Inspection on 22/12/05 for 10 Leyton Avenue

This inspection was carried out on 22nd 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 Leyton Avenue 03/10/08

10 Leyton Avenue 09/11/06

10 Leyton Avenue 09/06/05

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

CARE HOME ADULTS 18-65 10 Leyton Avenue 10 Leyton Avenue Gillingham Kent ME7 3DB Lead Inspector Sue McGrath Unannounced Inspection 22nd December 2005 10:00 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 10 Leyton Avenue Address 10 Leyton Avenue Gillingham Kent ME7 3DB 01634 280235 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) MCCH Society Limited Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 2005 Brief Description of the Service: 10 Leyton Avenue is one of a number of homes managed by MCCH Society Ltd. The home offers 24-hour care for 3 adults with a learning disability. It is located within a pleasant residential area. There is a local bus route nearby giving access to Gillingham town centre. The home is a semi-detached premises with accommodation on two floors. There are three single bedrooms. The first floor can only be accessed by a stairway. It employs one manager, care staff and sessional staff. There is one member of staff at night on waking nights and the organisation has an emergency on-call system for emergency cover. Catering, domestic chores, gardening and administration is dealt with by the care staff. Service users are encouraged to take part in daily activities to the best of their abilities and access the local community and amenities 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, under the terms of the Care Standards Act 2000, took place on the 22nd December 2005 between 10.00 and 12.30. One inspector was in the home and the main focus of the inspection was on the progress of the home in meeting with requirements made at the last inspection, the general environment and the well being of the residents. During the inspection documentation and records were read. A tour of the building was undertaken and all of the residents were spoken to. Time was also spent talking to the staff members on duty. The Manager was not on duty on the day but both of the staff at the home coped well with the inspection process and were very helpful. As this report was made following an unannounced visit and may not cover the standards in sufficient depth for the reader to make a judgment about the home, it is recommended that a copy of the last announced inspection report dated 9th June 2005 be also obtained. What the service does well: What has improved since the last inspection? The Manager had completed her registration with the Commission and was now the Registered Manager. The worktops in the kitchen and some broken tiles had been replaced. Some redecoration within the home had taken place. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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): 1and 5 The home’s Statement of Purpose and Service User Guide are comprehensive and provide prospective service users with the information they need to make an informed choice about moving into the home. Residents benefit from being provided with a statement of terms and condition of residency. EVIDENCE: Standards 2-4 were met at the last inspection. The home’s Statement of Purpose was seen and now contained the necessary information required under this standard. All of the residents had a written and costed contract/statement of terms and conditions. Due to the level of disability amongst the residents, it had been decided not to provide the contracts in a format suitable for their needs. Staff did confirm that every effort had been made to enable the residents to understand the concept of a contract. One area in the contract that needed amending was around a private room in which to meet with visitors. The home does not currently have this room available and this statement should be removed from the document. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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): Judgement made in the last report. Resident benefit from knowing their assessed and changing needs are reflected in their individual plan and that they are involved with making decisions about their lives where possible. Residents benefit from a robust confidentiality policy. EVIDENCE: Standards 6-10 were assessed as met at the last inspection. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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 the following standard(s): 14 Residents benefit from having the opportunity for personal development with their daily living skills and have appropriate level of leisure activities. Residents also benefit from being part of the local community. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. EVIDENCE: On the morning of the inspection the residents were feeling the effects of Christmas party the night before. Most had risen late and were having a late breakfast. During the meal it was very evident that they had really enjoyed the party and enjoyed meeting with all of the residents from other homes within the group. The positive interaction between the staff was very relaxed and clearly staff had enjoyed themselves as well. All of the residents had enjoyed holidays this year. Two residents had gone to Cornwall for a week in a dedication mobile home. Staff had hired a car and everyone had enjoyed the break. One resident explained how they went 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 Page 11 somewhere different every day and how much she had enjoyed herself. The other resident preferred to go on her own with staff and spent five days in a cottage in Suffolk. Staff stated they she had enjoyed the break and being with two dedicated members of staff. Staff felt that the holidays had been very positive and had a very good effect on the relationships between staff and residents. Plans were being put in place to book holidays for the coming year. The other standards were met at the last inspection. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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 the following standard(s): Judgement made in the last report Service users have clear and in-depth care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure changes are recorded and acted upon. Health needs are met and service users have full access to all professional health care services as required. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Standards 18-21 were met at the last inspection. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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 the following standard(s): The home has a robust complaints system and the home’s Adult Protection Policy and procedures protect residents from abuse. EVIDENCE: Standards 22-23 were met at the last inspection. There had been no complaints this year. Records indicated that not all staff had completed Adult Protection training recently. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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 the following standard(s): Parts of the home needs to be refurbished for the benefit of service users. Service users have access to safe and comfortable indoor and outdoor communal areas. Residents do not benefit from having a laundry area that meets approved professional guidelines and minimum standards. Whilst service users’ rooms are homely and comfortable not all service users benefit from living in rooms that meet the requirements for space. EVIDENCE: The two requirements made at the last inspection regarding the extension and the remedial work in the bathroom had not been complied with. The office and laundry room remained very damp with mould growing over the walls. Staff did say that maintenance workers had viewed the walls but no action had been taken. This will remain an urgent requirement and should be addressed. The laundry floor requires replacing with an impermeable surface and the walls must be easily cleanable. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 Page 15 A new freezer had been purchased and placed in the laundry room, consideration must be given as to whether this was a suitable site for this equipment considering soiled washing was handled only a few inches away. The bathroom remained in the same condition and the requirement to replace the flooring and bath panels will remain. New work surfaces had been fitted to the kitchen worktops and the tiles had been replaced. An accident earlier in the year with the grill tray had burnt the flooring and this should repaired or replaced. The kitchen was clean and tidy. The lip of the flooring between the kitchen and the office area had risen and was causing a trip hazard. This needs to be repaired or replaced urgently. Staff had decorated some parts of the home and work will continue. The lounge had been partially decorated but the old fireplace remained an eyesore with the hole blocked up. Discussion took place around removing the old wooded cladding that covered the chimneybreast wall and serious consideration should be given to this. Two of the bedrooms had been redecorated by staff and were well personalised and looked comfortable. The one very small room remained the same. The resident who occupied the room wanted a desk, but the room was too small to accommodate one. It is advised that if and when a larger room becomes available it is offered to this resident. The resident who occupied this room explained how she liked to spend a lot of time on her room listening and signing to her music. Her space was very limited to enjoy this activity. The area under the stairs that houses all the electric wires and fuse boxes needs to boxed in for safety reasons. This could easily be achieved by building an accessible cupboard under the stairs. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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 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): The residents benefit from being cared for by staff who have a good understanding of their needs. Residents are at risk due to some staff not having some of the mandatory training. EVIDENCE: Standards 31-36 were meet at the last inspection. Standards 35 was reassessed. Some areas of staff training was identified as having lapsed. These included Manual Handling and Adult Protection. Some training sessions for the above were last recorded as being completed in 2003. The manager is advised to ensure that all of the mandatory training is updated as soon as possible. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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 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): The residents benefit from having a manager who provides clear leadership throughout the home and by staff who demonstrate an awareness of their roles and responsibilities. EVIDENCE: The manager had recently successfully completed her registration with the Commission and was now officially the Registered Manager of the home. Although not on duty on the day of the inspection the Manager did arrive towards the end. Discussion with the staff confirmed that they felt the home was mainly managed well. All of the staff had undergone a lot of changes with the takeover of the home by MCCH and some areas had caused some disruption but these areas appeared to now be settled. The organisation had extensive policies and procedures and staff all signed each one to say they had read and understood them. The files for both the residents and staff were securely stored in the damp office and felt and smelt damp. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 Page 18 The staff on duty were unsure about whether the home had an effective quality assurance and quality monitoring system in place, so this will be assessed at the next inspection. With regards to the health and safety of the residents and staff a few minor areas were identified as needing improvement. The fridge temperatures had been reading high (average of 10 degrees centigrade) for the last two months. Although a column for taking action was included on the recording form, no action had been taken and the fridge remained warm. This must be addressed. When the fire drill records were examined, some staff had not completed a fire drill for over two years. Although regular fire drills were taking place they were hot happening across the board with all staff being included. All other required fire checks were taking place. Staff spoken with were aware of the importance of COSHH and all had been trained in Basic Food Hygiene. Moving and Handling training was not current for the majority of the staff and as this is one of the mandatory training this must be addressed urgently. The accident book was viewed and only one minor entry had been made. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 2 29 2 30 1 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 3 X 2 2 2 X 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 Page 20 YES 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 YA24 Regulation 23(2)(b) Requirement Timescale for action 31/01/06 2. YA27 23(2)(b) 3 YA30 23(2)(b) The Registered Person shall having regard to the number and needs of residents ensure that the premises to be used as a care home are of sound construction and kept in a good state of repair externally and internally. This requirement is made in respect of the damp extension. This requirement was not met from the last inspection. Action plan required. The Registered Person shall 31/01/06 having regard to the number and needs of the residents ensure that the premises to be used as a care home are of sound construction and kept in a good state of repair externally and internally. This requirement is made in respect of the flooring in the bathroom and bath panel that requires replacement. This requirement was not met from the last inspection. Action plan required. The Registered Person shall 31/01/06 having regard to the number and needs of the residents ensure DS0000064392.V274882.R01.S.doc Version 5.1 10 Leyton Avenue Page 21 4 YA24 13(4)(a) 5 YA24 23(2)(c) 6 YA35 18(1)(c) that the premises to be used as a care home are of sound construction and kept in a good state of repair externally and internally. This requirement is made in respect of the laundry floor and walls. Action plan required. The Registered Person shall 31/01/06 having regard to the number and needs of the residents ensure that the premises to be used as a care home are of sound construction and kept in a good state of repair externally and internally. This requirement is made in respect of the damaged edge on the floor between the kitchen and the passage to the office. The Registered Person shall 31/01/06 having regard to the number and needs of the residents ensure that equipment provided at the care home for use by residents or persons who work at the care home are maintained and in good working order. This requirement is made in respect of the broken fridge. The Registered Person shall 31/01/06 ensure that there is a staff training and development programme which ensures all mandatory training is completed. 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 YA25 Good Practice Recommendations It is recommended that the small bedroom is used for a private lounge for visitors, as it is not fit for purpose for DS0000064392.V274882.R01.S.doc Version 5.1 Page 22 10 Leyton Avenue 2 3 4 YA42 YA42 YA24 that particular resident and does not met her needs It is recommended that all staff complete a fire drill. It is recommended that the area under the stairs that houses all the electric meters and fuse boxes be boxed in. It is recommended that consideration be given to redecorating the chimneybreast in the lounge to make it more homely. 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone 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 10 Leyton Avenue DS0000064392.V274882.R01.S.doc Version 5.1 Page 24 - 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. 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