CARE HOME ADULTS 18-65
118 Beaver Lane 118 Beaver Lane Ashford Kent TN23 5NX Lead Inspector
Mrs Sue Gaskell Announced Inspection 13th December 2005 10:00 118 Beaver Lane DS0000023305.V258036.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 118 Beaver Lane DS0000023305.V258036.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. 118 Beaver Lane DS0000023305.V258036.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 118 Beaver Lane Address 118 Beaver Lane Ashford Kent TN23 5NX 01233 650526 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) The Kent Autistic Trust Mrs Zoe Rodda Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 118 Beaver Lane DS0000023305.V258036.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th June 2005 Brief Description of the Service: 118 Beaver Lane is a purpose built detached property owned by the London and Quadrant Housing Association property and managed by the Kent Autistic Trust. The home is in a residential area of Ashford, within 15 minutes walking distance of the town centre, with easy access to public transport, health and adult education centres, shops, churches, a swimming pool and other amenities. The house provides accommodation on 2 floors. In the main part of the house there are 4 single bedrooms for residents, with en-suite toilets and washing facilities and there are 2 self contained flats each with a single bedroom , lounge, kitchen and bathroom. In addition there is a staff sleeping in room, office/sleep in room, lounge/dining room, kitchen, toilets, storage areas and a large enclosed garden. Staffing comprises a registered manager, team leaders, support staff and day care staff. 118 Beaver Lane DS0000023305.V258036.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection was carried out over approximately 5 hours. Prior to this inspection the home had submitted a pre-inspection questionnaire completed by the registered manager and feedback questionnaires were received from residents’ families. The Inspector toured the building and inspected a number of records, policies and procedures. The Inspector and manager discussed various issues which have arisen over the needs of some of the residents. The Inspector spoke with three other members of staff and watched interactions between a resident and staff. What the service does well: What has improved since the last inspection? What they could do better:
Whilst it does not currently present a risk, some attention should be paid to the storage of a freezer in the laundry areas. 118 Beaver Lane DS0000023305.V258036.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. 118 Beaver Lane DS0000023305.V258036.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 118 Beaver Lane DS0000023305.V258036.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, and 3 Prospective residents are provided with as much information as possible in a format which is likely to be understood by them. Prospective residents’ healthcare, social needs and aspirations are fully assessed prior to admission EVIDENCE: Prospective residents and those living in the home are provided with a comprehensive service user guide which has been produced in various formats so that it can be understood by as many people as possible. Whilst no new residents have been admitted since the last announced inspection, there is evidence to show that there is a sound pre-admission assessment procedure with input from the prospective residents, Care Managers, families and other health care professionals. 118 Beaver Lane DS0000023305.V258036.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, 7 and 9 The health, general care and social needs of residents are well met and residents are consulted and encouraged to contribute to any decisions that affect their lives. Residents are supported in taking risks in the daily domestic and social activities that are part of an independent lifestyle. EVIDENCE: All of the care plans include details on short and long term goals and how the home will assist residents in achieving their goals, and these are reviewed regularly. Residents have key workers who monitor their individual needs and activities and help them understand the contents of their care plans. Risk assessments are prepared and include specific guidelines. 118 Beaver Lane DS0000023305.V258036.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): 12,13,15,16 and 17 There are good opportunities for personal development and social activities on a daily basis, including either an annual holiday or special days out. Meals in the home are good, offering a healthy, nutritious diet with choice and variety. EVIDENCE: Residents have access to a wide range of activities during the day and during the evenings. Some activities are carried out with the assistance of staff but residents are encouraged to be independent whenever appropriate. Staff confirmed that residents would not have to do something if they did not wish to. The inspector was concerned to read that one resident has been disadvantaged by losing items of clothing whilst on home visits but was satisfied that this is being attended to. The menus and contents of the store cupboard were seen to be varied and appropriate for a balanced diet. Special attention is given to the needs of residents’ with specific needs. The food seen on the day of the inspection appeared appetising and nutritious and residents are encouraged to make suggestions about the menus. 118 Beaver Lane DS0000023305.V258036.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): 18,19 and 20 Residents’ healthcare and social and emotional needs are constantly monitored and met. The medication management systems are sound with appropriate storage. EVIDENCE: The care plans include in depth monitoring of residents’ health care needs and there was evidence of pro-active actions undertaken by the manager and staff. The Inspector and manager discussed several issues which have arisen over the needs of some of the residents and the inspector was satisfied that these have been dealt with in a thoughtful and sensitive manner. Staff confirmed that they have received appropriate training in the administering or medication and the records were clear and current. The storage of medication is secure and appropriate. Staff interviewed referred to the importance of offering personal support in such a way as to preserve residents’ rights and maintain their dignity. 118 Beaver Lane DS0000023305.V258036.R01.S.doc Version 5.0 Page 12 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 and 23 The home has a satisfactory complaints process and residents are protected from harm or neglect. The home makes every effort to seek residents’ views. EVIDENCE: Staff said that every effort is made to ensure that residents can communicate their feelings if they are not happy with something and this was also confirmed by feedback from residents’ families. The home has adult abuse procedures in place and staff have received training on adult protection awareness. 118 Beaver Lane DS0000023305.V258036.R01.S.doc Version 5.0 Page 13 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, 26 and 30 The standard of the environment is very good. Residents’ bedrooms enable them to be as independent as possible. EVIDENCE: The bedrooms and living areas are furnished and decorated to a good standard, and contained the type of furniture and equipment necessary to provide a homely environment. All residents have en-suite facilities and some have their own cooking and living space. Outstanding maintenance has been carried out and all areas were clean and hygienic. 118 Beaver Lane DS0000023305.V258036.R01.S.doc Version 5.0 Page 14 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): 32, 34 ,35 and 36 Residents benefit from a competent, appropriately trained and well supported staff team. Residents are protected by sound recruitment practices. EVIDENCE: The high level of staffing during the day and at night enables staff to respond to residents’ needs, and there is also an emergency on call system. The staff confirmed that CRB, and POVA checks are carried out and references obtained and verified. Staff have access to a range of training in core issues and for personal development. All of the staff spoken to said that they enjoy working in the home and that the high level of morale is due to the good support from management and team leaders. 118 Beaver Lane DS0000023305.V258036.R01.S.doc Version 5.0 Page 15 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): 37,38, 39, 41 and 42 The home regularly reviews aspects of its performance, which includes seeking the views of residents, their relatives and staff. There are systems in place to promote and protect the health, safety and welfare of residents. EVIDENCE: The residents’ views and feelings are constantly monitored, either through talking to them or through other forms of communication. Quality assurance is given a high priority and any feedback from residents and/or their families or advocates is acted upon. The general management of the home and completion of records are of a high standard. There was evidence to show that health and safety issues, such as the importance of checks on the environment and risk assessments are regularly carried out and reviewed. 118 Beaver Lane DS0000023305.V258036.R01.S.doc Version 5.0 Page 16 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 4 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 4 X 4 X X X X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 4 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
118 Beaver Lane Score 3 4 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 4 X 3 3 X DS0000023305.V258036.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 118 Beaver Lane DS0000023305.V258036.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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