Inspection on 07/03/06 for 109-111 Mollands Lane Project

This inspection was carried out on 7th March 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

109-111 Mollands Lane Project 07/08/07

109-111 Mollands Lane Project 11/09/06

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 18-65 111 Mollands Lane Project 111 Mollands Lane South Ockendon Essex RM15 6DJ Lead Inspector Mrs Bernadette Little Unannounced Inspection 7th March 2006 11:35 111 Mollands Lane Project DS0000064863.V283918.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 111 Mollands Lane Project DS0000064863.V283918.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. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 111 Mollands Lane Project Address 111 Mollands Lane South Ockendon Essex RM15 6DJ 01708 856592 01708 856592 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) Satash Community Care Project Limited Mrs Thanaletchmi Loganathan Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This was the homes first inspection since registration. Brief Description of the Service: 111 Mollands Lane is a semi-detached property in a quiet residential area. It is registered to provide care to four younger adults who have a learning disability. There is one ensuite bedroom on the ground floor, along with a large lounge, separate dining room, activities room, kitchen and a small office at the front there were three further bedrooms upstairs two of which are ensuite and there is an additional separate bathroom. 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. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of 111 Mollands Lane since its registration was completed in October 2005. The home had only been opened to residents for five weeks previous to this inspection. This inspection was a routine unannounced inspection, which took place over a five-hour period. Time was spent talking with the residents, the staff and the registered manager as well is looking at records and documents and the premises. The assistance of the staff and the residents was greatly appreciated. What the service does well: What has improved since the last inspection? 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. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 6 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 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 7 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, 2, 4, 5 Residents and their supporters were provided with ample information to decide if 111 Mollands Lane was the right place for them to live. The home took appropriate steps to make sure that they could meet residents’ needs. EVIDENCE: Residents were provided with a copy of the statement of purpose, pictorial service user guide and complaints procedure prior to admission. The registered manager advised that these were taken home by the residents for their families to look through. Records confirmed that residents had a trial visit at the home prior to admission. They also confirmed that a resident had had the support of an independent advocate to confirm their choice to live at 111 Mollands Lane. The file for one of the two recently admitted residents was sampled. This shows that the home undertook a detailed assessment of all aspects of the residents needs. It was not signed and dated. A copy of the homes contract with the funding authority was on file. A copy of the homes statement of terms and conditions was available and had been signed by the resident. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 8 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, 7, 9 Basic care plans were in place. The home needed to better demonstrate they had considered appropriate risks to protect residents. EVIDENCE: The home had been opened to residents for five weeks. Basic care plans were in place and the registered manager confirmed that these would be developed further once they had had a chance to get to know the residents. There was evidence that residents were involved in the writing of their care plan. Risk assessments were not in place on the care plan sampled. The registered manager confirmed that these would be undertaken for all identified areas, for example making hot drinks, going out, and would also include medication. Discussion with the residents and staff as well as observation of the daily routines in the home confirmed that residents were offered opportunities to make decisions and to take risks in their everyday life. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 17 Residents were well supported to access and enjoy arrange of appropriate meaningful activities. Residents had ample choices of a nutritional diet. EVIDENCE: Discussion with residents confirmed that they attended a variety of individual activities on a regular basis. This included education to develop life skills and interests, leisure activities in the community such as cinema, bowling and swimming and community presence such as shopping and use of the library. This was confirmed in record sampled. A resident confirmed that they have regular contact with their family and go home for a visit at weekends. Both residents said that the food is nice and that they have choices, including the choice of meal each day. This was confirmed in both the menu and the record of food served. Residents had free access to the kitchen to make drinks and get snacks etc as they wished. One resident went shopping with a member of staff during the inspection. Ample supplies of quality food stocks were observed including fresh fruit and vegetables. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Residents’ health care needs were effectively identified and met. The medication system was assessed as adequate with some recording issues. EVIDENCE: Neither of the residents had mobility difficulties nor required particular equipment or support with transfers. Choice of individual clothes and hairstyles was supported. Residents had allocated keyworkers and knew who they were. Records demonstrated that the resident had been registered with a GP, and had access to appropriate healthcare professionals including the dentist and a Consultant psychiatrist. Storage of medication was appropriate. Protocols were available for as required (PRN) medications. Risk assessments should evidence why individual residents do not self medicate. The registered manager stated that there had been recent medication training on the new system and certificates were awaited. All receipt of medication and reasons for non-administration needed to be recorded. Two signatures should be used for transcribed medication records. A sample of staff signatures should be available. A copy of the Royal Pharmaceutical Society’s guidelines on medication in care homes should be available. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 11 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 Staff skills and knowledge and the home’s clear policies and procedures protected residents and supported them to express their views. EVIDENCE: A copy of the complaints procedure was displayed. Residents had a pictorial format version. A resident said they would feel able to approach staff if they were worried or concerned about anything. Policies, procedures and information on protecting vulnerable adults were available. Staff spoken with had appropriate knowledge and confirmed that this topic had been part of their induction. One of the two support staff had had training; two others were booked to attend training in the near future at Thurrock Borough Council. Staff had also been provided with a copy of the General Social Care Council code of practice. The registered manager advised that while a policy and procedure on restraint was available this was not an issue with the current residents at the home. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 111 Mollands Lane provided residents with a comfortable and pleasant living environment. EVIDENCE: The home was clean, well presented and furnished. Both residents said that their bedrooms and the communal rooms were comfortable and met their needs. The laundry facilities were sited in the kitchen. There were currently no continence management issues at 111 Mollands Lane. A risk assessment was not available in relation to the opening of the upstairs windows, which were not restricted. The registered person advised that the fire officer required that restraints were not fitted. There was no hot water available to one of the ensuites. The manager advised that this was being dealt with and the resident had the use of an additional bathroom. The downstairs WC was unusable following risk assessment, while a bi-fold door was being made. None of the residents had any specific requirement for additional equipment. There was a covered area at the back of the house for those who smoked. Risk assessment was needed as it was noted that a resident was smoking in their bedroom. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 13 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, 34, 35 Staff were appropriately skilled to support residents. The homes recruitment practices did not best protect residents. EVIDENCE: Two staff and the registered manager were spoken with. All had had previous experience working with this client group. The home were generally operating with one staff each shift with either the registered provider or the registered manager on call at all time. This will need to increase depending on further admission or any increase in residents need. The roster needs to have the full name of all staff. Two staff recruitment files were sampled. They did not evidence all the required checks for example to references in place prior to employment, one did not have a photograph, neither had a start date recorded, neither had a declaration of mental and physical health by the applicant. The registered manager was advised to ascertain who the referees were, in terms of employment history. It was noted positively that appropriate action had been taken to obtain Povafirst checks/Criminal Record Bureau checks. Both staff files sampled confirmed previous appropriate experience. They indicated a variety of training courses, although no evidence of these was available in most cases. This will need to be maintained. Induction training records were in place and had commenced. The first staff meeting was planned. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 14 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 Safety procedures and practices were in place to protect residents and staff, and now needed to develop in line with the service. EVIDENCE: Current safety inspection certificates were available in relation to fire equipment, fire alarm, emergency lighting, fixed electrical wiring and portable appliance testing. A record of weekly fire alarm tests was available but needs to include emergency lighting fire equipment and fire exits. Fire drills had not yet commenced. The registered manager advised that residents had been included in in-house fire training. A record of maintenance and repairs was available. An accident recording book was available. First-aid boxes were in place. A book of generic risk assessments from a consultative company were in place. A risk assessment was in place relating to legionella but did not include adequate detail or record cold water temperatures and maintenance of the outlet in unused rooms. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 15 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 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 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 1 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X X X X 2 X 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 16 N/A 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 YA6 Regulation 15(1) Requirement The care plan for each resident must include all aspects of their health and welfare and be supported by appropriate risk assessments. Full records must be kept of the receipt of medication and reasons for non-administration. Risk assessments must be undertaken in relation to the upstairs opening windows, with appropriate action to ensure a resident safety. The rota must include the full names of all staff working at the home. The person registered must evidence robust recruitment procedures and have all records required available in the home for inspection. The person registered must ensure the testing of fire equipment at regular intervals and ensure that residents and staff involved in regular fire drills and practices. The care plan for each resident must include all aspects of their health and welfare and be DS0000064863.V283918.R01.S.doc Timescale for action 01/05/06 2 3 YA20 YA24 13(2) 13(4)a& c 01/04/06 01/04/06 4 5 YA33 YA34 17(2)Sch 4 17(2) & Sch 4 01/04/06 01/04/06 6 YA42 23(4) 01/04/06 7 YA9 15(1) 01/05/06 111 Mollands Lane Project Version 5.1 Page 17 supported by appropriate risk assessments. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA20 YA20 YA20 YA42 Good Practice Recommendations Risk assessments should be available in relation to residents of administration of medication. A copy of the Royal Pharmaceutical Society guidelines for medication in care homes should be available. A sample lift of staff signatures should be available. The risk assessment relating to the water system should include more detail and clear instructions on actions to be taken. 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 18 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 111 Mollands Lane Project DS0000064863.V283918.R01.S.doc Version 5.1 Page 19 - 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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