Inspection on 07/08/07 for 109-111 Mollands Lane Project

This inspection was carried out on 7th August 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

109-111 Mollands Lane Project 11/09/06

109-111 Mollands Lane Project 07/03/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 109-111 Mollands Lane Project 109-111 Mollands Lane South Ockendon Essex RM15 6DJ Lead Inspector Mrs Bernadette Little Unannounced Inspection 7th August 2007 09:50 109-111 Mollands Lane Project DS0000064863.V346681.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 109-111 Mollands Lane Project DS0000064863.V346681.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. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 109-111 Mollands Lane Project Address 109-111 Mollands Lane South Ockendon Essex RM15 6DJ 01708 856592 01708 856592 satashcommunitycare@hotmail.co.uk www.satashcommunitycareprojects.co.uk Satash Community Care Project Limited 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) Mrs Thanaletchmi Loganathan Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th September 2006 Brief Description of the Service: 109-111 Mollands Lane are two adjoining semi-detached properties in a quiet residential area. 111 Mollands Lane was originally registered to provide care to four younger adults who have a learning disability. In June 2007 the adjoining, and almost identical, property was registered as part of the project to give an additional four single bedrooms. There is one ensuite bedroom on the ground floor in each house along with a large lounge, separate dining room, kitchen and a small office at the front. There were three further bedrooms upstairs in each house, two of which are ensuite and there is an additional separate bathroom. The two houses are registered as one facility and will be referred as one premises. There is adequate private parking to the front of the property and a large garden, which is accessible to residents at the rear. There is a covered area on the patio with a table and chairs available for residents who wish to smoke. The weekly fee is £1200 per week as confirmed by the registered person at the site visit. Additional charges/costs are incurred by residents relating to chiropody, purchase of personal toiletries, college course fees and some activities. The registered manager previously advised that the home provide twenty pounds per resident per week towards activities and generally residents pay for anything in excess of this. The home, however pay for all holiday and transport costs and have their own vehicle. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection undertaken over a seven hour period. All key standards were inspected and the homes progress against their previous requirements was assessed. A tour the premises were undertaken and medication, records, policies and procedures were sampled. At the time of this inspection there were five people living at 109-111 Mollands Lane, but one was away on holiday. Three residents, three staff and the registered person was spoken with on the day of the site visit. The commission sent out a number of surveys for people living at the home and other stakeholders. Completed surveys were received from four service users, one relative, four staff, one care manager and one healthcare professional. The information they provided was appreciated and is reflected throughout the report. All comments received were positive regarding the service provided to the people who live at the home. What the service does well: What has improved since the last inspection? Since the last inspection the home have surveyed all the people involved to ask them what they think about the quality of the care and the way the home is run. Staff have a contract of employment or a statement of terms and conditions so they have good information about their job. Records showed that staff had been involved in regular fire drills and practices and checks had been done on both the hot and cold water, which helps to keep everybody safe. The home have been in touch with the GP to find out about the safe use of ‘homely remedies’ and there were guidelines that explained when residents should have medication that was prescribed for them to have now and then when it was needed. This helps to keep residents safe. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 109-111 Mollands Lane Project DS0000064863.V346681.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 109-111 Mollands Lane Project DS0000064863.V346681.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): 2, 4, 5 Quality in this outcome area is good. People choosing to live at Mollands Lane Project can be confident they will receive adequate information about the home and their needs will be assessed before admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide will have been considered during the recent registration of the additional parts of the premises. The AQAA confirms that all residents are provided with a copy of the statement of purpose and service user guide prior to admission. Resident surveys confirmed that residents were asked if they wanted to move into this home and most felt that they had had enough information before they moved in so they could decide if it was the right place for them. The documentation for one more recently admitted resident was considered. A detailed pre-admission assessment process was evidenced with assessments both from the local authority as well as the homes are in assessment. The documentation took into account issues such as the person’s religious references and needs, communications, a specialist behaviour support and areas of risk. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 9 A statement of terms and conditions/contract was on file and signed by the manager and the resident. This did not clarify which was the resident’s room. The individual placement contract identified that there would not be a gradual move in due to specific circumstances. There was evidence in the records that showed that the resident did visit prior to admission. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 10 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): 6, 7, 8, 9 Quality in this outcome area is good. People living at 109-111 Mollands Lane benefit from a clear care-planning system but which was not offered to all residents in a timely manner on admission. They are supported to make decisions about their lives, to take risks appropriate to their individual abilities and wishes and to participate in all aspects of life in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was no current care plan relating to 109/111 Mollands Lane available for a more recently admitted resident. This was a disappointing repeat of the situation identified at the last inspection for a recently admitted resident. The previous care plan for this person related to life in a residential college, which was inappropriate for the resident in this care setting. A care plan was in place for another resident admitted since the last inspection and included issues such as mental health, diabetes and medication. It was supported by risk assessments for example in relation to bathing independently, failure to take medication, the preparation of hot drinks and 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 11 snacks and road safety. The care plan included the resident’s signature and it had been regularly reviewed. The main person centred care plan was available but was in the process of being reviewed. The care management documentation, information in the AQAA and observed routines at the site visit demonstrated that residents are supported to make decisions about their lives and to take risks as part of the independent lifestyle. A resident confirmed that they are now able to go to the local shops on their own. Residents also confirmed in the surveys that they can do to what they wanted to during the day, in the evening and at weekends. One resident added sometimes decisions are made about our days and nights out in a group, but when I have my one-to-one it is my decision what I want to do. The AQAA identifies that the weeks menu is planned on Monday and each resident chooses a meal for a particular day that they then help to plan and cook. There are regular resident meetings to offer residents to participate. One resident is in charge of the weekly checks of the home’s vehicle with staff. The vehicle provides transport for residents where this is required but residents are also encouraged to use public transport and risk assessment confirms that a resident comes home from their weekly work placement by bus. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15, 16, 17 Quality in this outcome area is excellent. Residents at 109-111 Mollands Lane are supported to access and enjoy a wide range of appropriate activities in the community. They are encouraged to maintain appropriate relationships and have the choice of a variety of nutritional foods. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The recently admitted resident had already been shopping for new clothes, bowling, out walking, attending a neighbours garden party, to register with a GP in the area and to the bank to open a bank account. The permanent residents have a structured activity programme that they have a copy of in their own room. Three of the residents use the local swimming pool but at a time that is convenient for them and not at the time allocated by the pool for use by people with disabilities. Two residents regularly attend a snooker/pool club 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 13 locally and the four permanent service users are members of two mainstream community social clubs which they also access regularly during the week evenings. Residents belong to a walking group, which they attend regularly. One resident confirmed in a survey that staff support them to visit their mother, who lives in a residential care home, perhaps three times a week but always after Mass on Sundays, “ and she loves to see me and me her”. All residents belong to a walking group. Residents were seen to choose go out unaccompanied to the shops or the bank during the site visit, or to come back having chosen spontaneously to have a haircut while they were out. Files showed that residents had been involved in travel training and there were supportive risk assessments in place. While all four residents attend college, the site visit took place during the summer holidays and residents were enjoying the break. One resident was gone abroad on holidays with their family. Another resident didnt get up until lunchtime, was encouraged to have lunch but made their own decision to have Weetabix. The provider then supported the resident to have their bath as the resident asked for the provider to do this. The resident confirmed that they do computing and maths at college and have certificates in their room and really enjoy it. The resident confirmed that they are registered to vote and had done so. One resident has moved rooms from one side of the premises to the other side and their agreement to this was documented. The younger residents now live on this side and the provider advised that another person currently being assessed for the home is also in that younger age group, so they will have appropriate peer interaction and support. Ample food stocks were observed to be available. The nutrition record demonstrates clearly that residents exercise choice that breakfast and lunch and occasionally have a take-away or a pub lunch. Theme nights involve a resident choosing a recipe and staff supporting them to produce it. A resident confirmed that they liked the food and that they had tea and cakes etc in the evening as a supper. A staff member spoke with confirmed that residents helped themselves to food as they need it as they are capable of making the decision, choosing and getting what they want. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 14 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): 18, 19, 20 Quality in this outcome area is good. People using the service receive very good personal and healthcare support that meets their needs. The home has systems in place to ensure the safe administration of medication and the protection of people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To date, residents have needed need limited support with mobility and personal care, but one resident does currently use a walking frame and has a history of falls and so needs more support. As there is one female resident, there is always at least one female member of staff available to support any personal care needs. All residents have a key worker and residents were aware of their key worker is. The provider advised that residents are encouraged undertake their own personal care with prompts and supervision, for example a staff member would check the temperature of the water before the resident got into the bath. The provider also advised that staff join residents for breakfast and then they work out between them who is going to help who to get ready for the day. Respect 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 15 for resident privacy and dignity was observed with staff knocking on doors, for example the bathroom and waiting to be told that they could come in. Records indicate that residents are supported to access and consult with relevant healthcare professionals and are registered with a local GP. Individual files contain information relating to individual medical conditions such as diabetes and recorded monthly weight monitoring, medication reviews, and appointments with for example, the dentist and the optician. Records show that staff noticed an itchy scalp and obtained a prescription for medicated shampoo and also arranged investigation/nail care. The AQAA confirms that residents’ mental health needs are also monitored and supported. The health professional survey commented the carers always seem very supportive of (resident) with a genuine interest in his needs. They liaise appropriately with primary care. Not all residents have prescribed medication. Medication was tracked for one resident. Medication was recorded as received, Medication Administration Records (MAR) contained a photograph of each resident, showed no omissions and tallied with the medications available. A protocol was available for one resident who has diazepam on an ‘as required’ basis. A homely remedies policy was supported with signed agreement for each resident to have paracetamol. Patient information leaflets were available as was the sample list of staffs signatures and initials. The registered provider confirmed that all 21 staff had been involved in training on the monitored dosage system used on the day prior to the site visit. Both he and the manager have undertaken the advanced medication course as to competence assessments with staff. This was seen to be available on a recently appointed member of staffs file. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 16 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): 22, 23 Quality in this outcome area is good. People who use the service have access to an effective and understandable complaints procedure that ensures that they are listened to. The home operates robust practices and procedures to safeguard the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The provider advised that no complaints have been received since the home was originally registered almost a year ago. A complaints procedure is available and all service users have a pictorial copy of the procedure in the bedroom. The AQAA confirms that all service users would be supported through making the complaint without prejudice. Residents confirmed that they would feel able to raise any concerns and one resident said I would just say that I want to make a complaint about whatever. A compliment was noted on file from a community nurse identifying how pleased they were to see staff supporting residents to increase their independence safely and sensibly while having fun. Another compliment was recorded from a social worker thanking the home for recent celebrations that contained positive comments such as the staff are very caring and residents very happy, staff are tuned into residents’ needs. The AQAA states that all staff have received training on Safeguarding (previously known as PoVA) and that dates are planned for new staff to attend this training. The provider advised that this was half a day training provided by Essex County Council as well as a half hour a DVD session that has gone 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 17 through with staff by the manager. Certificates confirming this were not available on all the staff files sampled. It was recommended that were safeguarding is discussed with new staff, this should be included on their firstday induction record. Spoken where they were aware of procedures for safeguarding vulnerable people and for reporting any concerns. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 18 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): 24, 25, 27, 28, 30 Quality in this outcome area is excellent. Residents of 109-111 Mollands Lane live in a clean, safe, well maintained and pleasant environment that offers good facilities and where residents are confident to use the space as their home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents have their own bedroom and many have their own ensuite. Some residents have had the opportunity to choose a downstairs bedroom where this suited their preference and this was recorded. One resident survey said I love my bedroom. All areas the premises were seen to be clean, well maintained and comfortably furnished. Bedrooms were personalised and each resident had opportunity to lock their bedroom door with their own key, and had a lockable safe in their room. Communal rooms had facilities for residents such as the new flat screen TV that residents requested through the residents’ meetings. Additional television channels have been purchased including a sports channel, again 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 19 through resident request and interest. The cream carpet it in the hallway and dining room was changed because it was impractical to keep it clean and looking nice. The gardens are accessible and well maintained. Residents were seen to use the gardens on the day of the site visits and sat out there as the weather was nice. Furniture and a covered patio area are provided. There are plans to build a small garden ‘ hut’ for one resident who smokes and have effective ventilation systems to keep it pleasant. The AQAA identifies a plan to have a vegetable garden so that residents can grow their own vegetables. They also hope to involve service uses to become actively involved in the decorating of their bedrooms in the next 12 months if they wish to help them to be more personalised. All areas were seen to be clean. Toilet areas had liquid hand washing soap and paper towels with appropriate covered bins for the disposal. Staff were aware that laundry was not to be undertaken at the same time as food preparation. Staff files sampled confirmed that staff had had infection control training. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 20 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): 31, 32, 33, 34, 35, Quality in this outcome area is good. People who live at 109-111 Mollands Lane will be supported and offered positive relationships by competent and motivated staff. They would be better safeguarded by improvements to some aspects of the recruitment and staff development systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken with were clear on their roles and responsibilities and this was observed in practice were staff worked unobtrusively as a team in a calm and supportive way. The provider and staff spoken with confirmed that there is now a minimum staffing level of one senior and one support worker on each side of the building during the day and two awake staff, one on each side at night for the current resident numbers. As noted previously, there is always one female member of staff on duty. Each resident has an agreed one-to-one time with a staff member to do the things that the resident wish to do. The AQAA identifies that this is one way that the home shows that it offers value for money, as they do not receive any funding to provide any one-to-one care for residents. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 21 The AQAA informs that three staff have been put forward to complete NVQ level 2 in care, they are supporting one staff to complete NVQ level 3 and one staff to complete NVQ level 4, Registered Managers Award, with the plan that these will be completed by June 2008. One member of staff had a certificate on their file that confirmed that they had already achieved NVQ level 2 in care. Staff retention has been effective with only one part-time member of staff having left in the past year and the AQAA advises that there has been no staff sickness. Staff spoken with felt supported and were aware of the homes aims and objectives. Additional staff have been recruited and there has been no use of agency staff. It was noted most positively that interview notes confirmed service user participation in the recruitment process. Recruitment finals were sampled for three more recently appointed staff and sampled in part for one staff. There was no photograph available on two of the staff files although one of the photographs was displayed on the information board that showed residents, which staff were on duty. Not all files had a declaration of health although they did have a questionnaire. Applications were on file, along with references obtained in a timely manner and evidence of identity. Povafirst checks and/or Criminal Record Bureau (CRB) checks were in place for all but one member of staff. The manager explained that the person had a police clearance certificate from their own country, but was subsequently advised that this is unacceptable and that a Povafirst/CRB check is required to be in place for all staff prior to employment commencing in the home to protect residents. There was not evidence that all staff had received training in basic issues such as moving and handling, safeguarding (previously known as PoVA) and fire. Other staff files sampled demonstrated recent training in for example creative activities, report writing, learning disability awareness and challenging behaviour. There was evidence of previous training on issues such as infection control, protection of vulnerable adults, first aid, fire, food hygiene, autism, epilepsy awareness, equality and diversity and health and safety. The training matrix needs to be updated, supported by a training needs analysis that includes new staff, and updates arranged for basic training as required. Files sampled confirmed the AQAA information that the home provide induction to Skills for Care level. The provider advised that one new member of staff would have an eight week supernumerary induction because they would new to the care field, while other staff would have a shorter supernumerary period based on their previous experience and training. Discussion with staff and information in surveys indicated that staff felt well inducted, informed and supported and demonstrated a commitment to meeting the home’s aims such as promoting independence and quality life experiences for residents and expressed a desire to continue to be offered opportunities for training and development. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 22 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): 37, 38, 39, 42 Quality in this outcome area is good. People living at 109-111 Mollands Lane benefit from a home that is managed by a competent person and where their views are monitored and listened to. The health and safety of individuals living and working in the home is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 109-111 Mollands Lane presents as well organised and effectively managed. The manager has appropriate qualifications in both care and management and there was evidence of recent training, for example in management of behaviour that challenges. Residents and staff thought that the manager is approachable, accessible and supportive and staff members commented she is always on hand whenever she is needed, you can depend on her, and my manager is very helpful. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 23 The provider advised that the home plan to appoint a deputy manager post and that two applicants have been identified so far. The home have recently registered under the data protection. 109-111 Mollands Lane have recently undertaken quality surveys that included social workers, community nurses, family members, GP, chiropodist, student placements and contracting authority. The information was waiting to be collated and they positive comment noted was residents are well cared for. And there were also positive comments about the newsletter and the use of the garden. A report was also available by the local authority that had completed a contract compliance visit. The provider had prepared a quality audit tool on each National Minimum Standard, the broken down into points on how it was to be met and how this was demonstrated in practice. It is planned to have an outside person to audit this annually at first. Regulation 26 reports have not been undertaken regularly by the provider to show that he has reassured himself that all is well in the home. Residents’ views are also heard through the residents meetings as shown through the opportunity to participate in the agenda, the minutes of these meetings and the actions that are taken in response to them. Records examined relating to Health and Safety were found to be in order. This included checks of the fire alarm, house maintenance, fire drills and hot and cold water. Certificates were available in relation to portable appliance testing, legionella and gas safety. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 24 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 3 5 3 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 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 X X 3 x 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15(1) Requirement So that residents are cared for consistently and safely there must be a current care plan in place for each resident that identifies all their assessed needs supported by risk assessment, so that staff have enough information to enable them to offer residents consistent care and assistance. A previous timescale of 01/10/06 not met. 2. YA39 24 So that he can be assured that the home is being well run and residents were looked after, the registered person must visit and make a report on the home each month. To safeguard residents, records must be maintained in the care home, as required by regulation and schedule to show that all appropriate references and checks on staff have been obtained. 01/09/07 Timescale for action 01/09/07 3. YA34 17(2) & Sch 2 01/09/07 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 26 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 YA35 Good Practice Recommendations So that staff are provided with all the necessary training and the manager can plan effectively, and analysis of staff training needs should be undertaken and the training matrix should be kept updated. 109-111 Mollands Lane Project DS0000064863.V346681.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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. 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