Inspection on 09/11/06 for 10 Leyton Avenue

This inspection was carried out on 9th November 2006.

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 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 4 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 22/12/05

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 Jo Griffiths Key Unannounced Inspection 9th November 2006 10:30 10 Leyton Avenue DS0000064392.V319611.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 10 Leyton Avenue DS0000064392.V319611.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. 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 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 Miss Karen McCaw Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd December 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 semi-detached with accommodation on two floors. There are three single bedrooms on the first floor. The home employs one manager, a deputy and care staff. There is one member of staff at night on waking nights and the organisation has an 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.V319611.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced. The deputy Manager was on duty and gave feedback on the achievements made since the last inspection. Some records were viewed and two of the people living at the home were spoken with. One person was able to give their views and another person was observed being supported by carers. Two comment cards were received from service users and three from relatives. The comments about the home were positive and included “I know my sister is well looked after” and “The Manager is very easy to talk to” What the service does well: What has improved since the last inspection? What they could do better: There is still some work needed to the extension where the laundry, toilet and office are. It is very damp and unpleasant for service users and staff to use. The floor and walls in the laundry need to be sealed so that they can be easily wiped clean to avoid infection risks. This was required at our last inspection and a recent Environmental Health visit, but has not been done. One person’s care plan should be reviewed to make sure it includes up to date information about meeting their nutritional needs. This is because the staff said that the person does not always eat their meals but the care plan did not 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 6 reflect this. It would also be useful if the staff had some training in nutrition to help them ensure the menu is balanced nutritionally. A policy for monitoring the quality of the service needs to be written by MCCH. 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. 10 Leyton Avenue DS0000064392.V319611.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 10 Leyton Avenue DS0000064392.V319611.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): Standard 2 was inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that they will have their needs assessed before moving to the home or moving on. EVIDENCE: The three people living at the home have been there for some time. They have their needs reviewed through the review of the care plan. One service user is looking to move on to a new home and the Manager and Care Manager are working together to make sure her needs are going to be met. The Manager hopes to then change the home to a two bedded home as the third bedroom is below the recommended standards. 10 Leyton Avenue DS0000064392.V319611.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): Standards 6, 7 and 9 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users have an individual plan that meets their needs. Service users are supported to make daily decisions. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: Each person has an individual plan that identifies their needs and how these will be met. A new format for planning is being introduced and work was underway on this. The plans have been signed by the service user, where possible, and have been reviewed each month. A formal review meeting is held each year. The personal profile written for each person was very informative and written in a style that promotes the independence and individuality of that person. 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 10 One person’s plan did not include enough information about their dietary needs. The staff on duty reported that this person does not always eat vegetables or fruit and will often refuse meals. Whilst they are not concerned that this is affecting her wellbeing it should be addressed within the plan. Training is planned for staff in Person centred planning to help them to support service users to be able to have more control over their lives and make more decisions. At the moment service users are supported to make daily choices, such as what to eat and what activities to do. Risk assessments are in place for all the activities service users participate in that may present some risk. The risks have been clearly identified and minimised so that the person can enjoy a fulfilled lifestyle. The risk assessments are very well written and involve the service user where possible. 10 Leyton Avenue DS0000064392.V319611.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): Standards 12, 13, 15, 16 and 17 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to enjoy a range of activities both within the community and at home. Service users are supported to make and maintain relationships. Service users rights are respected within the home. Service users enjoy a varied diet. EVIDENCE: Service users have a plan of activities that they like to do each week. This includes going to a social club, relaxation, line dancing, keep fit and shopping. Service users access local facilities for their personal shopping needs and use 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 12 pubs and restaurants as they wish to. Other activities can be arranged as people choose. Service users are supported to maintain contact with their family and friends and are supported to make new friends through their various activities. The deputy Manager said that visitors are welcome at the home at anytime and can either see the service user in their own room or use the dining room. Service users are encouraged to be involved in some household tasks and are given the support they need to do this. They have a tenancy agreement and understand that they need to respect the other people in the home. Their own personal space and their right to make decisions are respected by staff. Service users choose what they want to eat on a daily basis. It would be useful for at least one member of staff to have training in nutrition to help them to review the menus to check they are nutritionally balanced each week. One service user spoken with said she liked the food. 10 Leyton Avenue DS0000064392.V319611.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): Standard 18, 19 and 20 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users personal needs are met. Service users’ health needs are mostly met. Service users are supported to manage their medication safely. EVIDENCE: Records showed that each person’s health needs were being met by the GP and other professionals. Staff must ensure that the weight of the person who often refuses meals is taken regularly to ensure she is not losing weight. Personal care needs are detailed in the care plan and staff are given the information they need to offer the correct levels of support to the person. Service users emotional needs are met by the care staff and service users know they can also contact their care Manager if they have any worries or things they wish to discuss. 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 14 The service users of the home need the staff to hold their medication safely and help them to take it. Medication is stored safely within a locked cabinet and accurate records are kept. Staff have completed training in medication and the Manager has assessed their competence to safely give medicines to service users. 10 Leyton Avenue DS0000064392.V319611.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): Standards 22 and 23 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users know they can make a complaint and that they will be listened to. Service users can be confident that they will be protected from abuse. EVIDENCE: The service user spoken with said she knew whom to talk to if she had any problems. There is a picture chart on the door with all the staff photos on it showing who will be at the home each day. There is a complaints procedure for the home. There have been no complaints received. All staff have received training in safeguarding vulnerable adults. There are robust procedures in place and a whistle blowing policy. 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 27, 28, 30 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a homely environment, but would benefit from maintenance works to some areas to address damp. Service users bedrooms meet their needs. Service users have sufficient bathroom facilities. Service users have access to sufficient communal space. Service users benefit from a generally clean home, but there is some infection risk within the laundry room. EVIDENCE: Generally the environment is homely and meets the needs of the people living there. However, there are still concerns about the environment of the 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 17 extension housing the records of the home, the service users toilet and the laundry facilities. A requirement was made at the last visit that the damp problem should be addressed and that the laundry walls and floor must be suitably sealed to ensure they can be easily cleaned and cannot present an infection risk. This has not been done. The Environmental Health department visited the home in June 2006 and also asked for this work to be done by October 2006. It has still not been completed. The provider must address this. The rest of the home was clean and well furnished. Two of the bedrooms had been decorated and reflected the occupants’ individual taste. The third bedroom is very small and the person living there is looking to move on as it is no longer meeting her changing needs. Her Care Manager is involved and is looking at new homes. The bath panel and flooring in the bathroom have now been replaced and the lounge has been redecorated. It looks very homely. A new dining table has been purchased and new chairs are on order. The electrics under the stairs have been boarded in for safety. 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, and 35 were inspected. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can be confident that they are supported by qualified staff. The quality of care offered to service users is enhanced because they are supported by trained staff. EVIDENCE: Standard 34 is to be inspected separately to this visit by the Provider Relationship Manager for CSCI. There are 60 of staff with an NVQ award at level 2 or above. This is very positive for service users who can be assured they are supported by qualified staff. The training records for the home are very good and staff have received training in all the areas they need to do their job. Certificates are held and more recent certificates show the content of the course. 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 19 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): Standards 37, 39 and 42 were inspected. 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 living in a well run home. Service users can be confident that they will be asked their views of the running of the home. Service users can be confident that their health and welfare will be protected. EVIDENCE: The Manager is qualified in NVQ and is undertaking a management training course through MCCH. She has experience of supporting this service user group and provides clear leadership for the home. 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 20 Whilst there is not a formal policy for quality assurance for the home there are some opportunities for service users to share their views with staff and the Manager. MCCH send out questionnaires annually to gather the views of service users and their relatives. A formal policy stating the organisations quality assurance programme should be developed. Apart from the issue described under the environmental standards there are no concerns about health and safety practice within the home. 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 21 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 x 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 3 26 x 27 2 28 3 29 x 30 2 STAFFING Standard No Score 31 x 32 4 33 x 34 x 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 2 x x 3 x 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES 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 YA30 Regulation 23(2)(b) Requirement 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. In that, The damp in the extension, including the office, laundry and service users toilet, must be addressed. The laundry floor and walls must be impermeable and therefore easy clean. This requirement was not met from the last 2 inspections. 2. YA6 12(1)(a) The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users; DS0000064392.V319611.R01.S.doc Timescale for action 31/01/07 01/12/06 10 Leyton Avenue Version 5.2 Page 23 In that, service users nutritional needs must be properly addressed within the care plan. 3 YA39 24(1) The registered person shall establish and maintain a system for evaluating the quality of the services provided at the care home. In that, a policy for quality assurance must be developed. 31/01/07 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. Refer to Standard YA17 YA17 Good Practice Recommendations It is recommended that a least one staff member undertake training in nutrition. It is recommended that appropriate monitoring of service users weight is in place, especially for the service user who often refuses their meals. 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 Page 24 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 10 Leyton Avenue DS0000064392.V319611.R01.S.doc Version 5.2 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. 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