Inspection on 09/06/05 for 1 & 2 The Hedgerows

This inspection was carried out on 9th June 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

1 & 2 The Hedgerows 16/05/07

1 & 2 The Hedgerows 01/11/05

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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Seabourne House

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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 OQQ Lead Inspector Sophie Wood Announced 9 June 2005 14:00 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. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 1&2 The Hedgerows Address Station Road Staplehurst Kent TN12 OQQ 01580 893269 01580 893661 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) Kent County Council Mrs Susan Ann Pattenden CRH Care Home 5 Category(ies) of LD Learning Disability (5) registration, with number of places H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service Users may also have a physical disability Date of last inspection 8 October 2004 Brief Description of the Service: The Hedgerows was originally the Police Station for Staplehurst. The Home 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. The Home 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. 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. Limited parking is available to the front of the building and there is a large garden to the rear. 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. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted on 9th June 2005 and lasted for six hours. Time was spent interviewing the manager, staff members and speaking with the five individuals using this respite facility at the time. Additional information was obtained through receipt of the manager’s pre inspection questionnaire, a tour of the premises, perusal of policies and procedures and conducting a case tracking exercise, by reading the care plans of the five service users in residence. Comment cards were received from five users of the service and included the following statements, “Hedgerows is a great place to go” and “appreciate the support given”. Seven comment cards were received from relatives / visitors and all indicated that they were kept informed of important matters and knew how to make a complaint, though had never had cause to. Five comment cards were received from Care Managers who indicated that the home works in compliance with their care plans. The home was clean and well maintained. Documentation was in good order and the recommendations from the previous inspection had been fully implemented. Service Users appeared relaxed and happy and the number of staff on duty was meeting the individual and collective needs of those in residence. What the service does well: Care plans are specific and concise. They detail the exact nature of presenting needs and how these are to be met by care staff. A clear system is in place, which ensures this information is reviewed and updated every time a service user returns to the home. Staff are well supported through regular supervision and appraisal. They have access to a range of courses, which are relevant to inform the staff and therefore enhance the quality of care provided to service users. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 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. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 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 H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 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) 1,2,3,4. Prospective service users and their families are given the information they need to make an informed choice about whether to use the service. EVIDENCE: A clear procedure is followed in practice with regards new admissions into the home. Written evidence in care files supports that care managers, the service user and family members all contribute in providing current and necessary information. The home is equally clear about the services it provides, in terms of the needs it can and cannot meet. All of the service users routinely staying at the home have conducted initial tea and overnight visits, before deciding that they would like to stay on a regular basis. At the time of this inspection, one individual had arrived the night before as an ‘emergency admission and the inspector and manager discussed the procedure that had been used. Whilst the policy on emergencies had been followed, it was recommended that this be reviewed, with particular emphasis placed upon the use of risk assessments. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 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. Service Users know the contents of their care plans and where possible, assist care staff when these are reviewed and updated. Activities, meals and outings are planned in consultation and all care files contain collective and individual risk assessments. EVIDENCE: The service users spoken with confirmed an understanding of the contents of their own care plans. They are able to view their own files and their own views about the services offered, including the quality are regularly obtained through questionnaires and other, more informal, routes. Evidence was seen within care plans to support that clear and relevant risk assessments are followed in order that independence is promoted, whilst safety is maintained. Such areas included; meal preparation, using public transport and following own hobbies and interests. Throughout the course of the visit, staff were observed to routinely consult with those in residence with regards how they would like to spend their evening and given the number of staff on duty, the requests made could be met. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16, 17. Service users benefit from accessing a wide and varied range of leisure activities, which frequently involves the local community. Important relationships are respected and encouraged and service users feel valued. Staff encourage individuals to take responsibility for their own actions. Meals are wholesome and mealtimes are social, enjoyable occasions. EVIDENCE: The specific hobbies and interests of service users are clearly recorded within all care plans and individuals are able to bring in own personal items from home if they so wish. Provided within the home are; televisions, music systems, books, magazines, videos, DVD’s, board games, etc and a number of communal rooms enables people to choose whether to be alone or join in with a group activity. Shops and pubs are within walking distance and the town of Maidstone is easily accessible by car, (the home has its own transport), therefore leisure centres, cinemas and restaurants are easily visited. Service users enjoy the regular outings provided by the home, including camping trips, H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 11 excursions to the coast and the annual garden party, to which neighbours and other supporters / friends of the service, are invited. Service users’ important social relationships / friendships are sensitively described within care plans and these are respected by staff. The evening meal was well presented and reflected the personal choices of those in residence. People could have second helpings if they wished. Staff and service users sat together; all engaged in appropriate banter and one individual was given discreet and appropriate support by a staff member. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 12 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, 20. Personal care needs are sensitively attended to, in accordance with service users’ expressed wishes. All medication is safely and appropriately stored and administered. EVIDENCE: Care plans specifically detail the type and nature of support that individuals need, in order to maintain optimum physical and emotional health. Staff confirmed that the clarity of individual care plans helps them to deliver care in a way that the individual is comfortable with. This is particularly important for those requiring assistance with personal care and the home follows clear guidance with regards same gender and intimate care needs; wherever practicable and possible, working in the preferred way of the individual. At the time of the inspection, no service user was retaining own medication. Storage, stock and administration records were inspected, with all found to be in good order. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 13 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, 23. Service users know their opinions matter and they trust that staff act positively on their behalf. Clearly defined systems and processes within the home promote the safety of those staying there. EVIDENCE: Service users told the inspector that staff always listen when they want to tell or ask them something and returned comment cards from service users, visiting professionals and family members, all confirmed that people are fully aware of the home’s complaint’s procedure. The complaint’s file was inspected, with two entries made since the last visit. One had been resolved and concluded, whilst the other was still being investigated. The inspector and manager discussed the need to review the detail currently included and recorded in this folder, to ensure it is sufficient. Staff were clear about how to put relevant policies and procedures, regarding the protection of vulnerable adults, into practice and further supporting evidence was seen to include regular and appropriate training in this area for all staff. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 14 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, 27, 28, 30. Service users stay in a clean, warm and homely environment. Bathrooms and toilets are well maintained and afford privacy. Cooking, laundry and bathing facilities promote good standards of hygiene and there is ample communal space, which can be easily accessed by every individual using the service. EVIDENCE: All areas of the home were toured and found to be in a good state of decoration and repair. This element has been further enhanced due to the employment of a part time ‘handyman’ who, at the time of this visit was undertaking major works within the garden. Service users and staff were particularly pleased about this project, which includes wide paths, scented areas, seating and a patio. The two lounges are well equipped and the transformation of a ‘wasted’ storage area into additional leisure space means that there is ample provision for people to be alone or in groups, as they wish. The bathrooms and laundry were suitably clean, as was the kitchen and equipment within. Staff take appropriate measures to maintain good hygiene practices and this is further endorsed by appropriate training and clear policy and procedural guidance for them to work to. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 15 H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 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, 34, 35, 36. All staff have clearly defined job descriptions and contracts of employment. Training is offered beyond the minimum requirements and all staff benefit from receiving regular, documented supervision and appraisal. EVIDENCE: Through inspecting personnel files and speaking with staff members, it was evident that individuals work to clearly defined job descriptions and know what is expected of them. There is one staffing vacancy at present and this is being covered through the use of regular casual staff, who are familiar with the policies and procedures of the home. NVQ training continues and the file of a relatively new employee demonstrated that a clear induction package is being followed. Staff spoken with confirmed their own experience of a sound and thorough recruitment process and the supporting evidence seen in terms of the ongoing training courses provided, was of good quality. All of the staff files seen showed clear evidence of regular, documented supervision and appraisal meetings and the manager advised the inspector of Kent County Council’s newly introduced ‘Behaviours for Success’ package, which is to be used in addition to supervision and appraisal to further enable the personal development of staff. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 17 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) 37, 39, 41, 42. The home is run efficiently and effectively and the views and opinions of service users and their families are used to develop and shape the continued development of the service. Record keeping policies and procedures protect vulnerable adults, whose health, safety and welfare is continually promoted. EVIDENCE: The manager and staff team work cohesively and support service users to follow flexible routines. The service is financially viable. Clear audit trails and monitoring systems are in place and the views expressed by service users and their families are valued as a key ‘quality assurance’ tool. At the time of this visit, the Regulation 26 Visitor was conducting an un announced inspection, focusing largely upon fire safety. He also spent time speaking with staff and service users, to obtain their views about the operation of the service. Personnel records are securely held, however; they do not contain all of the information required for the purposes of CSCI inspections, for example, original references. These records are obtained; they are held at Kent County H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 18 Council Head Quarters Personnel Department. This omission must be addressed. The health and safety policy and other associated guidance is clear and available. It was demonstrated by those staff spoken with that they understand and follow such guidance. Risk assessments are in place and staff and service users know and practise emergency procedures, such as fire evacuations. Certificates and up to date reports demonstrate that the home has adequate insurance cover and ensures the routine inspection and servicing of equipment and electrical and gas appliances. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 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 3 3 3 2 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 4 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x 1 3 x H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 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 41 Regulation 19, Schedule 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. The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. This requirement is made within the context of the emergency admissions procedure being reviewed to include a clear risk assessment approach, in particular, when potential risks are identified at the referral stage. Timescale for action Action Plan to be received by CSCI by 21/7/05 Action Plan to be received by CSCI by 21/7/05 2. 4 13 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. Refer to Standard 22 Good Practice Recommendations it is recommended that the information currently held H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 21 2. 2 3. 20 within the homes complaints file be reviewed, to ensure sufficient information demonstrates how a complaint has been investigated to the point of resolution / conclusion. It is recommended that consideration be given as to the detail recorded on individual care plans in respect of current medication taken. This recommendation is made in terms of service users using the service for a few weeks each year and as such, routine dosages and types of medication used can change in between stays. If dosages are to be recorded on care plans, these must tally with the directions as stated on the original packaging. It is recommended that the written information available for staff pertaining to PRN medication commonly used, be expanded upon, to include its purpose, amount to be taken, under what circumstances and possible contraindications. H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 H56-H06 S37839 Hedgerows V222934 090605 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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