Inspection on 12/09/06 for 14 Mengham Avenue

This inspection was carried out on 12th September 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

14 Mengham Avenue 21/02/06

14 Mengham Avenue 13/10/05

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

CARE HOME ADULTS 18-65 14 Mengham Avenue Hayling Island Hampshire PO11 9JB Lead Inspector Anita Tengnah Unannounced Inspection 12th September 2006 10:00 14 Mengham Avenue DS0000064990.V306869.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 14 Mengham Avenue DS0000064990.V306869.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. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 14 Mengham Avenue Address Hayling Island Hampshire PO11 9JB 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) 0151 420 3637 www.c-i-c.co.uk. Community Integrated Care To Be Confirmed Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21/02/2006 Brief Description of the Service: This is a home set in an attractive residential area of Hayling Island. The property cannot be distinguished as a residential service. The local shops are within walking distance. There are four single bedrooms on the first floor and one on the ground floor. One bathroom is available on the first floor with a separate WC. A shower room with WC is available to the rear of the ground floor and is accessed through the laundry. Residents have an adequately sized kitchen/diner and separate lounge for recreation and leisure. A garden is also available and residents are encouraged to use it. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced fieldwork visit was undertaken on the 12th of September 2006. The inspection process included a tour of the service where a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. Staff practices were observed; service users and staff records were also examined. As part of the case tracking one service user was spoken with, as the others were attending day care and the staff views were sought. Staff supported the service users to attend a variety of activities and use facilities in the local area. The home has a manager who confirmed that she would be submitting an application to be registered with the commission for social care inspection (CSCI). The certificate of registration was not displayed at the service at the time of the visit. The manger reported that this had been returned when the previous manager left. A new certificate has been sent to the service. The current fee charged is £249.40. There were 5 service users accommodated at the time of the visit. What the service does well: What has improved since the last inspection? 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 6 A procedure for the returned medication has been recently developed to ensure that medication is managed properly. Thermostatic valves have been fitted to communal baths and sinks. 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. 14 Mengham Avenue DS0000064990.V306869.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 14 Mengham Avenue DS0000064990.V306869.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The pre assessment process is good and ensures that service users’ needs could be met. EVIDENCE: The record of a newly admitted service users was seen as part of the case tracking. It showed that a pre assessment was undertaken and care manager’s assessment was also secured prior to admission. This enables the home to make an informed decision on how they can meet the needs of the service user. Staff reported that the service users are encouraged to stay at the home and this forms part of their assessment. This gave the new service users a chance of building relationship and in assessing his/ her suitability to the service. The service user was issued with a contract that was signed by her next of kin and included terms and condition of residency. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The health and personal care needs of the service users are well met. The service users are supported to take risks as part of daily living. EVIDENCE: A sample of two care plans was seen as part of care tracking. This demonstrated that risk assessment are undertaken and care plans are put in place to show how these needs would be met. Risk assessments and care plans were detailed and contained a range of information to inform practice. These plans included assessments of daily activities, detailed personal care, environmental risks and bathing. As reported in the last report the care plans would benefit from evidence of service users’ involvement and records of regular review with the key worker. These were not available in the care plans seen. Staff reported that care plans are being further developed to include goals setting. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 10 Observation and discussion with one service user showed that the staff offer support in a way that respects the privacy and dignity of the service users. It was evident from interaction seen that the staff have developed good relationship with the service users. Comment from a service user included “I get up whenever I want” and the staff are good. Service users are addressed by their preferred names. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 16, 17 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The meals are well managed and service users are supported to take part in varied activities to suit their needs. Service users feel that they are treated with respect and their autonomy and choices respected. EVIDENCE: Staff and service users spoken with and records seen and observations indicated that staff assist residents to become part of and participate in the local community in accordance with assessed needs and wishes. Four of the service users were attending the day care service on the day of the visit. A service user spoken with confirmed that she has autonomy and choice with her activities of daily living. A staff member was supporting her on her 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 12 day of the visit to go shopping as she said she was going to buy some clothes. Discussion with staff and observation of practices showed that the service users are supported according to their wishes and good relationship had been formed between the staff and the service users. Comment included “ the staff are good” and “ I am happy living here” and she attended day care on a Wednesday. Staff reported that supporting social skills and personal relationships was part of their daily role in the home. Staff discussed how they were working with and monitoring a particular relationship within the home. The manager talked about recording in personal diary and 1-1 support/ discussion with the service user. This was reported to be working well as it gave the service user ownership and staff work with her to reach a solution. A varied menu is provided and the service users are involved in the preparation of food. This was observed on the day of the visit with one service user preparing lunch. Staff said that when food shopping the service users are involved in choices. Comment from one service user was “food is good and we can choose what to eat”. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The medication and the service users’ access to meet their healthcare needs are satisfactory. EVIDENCE: Discussion with staff showed that individual support with personal care was given to the service users as recorded in the care plans. Two staff members said that care needs were recorded in the plans and that support varied according to levels of dependency. A service user said that her right to privacy was respected and she required minimal support with personal care. The service users’ access to healthcare was maintained and included visits to the optician, dental care and chiropody as required. Staff reported that the service users attended the surgery and the GP would visit as requested. The home has policies and procedures for medication that the staff followed. A procedure for returned medication has been developed recently. A record of prescription was kept at the service. The home uses the Monitored Dosage System( MDS) that ran on a 28 days cycle. There was no service user who was administering their medication at the time of the visit. Discussed with the 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 14 manager who confirmed that medication risk assessments would be developed for all the service users. The manager said that the procedure for the management of over the counter medication would be rectified in consultation with the GP. The manager confirmed that only the senior carers were responsible for medication following training. The manager said that further training in medication was planned. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The complaint procedure was available and further amendments would ensure that it contains adequate information about how to make a complaint. Staff understanding of adult protection and the reporting process was satisfactory. Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. EVIDENCE: Staff were observed to consult and listen to the views of a service user at the time of the visit. The manager encourages an open culture and a service user spoken with said that she would approach the staff if she had any concerns. The home has a complaint procedure in place. Amendments were needed to the procedure to include the name and address of the commission. The manager said that this would be rectified. A complaint log was available and three complaints about the same issue were recorded. This had now been resolved. Two staff members spoken with were aware had understanding of adult protection and training was available in two new staff records seen. Policies and procedures for the protection of the service users were available. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 16 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 17 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): 24,29, 30 Quality outcome in this area is adequate. The judgement has been made using available evidence including a visit to the service. Service users are provided with personalised rooms that meet their needs The bathroom facility should be reviewed to include assisted facility according to the needs of the service users. EVIDENCE: A tour of the service was undertaken as part of the inspection and one of the service user’s bedrooms was seen. It was evident that the service users are encouraged to bring in items of personal belongings on admission to the home. All areas of the home were clean. The service user’s bedrooms was personalised and adequately furnished to meet her needs. Comment from the service user included” I have everything I need in here” and was very proud to show off her bedroom. There are adequate communal areas at the home and service users have access to various parts of the home and the garden throughout the day. The service benefits from a garden that is accessible and staff reported that the service users made use of this facility, where seating was also provided. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 18 Staff reported that the communal bathroom on the first floor has been decorated and appeared in reasonable state of repair. There is one service user who is unable to use the bathroom facility at present. Staff reported that she used the shower room, however she liked a bath but required assisted facility in the bathroom and this was not available. This was discussed and the manager and said that this would be brought to the attention of the provider. Staff also discussed that a review of the bathroom was planned to allow for more space. The registered person must ensure that there is adequate bathing facility in order to meet the needs of all the service users including assisted facility as required. It was noted that record of water temperature was maintained. However the recordings were higher than the recommended hot water temperature. Staff were aware of this and said that they assisted the service users in running a bath and agreed that this should be resolved as it posed risks to the service users. The manager confirms that this would be rectified. Report of February 06 reflected that the communal lounge and dining rooms were planned for refurbishment. Staff said that this has not been achieved as yet. The home has a laundry and infection control procedures were in place. The laundry floor was impermeable and adequately equipped. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 19 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): 32,34,35,36 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The home recruitment and training programme is good and ensures that the service users are protected and staff have the skills to deliver care effectively. EVIDENCE: A requirement was made at the last inspection regarding records for agency staff that needed to be maintained at the service. Following discussion with the manager, she had confirmed that the agency does not use agency staff and that the company’s own “ bank” system covers sickness and staff shortages. This also provided continuity of care, as these staffs are familiar to the service users. The records for two staff appointed since the last inspection was seen. All have had completed application forms; references and appropriate checks were undertaken prior to employment including Criminal Record Bureau Checks. Confirmation with regards to POVA first check was not found. The manager confirmed that all checks are undertaken and that the staff records were in the process of being reviewed to ensure that all records are kept bound together and easily accessible. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 20 The home has a training programme in place. Records of recent training for the new staff seen included adult protection, food hygiene, fire safety and first aid. Comprehensive induction record was also available in two records and staff are given the company’s code of conduct and that of the general social care council. A structured staff supervision programme was in place. Two records showed that recent supervision was undertaken in Jun/July 2006. The manager is aware that staff should have at least 6 supervision sessions a year and to maintain record of this. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 21 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): 37,39,42 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The health and safety of the service users is promoted. EVIDENCE: The home has a manager and discussion with staff and service users showed that the home is well managed and views of the service users are sought. Application for the manager to be registered with the commission was discussed. The manager confirmed that this was in hand and will be submitted soon. The new registration process was discussed with the manager. The manager said that she undertook updates to maintain her skills, however, the National Vocational Qualification level 4 and Registered Manager’s Award or equivalent has yet to be achieved. The manager confirmed that she was planning to register for this. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 22 A sample of the servicing records and fire safety check including weekly fire alarm testing was seen. The emergency light was serviced in June 06 and the five- year electrical check was completed in May 05. The environmental officer issued some recommendations during his visit in May 06 and his follow up visit showed that these had been met. Evidence seen showed that the health and safety of residents in the home is promoted. Staff said that the service users are reminded of fire evacuation procedures at monthly meetings and weekly fire alarm testing was carried out. 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X 2 X 3 X X 3 X 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 24 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 YA29 Regulation 23(2) (n) Requirement The provider must ensure that suitable equipment and facilities such as assisted bathing facility are available as required to meet the needs of the service users. Timescale for action 30/10/06 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 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 14 Mengham Avenue DS0000064990.V306869.R01.S.doc Version 5.2 Page 26 - 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. 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