Inspection on 14/11/05 for 15-17 Kew Gardens

This inspection was carried out on 14th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

15-17 Kew Gardens 05/12/08

15-17 Kew Gardens 08/06/06

15-17 Kew Gardens 19/07/05

15-17 Kew Gardens 11/11/04

15-17 Kew Gardens 25/06/04

15-17 Kew Gardens 09/02/04

Similar services:

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Dovedale Court

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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 15-17 Kew Gardens West Mead Drive Bognor Regis West Sussex PO21 5RD Lead Inspector Mrs L O’Donnell Unannounced Inspection 14th November 2005 02:00 15-17 Kew Gardens DS0000014276.V265720.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 15-17 Kew Gardens DS0000014276.V265720.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. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 15-17 Kew Gardens Address West Mead Drive Bognor Regis West Sussex PO21 5RD 01243 830214/830242 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) Royal Mencap (Housing & Support Services) Mrs Ruth Dukes Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to Eight (8) male and/or Female service users between the ages of Eighteen (18) and Sixty Five (65) years in the category of Learning Disability may be accommodated. Up to Two (2) people may have an additional Physical Disability. Total of Eight (8) service users may be accommodated. 2. 3. Date of last inspection 19th July 2005 Brief Description of the Service: Kew Gardens is registered to provide accommodation for up to eight residents within the category of adults with a learning disability. The home is situated in a quiet residential area in Bognor Regis. The property is divided into two selfcontained houses, which are linked on the first floor. Four residents live in each of the houses. Each house provides four bedrooms, a lounge and dining room, kitchen and bathroom facilities. There is a garden at the rear of the property. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection, which took place during the afternoon and early evening. Prior to the inspection, the Inspector reviewed the previous inspection report and any communication received. During the inspection, a tour of the home was undertaken and the Inspector spoke with residents and staff. Residents were observed to be relaxed both within the home and with the staff team. A variety of records were also reviewed as part of the inspection. 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. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 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 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 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): These standards were not assessed at this inspection. No new residents have moved into the home since the last inspection. EVIDENCE: 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 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 Each resident has a care plan in place which provides information on their individual needs, goals and objectives, and how these are to be met. Residents are supported to make decisions about their own lives. EVIDENCE: Although it was noted that all residents have a care plan in place a sample of care plans were seen in each of the two houses. These contained detailed information on the assessed needs of the residents and how these were to be met. They also contained information as to resident personal preferences and outlined what the residents are able to do independently. However it is recommended that these are reviewed as some aspects of the care plans had not been reviewed this year. Each resident has a ‘pen picture’ included within the care plan which provides a summary of individual likes and dislikes and identifies the areas in which the resident requires support from staff. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 9 Goals and opportunities are included within the plans. A monthly goal monitoring form was seen however again in some cases this had not been reviewed this year. Risk assessments were seen to be in place and it was noted that these were linked to the individual needs identified either through assessments or care planning. Some had been reviewed six monthly, others annually. Any restrictions imposed on a resident are detailed within the care plan and the reasons for this are included. Information on any behavioural issues including triggers, are also included within the care plans. A daily handover report is also completed for each resident which details any community or house based activities the residents have enjoyed, any incidents that have occurred, any information as to health care needs, choices and decisions made by the residents and meals they have had during the day. It was evident through the care plans seen that residents are supported to make their own decisions and this was confirmed by those residents who were able to do so. Clear and detailed finance records were seen during the inspection. Staff do support residents to manage their finances, and all expenditure is documented and supported by receipts. 15-17 Kew Gardens DS0000014276.V265720.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): 11, 12, 14, 17 Residents do have opportunities to maintain and develop social and independent living skills. Residents are able to access a variety of educational and leisure activities Residents enjoy balanced and varied meals EVIDENCE: It was clear through records seen, discussions with staff and residents and observations made during the inspection that residents have opportunities to learn and use practical life skills. Residents who are able to, assist with day-to-day duties around the home i.e. meal preparation. The educational opportunies available to residents has decreased this term due to changes made to the selection criteria of courses at Brinsbury college where 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 11 a number of residents used to go. Staff are currently seeking alternatives for residents. Records show that residents enjoyed their previous experiences at the college and changes to individual behaviour have been noted since they have not been able to go. It was clear through records seen and discussions with staff that residents are supported to participate in the local community. Those residents who were able to speak with the inspector confirmed this. This included shopping, lunches out, trips and picnics. Through observations made during the inspection it was clear that residents are able to pursue their own interests and hobbies with one resident speaking about their enjoyment of music. One resident spoke to the Inspector about a holiday that they had enjoyed this year. Menus were seen and these showed that a variety of meals are provided within the home. The menus were drawn up by a member of staff who has previously worked as a chef. He confirmed that the menus take into consideration the likes and dislikes of the residents. All residents who were able to advised that they enjoyed the meals served within the home. During the inspection it was observed that residents who are able to assist with the meal preparation and cooking. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 12 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): 20 Good practices in the administration of medication were noted. EVIDENCE: Staff spoken with confirmed that they had received training in the administration of medication. It was confirmed by a member of staff that all care staff except one recently employed have received this training. Medication was seen to be stored securely and all records in relation to its administration were up to date. It was noted that one member of staff takes responsibility for medication, including ordering, recording receipt of etc. There is an appropriate policy and procedure in place. For each resident there is an information sheet with details of their current medication, why they are taking it and any possible side affects linked to it. There is also a procedure in place for homely remedies, which the doctor has signed. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 13 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 There is a clear complaints procedure in place There are appropriate policies and procedures in place to protect residents from abuse. EVIDENCE: There is a complaints procedure in place with forms to record any complaints or compliments received. Staff would support residents to complete these if necessary. It was noted that no complaints had been received since the last inspection. There are clear policies and procedures in place with regards to the protection of vulnerable adults. A member of staff advised that adult protection training had been arranged and staff would be undertaking this soon. Members of staff when asked were very clear as to their role and responsibility with regards to adult protection. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 14 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, 27 Residents are able to live in a homely, well-maintained environment. All residents have their own rooms which meet their individual needs. Bathroom facilities at the home have been upgraded and improved. EVIDENCE: The home is well decorated and furnished and provides a homely atmosphere. In each of the two houses there is a lounge and separate dining room. During the inspection the residents were observed to choose where they wished to be during the afternoon and early evening. Each resident has their own room which they are able to decorate and personalise as they wish. The inspector saw one resident in his room and he confirmed that he was very happy with it and had everything that he needed. Records seen showed that that the home was well maintained with equipment and services checked as required. There is a garden with paved area at the rear of the home. Through discussions with a staff member it was demonstrated that work is to be 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 15 undertaken to develop the garden area further with the provision of raised beds to enable residents to grow their own vegetables next year. There are two bathrooms within each of the houses, one on the ground floor and one on the first floor. These have been upgraded since the last inspection and are now fully operational with one bathroom in each house providing a fully assisted bath. One bathroom also now has a tracking hoist above the bath. It was highlighted at the previous inspection that staff had to use one of the dining rooms as their sleep in area. This was found to be unacceptable due to the restrictions this imposed on residents and privacy concerns for the staff. It was noted at this inspection that this is still the practice within the home however the Housing Association who owns the house has now visited in order to progress plans to convert one of the upstairs offices into a staff room. Another concern identified at the previous inspection related to the storage and disposal of infected waste. It was noted at this inspection that this has now been addressed and there are now adequate bins which are stored behind a closed gated area. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 16 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, 36 Residents are supported by a competent staff team. Staff receive regular supervision. EVIDENCE: Throughout the inspection staff were observed to be accessible to residents. Residents were relaxed with the staff on duty and approached and spoke with them as they wished. Staff demonstrated a good understanding of the needs of the residents. There is currently a need for agency staff to be employed within the home. However both staff and the person in charge at the time of inspection advised that wherever possible they have the same agency staff. During the inspection the inspector spoke to one agency worker who advised that he had been to the home before. He was also able to demonstrate an understanding and awareness of the needs of the residents. Mencap has also now established its own bank/relief staff team and therefore this should allow for further continuity if and when used. The relief staff will also undertake the same training as permanent members of staff. Residents who were able to, advised that they liked the staff and that they provided them with any help and support they needed. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 17 It was clear that training in a variety of areas is made available to staff. Through discussions with staff it was clear that regular supervision is undertaken. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 18 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): 39, 42 There are quality assurance and monitoring systems in place which seek feedback from the residents. As far as is reasonably practicable the health safety and welfare of the residents is promoted. EVIDENCE: The Registered Providers have developed a quality assurance system. The outcome of the last audit was available within the home and this showed that the views of residents are sought as part of this process. On the information seen during the inspection it is recommended that this system is developed further to ensure that the views of all interested stakeholders are sought. There are policies and procedures in place in respect of health and safety. Staff when asked confirmed that they had received training in health and safety areas. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 19 Records seen during the inspection indicated that the property was maintained with equipment and services checked and inspected as required. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 20 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 X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X X X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 15-17 Kew Gardens Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000014276.V265720.R01.S.doc Version 5.0 Page 21 YES 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 YA28 Regulation 23 (3 b) Requirement The Registered Person shall provide for staff, sleeping accommodation in connection with their work at the care home. (Outstanding from previous inspection) Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The Registered Person should ensure that all care plans are reviewed on a regular basis. 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 15-17 Kew Gardens DS0000014276.V265720.R01.S.doc Version 5.0 Page 23 - 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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