The Hedgerows DS0000037839.V340139.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. 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 & 2 The Hedgerows Address Station Road Staplehurst Kent TN12 0QQ 01580 893269 01580 893661 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) Kent County Council Mrs Susan Ann Pattenden Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users may also have a physical disability. Date of last inspection 1st November 2005 Brief Description of the Service: The Hedgerows offers respite care for short periods only. Service Users are required to attend day services, work experience and / or colleges from Monday to Friday. 24 - hour care is provided over the weekend / bank holiday periods, except in exceptional circumstances. There are 5 single bedrooms, one of which is on the ground floor and is used by people with mobility difficulties. The Home does not offer services for wheelchair users requiring full care as there is not the equipment or facilities available to provide this. Many of the homes service users have been attending the home for several years for periods of phased respite, the usual length of stay is 1 to 2 weeks. Staff work a rota that includes one member of staff sleeping in at night. Support workers assist Service Users with meal preparation and domestic cleaning. The Hedgerows is owned and run by Kent County Council. The Hedgerows is situated on the outskirts of the village of Staplehurst, which has a range of facilities including shops, library, medical centre, pubs and the village Community Centre. The nearest bus stop is on the main road, and there is a mainline railway station a short distance away. Limited parking is available to the front of the building and there is a large garden to the rear. The current fees range from Nil to a maximum of £72.15 per night.(The average amount paid by carers is £9.14 per night. This information was given by the manager in writing. 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on 16th May 2007 between 9.30 am and 11am and a 2nd visit was conducted on the 21st may 2007 between 1pm and 3pm in order to speak with the manager and access all the necessary records. Regulatory inspector Justine Williams carried out the inspection. During that time the inspector spoke with staff members and the registered manager. Feedback was given during and at the end of the inspection. This report contains assessments made from observation, conversation and records, as well as case tracking. As part of the inspection process surveys were sent to service users who have had respite at the home and to GP’s, health care professionals, care managers and relatives of residents. The surveys received indicated good levels of satisfaction with the service in general. Specific comments included; “A friendly welcoming environment” “Hedgerows offers a variety of activities” “(My relative) is always very keen to attend Hedgerows” “we want to thank hedgerows for providing this service” “I like staying here very much and would like to stay more often” “our (relative) always enjoys going to hedgerows, this is very helpful for us to enjoy a break knowing he is going to be happy” What the service does well: The home continues to use a sound process for the admission of new service users, allowing plenty of time for them and their carers to get used to the home and make a positive decision to have their respite there. The care plans are concise, but detailing service users strengths, needs and right to make decisions, care plans regularly reviewed, at each admission and as new information is found. Service users benefit from the variety of activities offered, and the themed weekends. They can chose to coincide their stay with those they are interested in. Staff continue to be well prepared for their roles through regular supervision, and good access to a variety of training. 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 1 & 2 The Hedgerows DS0000037839.V340139.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 1 & 2 The Hedgerows DS0000037839.V340139.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): 2,4 Quality in this outcome area is excellent, This judgement has been made using available evidence including a visit to this service. Service users have their needs fully assessed prior to their stay at the home. EVIDENCE: All the service users have been referred to the home by care management and a copy of the most recent care managers assessment is always asked for prior to accepting an individual. Service users who have never been to the home are invited to visit and stay for tea, at least once with some visiting on several occasions before they come for an overnight visit, their carers are invited to come with them. The senior staff carry out their own assessment and begin to write the care plan at these visits with additional information being added whenever necessary. Emergency periods of respite are unusual but there is a comprehensive procedure for staff to follow, should the occasion arise. Many of the residents have been using the home for respite care for many years and may have around 6 stays per year at the home. The documentation for these service users is reviewed at each admission and updates as needed. 1 & 2 The Hedgerows DS0000037839.V340139.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. Service users needs, likes and dislikes are documented and respected, and they are enabled to make decisions and take risks. EVIDENCE: Each service user has a comprehensive plan of care from the home and one from care management, and these compliment one another. The care plans include detailed information about the service users needs, and include the services to be provided by the home. The plans are simple with some pictorial formatting, staff said the care plans are explained to service users. The care plans include information about the support service users need in decision making. Evidence of staff enabling decision making was found in the care plan and the daily records. Service users who are able are encouraged to look after their own money and suitable facilities are provided for locking away valuables. 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 10 Comprehensive risk assessments are recorded for all service users and include use of the kitchen, fire, moving and handling, travelling in the car, specific activities such as construction, swimming etc. the risk assessments are reviewed at each new period of respite and updates whenever necessary. The home cares for service users with a range of abilities and needs and the manager and staff are aware of the need to continually reassess service users, and respond to changes. Service users said they liked the way they were treated by staff. 1 & 2 The Hedgerows DS0000037839.V340139.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 good, This judgement has been made using available evidence including a visit to this service. Service users access a wide range of activities, which are often in the local community. Service users rights and responsibilities are respected. The home provides variety and plenty of choice at mealtimes. EVIDENCE: Due to the nature of the service, the service users are required to attend day centres usually the SEC, as the home is not staffed throughout the day. The SEC is a large day centre providing cares for around 80 people, a range of activities are offered there such as cooking, arts and crafts, woodwork etc. Efforts are made to transport service users to their usual colleges and centres if they are close by. Evening and weekend activities are very varied and led by the service users preferences. Service users are contacted and told of the homes programmed activities such as theatre weekends, music and dance weekends, France day 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 12 trip, camping weekend, theme park weekend etc. Service users periods of respite are then arranged around the weekends they are interested in. comments received by the home included ”This year I spent a weekend camping in the garden, which I really enjoyed”. Weekends that are not pre planned may involve pub lunches, cinema, shopping trips, visits to the coast etc, these are arranged with the residents once they have arrived. Due to the nature of the service, providing a break for carers and for the service users, family visits are not always frequent, however the home welcomes visitors to the home and service users chose who they see and when. Service users privacy is respected and they are offered keys to their rooms if they are able to manage using them. Service users contracts ask that they respect each other’s privacy. Responsibilities for household takes are agreed with the service users and support is offered whenever needed. The home has a menu, which is very flexible and varied. Service users help with cooking, preparing snacks, shopping etc, depending on their ability. Service users said they liked the food. 1 & 2 The Hedgerows DS0000037839.V340139.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 good, This judgement has been made using available evidence including a visit to this service. Service users health needs are appropriately managed. EVIDENCE: The comprehensive care plans set out how service users are to be supported in the way they prefer and with due regard to health and safety. Preferred times for getting up etc are all included in the care plan. One resident has increasing moving and handling needs and the home has re claimed its hoist on loan elsewhere and provided training updates for all staff prior to the service users period of respite in case the hoist is required. The home employs male and female staff so service users have some choice in which staff work with them. The healthcare needs of service users are well managed with the home arranging training updates for staff in diabetes care, epilepsy etc prior to service users stays. The home has lockable storage space for any service users wishing to self medicate and the manager said a comprehensive risk assessment would be done. The home has secure facilities for medications storage and records are 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 14 kept of medicines entering and leaving the home. All staff who are responsible for administering medicine receive competency based training. The homes procedure for handling medicine for service users attending day centres is recorded clearly. The Kent County Council policy is used at the home. The homes medication fridge is not appropriate for medication storage as it is not lockable and does not have a temperature gauge. The use of PRN medication is now included in the care plan. 1 & 2 The Hedgerows DS0000037839.V340139.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): 22,23 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Service users are listened to and any concerns are acted upon. The homes policies protect service users from abuse as far as possible. EVIDENCE: The home uses the Kent County Council complaints policy which is clear and available in varying formats. The home has produced an accompanying document, which gives the NCSC as the regulatory body, this needs amending. The complaint file clearly recorded details of complaints made and the manager is aware of the need to clearly record investigations undertaken and actions taken. The home has received no complaints since the last inspection. Minor expressions of dissatisfaction are recorded in the individuals daily record. This makes tracking and looking for trends very difficult, if this information was kept together it would facilitate the quality assurance process and provide evidence that the service is responsive. Staff have received training in adult protection at their induction and have attended POVA training, staff were aware of the actions they must take in the event of abuse being alleged. The homes uses the Kent and Medway Social Services Policy, a copy of which is available to staff. The relevant checks are carried out on all staff and new staff do not start work at the home until the manager has received a satisfactory POVA check. The home has recently raised an adult protection alert. 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 16 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 17 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): 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment for service users. EVIDENCE: All areas of the home were toured and found to be in a good state of repair. Some areas have been redecorated recently. Measures could be taken to make the bedrooms look more homely and welcoming. There are 5 bedrooms one en-suite, 2 bathrooms 2 staff sleep in rooms, 1 lounge diner and a separate lounge, activity room, and kitchen. The home has inherited a part time ‘handyman’ after the closure of another unit, who has vastly improved the garden, which is very pleasant with seating areas, lawns, flower beds etc. The handyman has recently redecorated the smaller of the 2 lounges, and the home has a redecoration and refurbishment plan. The kitchen will benefit from refurbishment, which is planned in the near future. 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 18 The laundry was clean, and organised, and the washing machine has a sluicing cycle for foul or infected linen. All areas of the home were clean and hygienic. 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 19 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. Service users receive care and support from appropriately trained and safely recruited staff. EVIDENCE: Staff are encouraged and supported to undertake NVQ training and 5 of the 8 staff have attained NVQ at level 2 or above. In addition to core training such as fire and health and safety training staff receive training in managing challenging behaviour, autism, sexuality and relationships, communication etc. All new staff are required to complete Learning disability award framework (LDAF) training. The home uses a bank of casual staff who provide cover for permanent staff, these staff are familiar with the homes policies and procedures. The files for 2 newly recruited staff were seen, not all the documents required were in the files as some are being held at the Kent County Council central personnel department, copies or originals must be available at the home. The staff receive the relevant police checks and references are requested, a transcript of the interview is kept, and all staff receive contracts. 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 20 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 21 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. Service users benefit from a well run home. EVIDENCE: The registered manager is experienced in working with adults with learning difficulties, and holds a Diploma and an N.V.Q. Level 4 in Management. She is currently working towards additional units for the Registered Managers Award. The home has some quality assurance systems in place, surveys are carried out annually, these include questionnaires to all those who have stayed at the home in that year, and their relatives, as well as others who visit the home 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 22 such as healthcare professionals. The last surveys indicated 3 of carers described the overall service offered by Hedgerows as “fair”,47 Excellent. 50 good. 98 said they ”liked the way they were treated by staff” 100 said “they generally enjoyed their stays “, 100 said ”they liked the food they had at Hedgerows. Staff meetings take place regularly and regular reports under regulation 26 are carried out. The manager now needs to further develop the quality assurance process in line with the changes to the regulations. The information received in the pre inspection questionnaire indicates that the home meets its responsibilities in checking and servicing of equipment, gas and electrical appliances. The home has policies and procedures in place to ensure the health and safety of service users and staff. these policies along with training and regular supervision of staff ensure safe working practices. 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 23 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 X 2 3 3 X 4 4 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 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 24 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 YA41 Regulation 19, Sch 2 Requirement The registered person shall ensure that the personnel files held at the home contain all of the information as listed under Schedule 2 of the Care Homes Regulations, for the purposes of CSCI inspections. Outstanding from inspections 09/06/05 and 01/11/05 Timescale for action 01/07/07 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 3 Refer to Standard YA20 YA22 YA24 Good Practice Recommendations It is strongly recommended that a suitable fridge be used for the storage of medication in line with good practice. It is recommended that minor expressions of dissatisfaction be recorded and included in the homes quality assurance systems. Whilst it is acknowledged that personalising bedrooms is difficult, it is recommended that efforts be made to make DS0000037839.V340139.R01.S.doc Version 5.2 Page 25 1 & 2 The Hedgerows 4 YA39 the bedrooms more homely and welcoming. It is recommended that the quality assurance systems be developed further in line with changes in regulation. 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 1 & 2 The Hedgerows DS0000037839.V340139.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!