Inspection on 14/09/05 for 104 Wimborne Road

This inspection was carried out on 14th September 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 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

104 Wimborne Road 09/08/07

104 Wimborne Road 06/11/06

104 Wimborne Road 22/02/06

104 Wimborne Road 10/02/05

104 Wimborne Road 29/07/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Wimborne Road (104) 104 Wimborne Road Southend On Sea Essex SS2 4JR Lead Inspector Mr Trevor Davey Unannounced Inspection 14th September 2005 10:00 Wimborne Road (104) DS0000015488.V251622.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 Wimborne Road (104) DS0000015488.V251622.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. Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wimborne Road (104) Address 104 Wimborne Road Southend On Sea Essex SS2 4JR 01702 603698 01702 603698 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 Mr Michael George Sharp Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2005 Brief Description of the Service: 104 Wimborne Road provides accommodation and personal care for up to six adults with a mental disorder. The premises are a two-storey house in a residential area situated in Southchurch, Southend-on-Sea and is in close proximity to all local community facilities, amenities and transport links. The accommodation includes six single bedrooms all of which have call bells, television and telephone points. There are separate lounge and dining areas, kitchen, and a small garden with a patio. The surrounding area provides good parking facilities. Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on 14th.September 2005 lasting 3 hours. The inspection process included discussions with the senior support worker who was in charge at the time, and also another support worker who was also on duty. In addition, the inspector had conversations with three of the residents who were in the home at the time. A tour of the premises took place and a sample of policies and records were inspected. Ten standards were covered and requirements and recommendations, where these apply, are listed in the report. What the service does well: What has improved since the last inspection? What they could do better: From the sample check made, some of the dates in personal care records were inconsistent with other information documented where reviews had taken place. Maintenance items reported to the Registered Provider in the last few months, had not always been dealt with promptly and were still outstanding. Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 6 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. Wimborne Road (104) DS0000015488.V251622.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 Wimborne Road (104) DS0000015488.V251622.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 The homes Statement of Purpose and Service User Guide has been updated and provides detailed information for residents and prospective service users of the services the home provides, enabling an informed decision about admission to the home. EVIDENCE: Copies of the Statement of Purpose and Service User Guide were made available for inspection, which had been updated recently. Copies of the Service User Guide have been given to all residents. No new admissions have taken place since the last inspection. Wimborne Road (104) DS0000015488.V251622.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&9 The systems for resident consultation are good with a variety of evidence that indicates residents’ views are both sought and acted upon. Residents are encouraged to pursue an independent lifestyle supported by risk assessments where appropriate. EVIDENCE: Care plans and reviews gave detailed information of issues discussed with residents who had signed, together with a member of staff, acknowledging their agreement with the decisions reached. It was noted that there were some inconsistencies in the dates recorded in relation to care plans where reviews had taken place. Some of the residents spoken to were positive in the support received from members of staff and confirmed that they were approachable and that matters concerning their care and future plans, were discussed with them. Risk assessments were also available where appropriate, to ensure that residents could pursue their chosen lifestyle and outside activities safely and in a manner minimising possible risks to themselves and others. Outside activities included visits to day centres. Local shopping and art and craft classes. All residents are able to go out unsupervised on a regular basis. Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 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): X EVIDENCE: Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 11 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): 19 & 20 A holistic approach is taken in meeting the health and personal needs of residents. Support from some health care professionals is good whilst the standard of service received from others is inadequate. The administration of medication was being maintained in accordance with accepted and approved procedures. EVIDENCE: Detailed and comprehensive records were available which included care plans and risk assessments. Information included identified need, objective and expected outcome. Protocols had been completed and records of house reviews were in place. When challenging behaviour had been exhibited, this had been recorded together with the action taken as well as other health care professionals consulted. Some residents were waiting multi disciplinary reviews and whilst there was evidence to show very positive responses from community psychiatric nurses, in other cases, the response received was inadequate and had not been followed through with sufficient urgency. This meant increased pressure being put upon residents and the staff team. It is understood that the Area Co-ordinator has taken these issues up with the Primary Care Trust. From samples of records inspected, community psychiatric nurses had also been involved with updating care plans regarding mental health needs and residents concerned were also present during these Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 12 reviews. Where injections are required, these are given on a regular basis by both visiting C.P.Ns and C.P.Ns based at a local health centre. A sample check was made of medication administrative records and these had been completed and documented in accordance with laid down procedures. The last audit of medication by the pharmacist was recorded as taking place in May 2005. The Inspector was advised that there was a good working relationship with local doctors. Protocols were in place for P.R.N. medication. Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 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): 22 & 23 There is an established complaints procedure of which residents are aware and they have opportunity to express their views. Up to date policies and a whistle blowing procedure for the protection of vulnerable adults is available. EVIDENCE: Details of the complaints procedure is included in the Service Users’ Guide copies of which have been given to residents. No official complaints have been recorded since the last inspection. Details of the reporting procedure and other agencies to contact in the event of alleged abuse or an actual incident involving residents, were included in the whistle blowing procedure. Details of the procedure to be followed were included in the policy distributed to the home by Southend Social Services Department. Staff spoken to, had an awareness P.O.V.A. procedures and some have attended training. Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 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): 30 The home was clean and hygienic with cleaning materials being stored safely in accordance with Control of Substances Hazardous to Health Regulations. EVIDENCE: Staff have an awareness of C.O.S.H.H. Regulations and infection control procedures. The premises were clean, well maintained and residents are encouraged to clean their own rooms as part of their normal daily routine. Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 15 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): 33 Residents are supported by an effective staff team where individual and joint needs are met. EVIDENCE: At the time of inspection, sufficient levels of staff were available with an appropriate skills mix in order to support and meet the needs of residents. A current rota was displayed showing the deployment of staff and cover throughout a 24-hour period. In the absence of the manager who has been on sick leave, the senior support worker and other staff have been shift leaders with the local Area Co-ordinator overseeing the home and giving input on a regular basis. There is always a minimum of two staff on duty between the hours of 7a.m. & 9.30 p.m. Sometimes the senior support worker is able to be in the home on a supernumerary basis as a third person. At the time of inspection, there were two full-time vacancies and selection interviews had been arranged. In the meantime, agency and ‘bank’ staff have been included on the staff rota. An awake member of staff is on duty at night who has access to local on-call staff should this be necessary as well as having a direct link to the care line. It was not possible to have access to staff recruitment records, as the manager was absent. Procedures adopted by the home for recruitment will be assessed at the next inspection. Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 16 Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 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): 42 The health and safety of residents are promoted and protected but some items reported for repair and maintenance, are not always dealt with promptly. EVIDENCE: Health and safety policies are in the home and staff are aware of their importance and significance. Since the last inspection, a gas safety certificate has been issued and public liability insurance was up-to-date. A record was also available of fire drills and procedures undertaken by staff. It was noted from the maintenance record book, that the floor in the bathroom needed attention, which was first reported on the 2nd of May 2005. The main freezer in the kitchen has been out of action since the 1st August 2005 and the home is still awaiting a replacement. The Registered Provider has a responsibility to ensure that the premises, facilities and equipment are maintained to ensure the health, safety and well being of residents. Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 18 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 x 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 X 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X X x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wimborne Road (104) Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 x DS0000015488.V251622.R01.S.doc Version 5.0 Page 19 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 42 Regulation 23 (2) Requirement The Registered Provider shall, having regard to the number and needs of the service users, ensure that the premises are kept in a good state of repair and equipment provided in the care home, is maintained in good working order. This applies to the flooring in the bathroom and the freezer in the kitchen. Timescale for action 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2. Refer to Standard 6 Good Practice Recommendations It is recommended that monitoring systems be reviewed to ensure that dates on personal-care records coincide with reviews and any changes agreed in the care and support provided to residents. It is recommended that approaches continue to be made to the Primary Care Trust to ensure residents always receive a prompt and consistent service relating to reviews necessary in meeting changing mental health needs. 2. 19 Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Wimborne Road (104) DS0000015488.V251622.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!