Inspection on 20/12/05 for 1 St Alphege Road

This inspection was carried out on 20th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 St Alphege Road 23/10/08

1 St Alphege Road 27/06/08

1 St Alphege Road 17/07/07

1 St Alphege Road 04/08/06

1 St Alphege Road 05/09/05

1 St Alphege Road 13/12/04

1 St Alphege Road 01/09/04

1 St Alphege Road 20/01/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 1 St Alphege Road Dover Kent CT16 2PU Lead Inspector Joseph Harris Announced Inspection 20th December 2005 10:00 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 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 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 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 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 1 St Alphege Road Address Dover Kent CT16 2PU 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) 020 8780 9686 None United Response Mr Marc Wood Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2005 Brief Description of the Service: 1 St Alphege Road is a 7 bedded home supporting people with enduring mental health problems. The service is owned and managed by United Response, which is a national charitable organisation specialising in the fields of mental health and learning disabilities. The house is on a residential road close to the centre of Dover, which has relatively good amenities and public transport links. The premises are set over 4 floors and provide of space for service users. All of the bedrooms are single occupancy and there are number of well appointed communal lounges and spaces. There are attractive gardens surrounding the building that are reasonably well maintained. Service users are encouraged and supported to work towards a more independent lifestyle with staff facilitating the choices and decisionmaking of the residents. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 20th December 2005 and lasted for around 7 hours. During the course of the inspection discussion were held with the acting manager, staff and service users. A tour of the premises was undertaken and a range of documentation was viewed. 2 requirements and 3 recommendations were made as a result of this visit. Satisfaction questionnaires were returned by 3 of the 5 current residents, which were all positive in their feedback. What the service does well: What has improved since the last inspection? The staff team has continued to develop individual service user files, which provide a good level of detail and guidance to address a range of support needs. Risk assessments are also completed to a good standard. There is clear evidence that staff have continued to work positively with service users, enabling one resident, in particular, to gain greater confidence in going out with staff support. Medication systems have also continued to be improved and shortfalls addressed since the last inspection. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 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 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 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 the following standard(s): 1 and 2. There is adequate information available regarding the service and prospective service users needs and aspirations are assessed prior to moving in to the home. EVIDENCE: The home has developed both a statement of purpose and service user guide containing all required and relevant up to date information regarding the home. Copies of both these documents are available on request and a service user guide is provided to all new and prospective service users. The home has well developed assessment processes addressing the needs and aspirations of those referred to the home. All prospective service users receive support under the care programme approach from multi-disciplinary mental health services. As a result of this the home ensures that current CPA documentation including care plans and risk assessments are made available as part of the assessment process. In addition to this the home has developed it’s own assessments tools focussing on aims, aspirations and support needs. Any potential restrictions are clearly identified and discussed with the service user and significant others. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 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 the following standard(s): 6, 8, 9 and 10. Each service user has an individual plan of care including adequate risk assessments. Residents are enabled to participate in the day-to-day running of the home. Information is maintained in a confidential manner. EVIDENCE: A number of individual service user files were viewed, which provide good levels of information, clear guidance to enable staff to meet and address care needs and detailed risk assessments. The plans aim to promote independence and empowerment and are developed in conjunction with the individual and their key worker. Plans are regularly reviewed and revised through focal meetings using a team approach. Regular reviews are held with the multidisciplinary team and care managers to further underpin the efficacy of the support plan. Residents are encouraged to take an active part in the running of the home and in organising their own time effectively. The focus of the home is upon rehabilitation and, as such, service users are supported to plan and prepare meals, maintain the cleanliness of the home and develop other daily living skills. Regular resident meetings are held and the organisation has a culture of user involvement with national and regional user groups in place. Residents 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 10 are also able to take part in the interviewing of staff and other aspects of the home. All documentation and information is retained in a confidential manner. Staff address issues of confidentiality through the induction programme and show good awareness of the need for these issues to be upheld. Records are kept securely in locked surroundings and there is an access to records policy in place. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 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 the following standard(s): 11, 14 and 16. Residents have opportunities for personal development and take part in a range of leisure activities. Service users are supported to take responsibility for their own lives. EVIDENCE: The home provides a supportive environment to enable service users to develop life skills. Support plans clearly identify the aims and needs of each service user covering holistic needs enabling them to work towards short and long-term goals. The focus of the home is to provide a rehabilitative framework assisting individuals to move towards a more independent life style. There is a range of recreational and leisure activities available in and out of the home. The majority of service users prefer to engage in activities on their own or with support from staff rather than as part of a group. However, occupational therapy groups are available at the nearby mental health day centre, as well as courses at local colleges. Some service users attend other groups in the local area and informal activities are available within the home. Service users have the opportunity to take an annual holiday with staff support where required. Residents are encouraged, wherever possible, to organise their own daily routines. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 12 There is a positive emphasis upon residents to live their lives as they wish to do so within therapeutic bounds. Times for getting up, going to bed, meals, etc are flexible. Residents are assisted to become as independent as possible and staff respect the space and privacy of each individual, knocking before entering rooms. Residents have keys to the home to enable freedom of access. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 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 the following standard(s): 18, 20 and 21. Residents receive personal support in a sensitive manner. Medication systems are adequate. Issues of ageing, illness and death are handled with respect. EVIDENCE: The majority of service users are fully self-caring requiring little support from staff other than encouragement and reminders. Where personal support is required in any aspect of daily life this is clearly documented and followed through by staff. Residents are enabled to establish routines that meet individual needs and preferences, but where support is required the staff team ably provide this. The home ensures that service users have access and are supported to visit their GPs, Psychiatrists and other healthcare professionals. A key worker system is in operation. All aspects of medication were inspected. The record keeping was well maintained and up to date in relation to administration, stock levels and disposal of medications. Storage facilities are adequate; medication is kept in a locked cupboard in a locked room. Three of the current service users are selfmedicating and adequate measures are in place to ensure monitoring and safety. Policies and procedures are clear, accessible and kept under review. Policies and procedures are also in place addressing ageing, illness and death. The staff in the home monitor the healthcare needs of service users and address any changing needs appropriately. The home maintains good contact 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 14 with resident’s families ensuring they are kept informed of any relevant and appropriate information. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. There is an adequate complaints process in place. Service users are protected from abuse. EVIDENCE: The home has a clear, comprehensive and accessible complaints procedure. Any disputes or concerns are addressed through residents meetings and 1:1 meetings as required. Initially it is hoped that complaints can be addressed on an informal basis within the home, but there are clear lines of accountability in the organisation should this prove unsatisfactory with involvement from senior managers as required. One complaint has been made since the last inspection about one service user by another. There was documented evidence regarding the investigation and clear outcomes addressed to both parties. The home has clear policies and procedures relating to issues of abuse, which are underpinned through the induction process and in additional training. Staff demonstrated a good awareness of adult protection protocols and the involvement of other regulatory bodies. A number of staff members have participated in adult protection training and copies of the Kent and Medway adult protection procedures are accessible. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 and 30 The home is suitable for the needs of the service users. Bedrooms are well furnished and toilets and bathrooms meet individual needs. There is adequate communal space and the home is clean and hygienic. EVIDENCE: The decor and furnishings in the home are of a good standard throughout and the premises are light, well ventilated and comfortable. The home meets the requirements of the fire and environmental health departments. Systems are in place to ensure maintenance and refurbishments are carried out as required. Bedrooms are adequate for the needs of each resident and all rooms are single occupancy. There is an adequate number of toilets and bathrooms in the home. There is a good range of communal space available and accessible to all service users including two large, well-appointed lounges, one of which is a designated smoking room. There is also a large kitchen with a breakfast bar, a comfortable dining room and a conservatory. There is a good-sized garden with outdoor furniture, which is accessible to all service users. The home was clean, hygienic and free from offensive odours. The laundry and kitchen facilities are adequate for the needs of the home. There are policies and procedures in place for the control of infection and staff have undertaken additional courses addressing this topic. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 17 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 and 36. Staff have clear roles and responsibilities. The organisation supports staff development and training, although some mandatory training needs to be updated. Recruitment practices are generally well managed, although some personnel files require updating. There is a supervision system in place, but following management changes these need to be reviewed and revised. EVIDENCE: United Response is a large nationwide organisation and has comprehensive job descriptions in place for all levels of employment. Staff were clear about their own and others responsibilities and there are clear lines of accountability throughout the home and organisation. There is a relatively experienced and stable staff team in the home who demonstrate good competencies and skills. Staff spend time with service users developing positive relationships and supporting individuals. 4 members of the staff team have achieved NVQ level 3 and 2 others are currently working towards NVQ level 2. The organisation has a good ethos regarding staff training and development with a dedicated training department, however it was noted that a number of staff require updated mandatory training, which the acting manager acknowledged and has already begun to address. Refer to requirement 1. A training matrix is in place, but is currently out of date and should be updated. Additional training is also provided including mental health awareness, adult protection and management of aggression. It is advised that all staff receive training covering these topics. Refer to recommendation 1. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 19 A number of staff personnel files were viewed, most of which contained all required information, however some files lacked proof of identity and evidence of CRB and/or POVA first checks. It was reported that these have all been acquired, but are currently held at the regional office. Refer to recommendation 2. The registered manager has recently left the home to take up another position within the organisation and the deputy manager is currently in an acting manager role. Due to this fact supervision systems need to be reviewed and revised ensuring that all staff receive regular formal supervision at least every two months. In discussion with staff however, they stated that the manager and area manager provide good levels of informal support. Refer to recommendation 3. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The home is currently without a registered manager. There are good quality assurance processes in place. The health, safety and welfare of service users is protected. EVIDENCE: The registered manager has recently left his position within the home to take up another role in the organisation and the deputy manager has taken on the acting manager role. At the time of the inspection the notice period of the registered manager was yet to have run its course, although due to annual leave the deputy manager had effectively commenced his new role. The organisation should ensure that the commission is duly notified when the registered manager has officially left his post. The deputy manager has been in post for 2-3 years and has a very good knowledge of the home and workings of the organisation. He is supported by the area manager in his role and staff members also confirmed that they are happy with this interim appointment. The home does need to appoint a manager to be put forward for registration within due course. Refer to requirement 2. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 21 The home and organisation has instituted robust quality assurance processes. The home is managed by United Response, which is a national charitable organisation and has a clear management structure with strong lines of accountability. The area manager visits the home at least on a monthly basis and completes Regulation 37 monitoring visits, which are made available to the Commission. There is clear evidence of service development including plans for a semi-independent flat and an outreach service. A programme of routine maintenance and refurbishment is planned on an annual basis. Systems are in place to get feedback from service users and stakeholders regarding the service through quality monitoring visits, satisfaction questionnaires and residents meetings. The home maintains clear and consistent health and safety records. Fire safety records were up to date and maintained as were the accident records. All routine maintenance checks were completed with records retained on file. Environmental risk assessments were also in place and are reviewed. Adequate systems are in place to ensure safe working practices. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 X 2 1 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1 St Alphege Road Score 3 X 3 3 Standard No 37 38 39 40 41 42 43 Score 1 X 3 X X 3 X DS0000023757.V262991.R01.S.doc Version 5.0 Page 23 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 YA35 Regulation 18 Requirement To ensure all staff receive all mandatory training within the first 6 months of employment and suitable updates thereafter. To appoint a manager who will be put forward for registration. Timescale for action 01/03/06 2 YA37 8, 9 01/03/06 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 YA34 YA35 YA36 Good Practice Recommendations To ensure all information relating to staff records is available for inspection at all times. To provide additional training for staff including mental health awareness and adult protection. To review formal supervision systems. 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 1 St Alphege Road DS0000023757.V262991.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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