Inspection on 13/10/05 for 14 Mengham Avenue

This inspection was carried out on 13th October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

14 Mengham Avenue 12/09/06

14 Mengham Avenue 21/02/06

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Dalewood Respite Care

Orchard,The

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Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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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 Ms Sue Kinch Unannounced Inspection 13th October 2005 15:00 14 Mengham Avenue DS0000064990.V257847.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 14 Mengham Avenue DS0000064990.V257847.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. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 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 Community Integrated Care Mr William Scoales Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16/11/04 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 recreational and leisure. A garden is also available and residents are encouraged to use it. Staff support residents to attend a variety of activities and use facilities in the local area. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was first inspection of the home since Community Integrated Care (C.I.C) was registered in respect of it. There has been no change of manager. One inspector completed the inspection in 5.15 hours. The inspector met and spoke with all of the residents, two staff members and the manager. Some records were viewed. All shared areas of the home and three bedrooms were observed. What the service does well: What has improved since the last inspection? What they could do better: There are plans to decorate some parts of the home but a plan is needed to redecorate the bathroom on the first floor. Spatial aspects could also be considered to provide more room. Attention is needed to ensure that sufficient records for staff are held in the home. The safety of residents is generally considered carefully and addressed. However an electrical issue in one of the bedrooms should be resolved. 14 Mengham Avenue DS0000064990.V257847.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. 14 Mengham Avenue DS0000064990.V257847.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 14 Mengham Avenue DS0000064990.V257847.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): 1,2,4 Systems are in place for prospective residents to visit and decide if the home can meet their needs before admission. EVIDENCE: The home has admitted one resident since the last inspection. Prior to this, the home obtained information from the care manager about care needs and the manager completed a pre admission assessment. The resident and member of staff confirmed that the home was visited before the admission and needs were discussed. The resident had an opportunity to meet the residents and staff, have a meal and an overnight stay. The resident was positive about the home. Since the admission needs have been assessed further and a more complex care plan was being prepared with the resident’s knowledge. A review of care for the new resident was due and staff were aware of this. The statement of purpose and the service user guide are being developed at the home. Work towards this was viewed. The manager agreed that these would be ready by the end of October 2005. 14 Mengham Avenue DS0000064990.V257847.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): 7.9. Residents are increasingly involved in day-to-day decision-making as person centred planning is developed in the home. Risks are assessed and action plans are developed to keep service users safe and to increase their independence. EVIDENCE: During the inspection many examples of residents making decisions were noted. This was assessed through observation and conversations with residents and staff. Two residents arrived home from day services and had keys to let themselves into the home. One resident had been able to change bedrooms when the last person moved out and had been supported to have a caravan holiday. Another resident, had brought home a cookery book and was thinking of cooking a meal at home. Later in the evening a list of ingredients and plans to cook were being made. Residents are able to answer the front door and the telephone. A member of staff described how she had supported a resident over decisions about a particular leisure activity. The situation had involved some discussion in order to consider the needs of other residents over a particular weekend. The member of staff had assisted the resident to negotiate and the activity had taken place .The member of staff demonstrated careful thought and consideration in supporting the resident’s decision-making. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 10 Risk assessments were discussed with a member of staff who was involved in the process of changing these to the CIC format. She confirmed that the risk assessments previously held in the home were still relevant and in use until the new forms were ready. Written evidence of the new ones being developed was viewed. Staff are encouraged to sign that they have read them and there was evidence of this. Residents need to be encouraged to be involved in assessments to increase levels of responsibility. Advice was given to the manager regarding the information included in risk assessments. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 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 Residents benefit from opportunities to join in with a range of activities based on personal preferences whilst rights and responsibilities are promoted. EVIDENCE: At the beginning of the inspection all of the residents were out engaged in activities mainly at day services. One resident was out with the manager. Two residents went out to a regular group in the evening. The two residents asked said that they liked their activities. One resident said she was looking forward to helping with the food shopping on the following Monday. The inspector heard about residents taking part in bowling, church, clubs, day trips, holidays, pub lunches, and shopping in the local community. During September the day service had shut for a week and staff were able to provide a week of activities based on individual choices. All those who spoke of it were very positive about the outcomes for the residents. Rights and responsibilities of residents are considered on a day-to-day basis. An example of this was a discussion taking place within the home about a resident’s expressed wish to attend the day service for a day less each week. Staff and the manager were aware of this and it had been discussed with the 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 12 resident. This was to be discussed in a formal meeting. The staff, however said that it was possible for the resident to have a day off if it was wanted in the meantime. Full consideration was being given to the resident’s rights. The inspector noted that photos of staff were used frequently for communication between residents and staff. This assisted in residents’ knowledge and awareness of activity in the house. Pictorial and other symbols could be used to a wider degree in the home such as for food, other activities and prompts. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 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): 19,20 Health and welfare of the residents is monitored and supported ensuring that needs are addressed. Residents benefit from a well managed medication system. EVIDENCE: Examples of how staff support residents on health matters arose during the inspection. One member of staff was helping a resident with a medical issue and explained the background to the situation. The current needs and most recent visit to the doctor were documented. The manager has a form for monitoring the appointments of residents. This had been recently introduced and he was in the process of checking that all appointments were up to date. Another member of staff was spoken to about health appointments and she confirmed that they were regular. She gave an example of supporting a resident and demonstrated that emotional needs had also been considered. Elements of the medication system were sampled and were correct. This included some checks of stocks against the records. Medication was stored securely. One person self-administers some moisturising cream and was clear 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 14 about when it should be used. It was advised that a risk assessment should be completed in respect of this. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 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 Residents are encouraged to speak for themselves and feel listened to but they would benefit from an accessible complaints procedure. EVIDENCE: Staff listen to residents respectfully and act on the issues that they raise. One resident said that staff members do listen. Another resident pointed out a problem with his bedroom window and confirmed that he had told the manager. The job was recorded in the maintenance book awaiting attention. The complaints procedure was seen in two rooms in a written format but neither resident knew what the sheet of paper was about. Some attention is needed to this. A logbook is in place for complaints to be recorded. No recent complaints were reported to have been made to the home. CSCI has not received any complaints about the home since the last inspection. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 16 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 Some further work is needed in the home to ensure that areas needing redecoration do not detract from the bright, comfortable environment provided for residents. EVIDENCE: The home was clean and attractive. There are plans to redecorate two bedrooms and residents have been involved in the selection of colours for the rooms. When one of the rooms is redecorated the wardrobe doors need to be replaced. The manager reported that some carpets are to be replaced by CIC. There is a maintenance book that has the details of all of the identified problems with the fabric of the building. The manager explained the system for ensuring that maintenance work is completed. The last piece of work had been completed on 15/9/05. There had been some confusion over the process but that had been cleared up and the manager anticipated that outstanding matters would be addressed promptly. CIC had addressed a problem of damp in one of the bedrooms and this was now being monitored to see if it was effective. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 17 The bathroom on the first floor is in need of redecoration and areas of the wood are in need of re-varnishing. The ceiling is low. Some consideration could be given to this when redecoration takes place. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 18 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 A positive, helpful and increasingly efficient staff team supports service users. More details about staff need to be checked to demonstrate that recruitment procedures are robust. EVIDENCE: Three residents spoke about staff positively. Photos were used during some of the conversation. One person said that staff were ‘alright’, and that the key worker was ‘helpful’. Others said they liked all of the staff. Staff working were caring and friendly towards the residents. Adequate numbers of staff are being provided to meet resident’s needs. Rotas are a record of the hours worked. The rotas are currently made up of permanent and relief staff because two full time posts are vacant. Agency staff are being used. They work regularly at the home and are known to the residents. The manager confirmed that he was using all of the hours allocated to the home. This is 242 hours a week. This was supported in the sample of rotas assessed. The manager reported to be in the process of recruiting staff. Two sets of recruitment records were sampled. Both records had most of the information needed but some was missing. There was an incomplete reference, a missing 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 19 statement regarding physical and mental health, and unexplained gaps in an employment record. Records were not available for relief and agency staff. This is needed to show that procedures are comprehensive. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 20 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 Residents are generally protected by an effective system of regular safety checks and maintenance but some attention to electrical safety in a bedroom would enhance this further. EVIDENCE: Health and safety is promoted in the home. A sample of records was viewed and indicated that checks were taking place regularly. It was noted that gas safety certificate was dated 9/2/05. Water temperatures are checked and monitored to maintain correct temperatures. Fire checks were sampled and had taken place. A Fire risk assessment had been completed. Observation of the home showed that radiators are covered, substances hazardous to health were locked away and mostly no obvious hazards were noted. The only concern raised by the inspector was that one of the residents had a lot of electrical equipment in regular use and only two sockets were provided in the bedroom. Having observed the electrical equipment in use, and a plug being inserted in to a live socket, the inspector felt that a further risk assessment was needed with consideration of more sockets being provided. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 x Standard No 22 23 Score 2 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x 2 x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 14 Mengham Avenue Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x DS0000064990.V257847.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? This is the first inspection since CIC registered the home. 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 2 Standard YA24 YA34 Regulation 23(2)(d) 19(1)(b) Requirement The registered provider must ensure that the bathroom is decorated. The registered provider must ensure that records are held in the home for relief and agency staff. The registered provider must review the risk assessment use of electrical equipment and take appropriate action. Timescale for action 13/01/05 13/12/05 3 YA42 13(4)(a) 13/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 22 Good Practice Recommendations The complaints procedure needs to be developed in various formats. 14 Mengham Avenue DS0000064990.V257847.R01.S.doc Version 5.0 Page 23 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.V257847.R01.S.doc Version 5.0 Page 24 - 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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