Inspection on 08/06/06 for 15-17 Kew Gardens

This inspection was carried out on 8th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

15-17 Kew Gardens 05/12/08

15-17 Kew Gardens 14/11/05

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

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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 J Aston Unannounced Inspection 8th June 2006 09:15 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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) www.mencap.org.uk Royal Mencap Society Post Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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 14th November 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. Mencap are responsible for the service. The Downland Housing Association owns the property. The Responsible Individual acting on behalf of the organisation is Ms Jan Tregelles. The newly appointed Manager is Ms Michelle Allen who is currently not registered with the Commission for Social Care Inspection. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is the first inspection in 2006-2007. It is called a key inspection and will determine the frequency of inspections hereafter. Planning for this inspection took place prior to the site visit. Surveys were sent to each service user and comment cards sent to relatives and Professionals who know the service. Service users received assistance to complete the surveys and all surveys were completed and returned. Five out of eight comment cards were received from relatives. One comment card was received from a Social Work Professional. A site visit took place on the 8th June 2006 and was an unannounced visit. Five and a half hours were spent in the home. A tour of the premises was undertaken, two members of staff were interviewed and a sample of records were examined. Six service users were seen during the visit however very limited conversations were held with each service user due to communication difficulties. What the service does well: What has improved since the last inspection? Separate sleeping in accommodation has now been provided for members of staff. Service user care plans are currently being reviewed and updated to provide a more person centred approach. All service users have received an assessment of their needs undertaken by a Social Worker. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 6 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.V290615.R01.S.doc Version 5.1 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 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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): Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Standard 2. The needs of prospective service users are appropriately assessed. EVIDENCE: No new service users have been admitted to the home on a permanent basis since the last inspection. A service user was admitted in an emergency from another Mencap home. This is still a temporary arrangement. Regular meetings are being held to review this situation. At the site visit the Inspector examined a sample of records relating to service users. The records included an assessment of need and a care plan undertaken by a Social Worker before admission. An assessment of the needs of the service users and their wishes was also undertaken by the home and this is kept under review. The organisation has a comprehensive assessment and admission policy and procedure for Registered Managers to follow to ensure each admission is undertaken in a planned way. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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 in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. Service users needs and wishes are recorded appropriately. Service users receive support and assistance from members of staff to make choices and decisions in their lives. Where service users lack capacity members of staff have to make decisions in the best interests of each service user. Service users are supported to lead their lives within a risk management framework. EVIDENCE: The records relating to four service users were examined. Service user plans provided comprehensive information about the needs and wishes of each service user. The service user plans are currently being updated. A Social worker had undertaken a needs assessment for all service users in January 2006. It was observed during the inspection that members of staff offered choices to service users. However due to the level of disability of some service user decisions have to be made in the best interests of service users but where their choice or wish is known this is recorded on their individual plan. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 10 There was evidence that potential risks for service users had been assessed and recorded on a risk assessment. Risk assessments were noted to be individual for each service user and covered areas in respect of bathing, road safety, travelling in vehicles etc. It was noted that the risk assessments had been reviewed on an annual basis. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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, 15, 16, 17. Quality in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. The service users currently accommodated are supported to live in an environment that meets their needs and provides them with a fulfilling lifestyle. Service users are supported to maintain contact with family and are provided with a varied menu that includes healthy eating. EVIDENCE: Service users are supported to undertake a wide range of activities that include educational, leisure and community activities. A member of staff spoken with at the time of the inspection said how he supports a service user to go to concerts, shopping, going to a pub or a restaurant and attending college. Each service user has a written programme of activities. Their key worker writes a monthly report that also confirms what activities have been undertaken. An activity co-ordinator is employed to work in the home Monday to Friday. The co-ordinator supports service users at college but also organises activities in the home. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 12 Five out of the eight relatives responded to the comment cards sent prior to the inspection. All relatives confirmed that they are kept informed about important matters affecting their relative and four out of the five said they were consulted about their care. Four out of the five said they were made welcome into the home and all said they could visit their relative in private. Members of staff spoken with during the inspection confirmed that service users go shopping with members of staff to choose and buy food that they like and that they are involved in planning menus. Members of staff also encourage and support service users to make drinks and to be involved in preparation of meals. The main meal of the day is eaten in the evening but breakfast and lunch can be at different times according to service users activities and wishes. Photographs have been taken of food items, drinks and contents of kitchen cupboards to aid communication and encourage service users to make choices. The photographs could be extended to cover meals on the menu to aid communication and assist in making choices. Members of staff spoken with said that the menu was currently under review to improve the flexibility and choice of meals. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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, 19, 20. Quality in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. Service users personal care and health needs are met appropriately. The service operates effective and safe procedures in the administration of medication. EVIDENCE: From the sample of service user plans examined at the site visit it was demonstrated that members of staff have comprehensive information about the personal care and health needs of each service user. Records demonstrated that new members of staff receive instructions about how to assist each service user and their practice is observed before assisting a service user alone. Health care check ups are recorded in the service user plan. Members of staff spoken with confirmed as key workers to service users they ensure that regular health checks are undertaken. Service users’ weight and other aspects of health are monitored and recorded as necessary. Members of staff confirmed that appropriate training in how to move service users and to use lifting equipment is provided and updated regularly. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 14 They confirmed that they have the necessary equipment for each service user and it is in good working order. Medication was seen to be stored appropriately in the home and an observation of a member of staff giving medication to service users demonstrated that this was done correctly. Records of medication administered were in good order. Each service user has a pen picture in relation to what medication they are taking and what it is for. The service users’ GP’s have been consulted and have given their consent for members of staff to administer medication. It was noted that where medication had been missed an incident record had been completed. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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 in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. Complaints are dealt with appropriately. The service has ensured as far as possible that service users are protected from abuse. EVIDENCE: The Commission has not received any complaints in respect of this service. The Manager informed the Inspector that there have been no complaints made to the home. The complaints record was examined and none were recorded for this year. Members of staff spoken with confirmed that they have received training in recognising signs of abuse and have recently received training in physical interventions. However members of staff confirmed that physical restraint is not required or used in this setting. The Manager confirmed that training in abuse awareness and reporting of allegations is being updated. An allegation of abuse has been received within the last month and an investigation is still ongoing and therefore remains an allegation. The Manager has reported the allegation appropriately and taken the correct action. There appears to be no breaches in regulation in connection with the allegation. All service users are supported to manage their finances. Service users’ benefits are paid directly into an individual Building Society Account. The Manager and members of staff are signatories for withdrawal of money from this account. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 16 The Manager and key workers assist service users to pay their rent and financial contribution to the service from this account and buy personal items. All transactions are recorded and receipts kept. The records are monitored and audited by the Manager and as part of the Regulation 26 inspections and through a more formal audit by the organisation. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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, 30. Quality in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. The standard of accommodation provided for service users is good and provides a safe environment. EVIDENCE: A tour of the premises was undertaken and records in relation to the safety of the property examined. The property is divided into two houses with access into both through a separate front door and through the garden at the rear of the property and through connecting offices on the first floor. Each house has four bedrooms, separate lounges, dining rooms and kitchens. There are also two bathrooms and toilets in each house. A sleeping in room has now been arranged using part of the offices on the first floor. Service user rooms looked individually decorated and furnished and suitable for the needs of the service users. The home looked clean throughout and well maintained. The garden was accessible to service users who use a wheelchair and was reasonably well kept. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 18 The property is of a high standard and provides a comfortable and homely environment. Records examined demonstrated that safety checks on the property and utilities are regularly undertaken and comply with safety legislation. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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. Quality in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. Service users are supported by a stable, experienced staff team that know them well and who have sufficient time to meet their needs. There are good recruitment procedures and individual supervision of staff is regularly undertaken. EVIDENCE: A sample of training records demonstrated that all staff had undertaken a wide range of training from induction through to National Vocational Qualifications level 2 & 3. Training in Health & Safety topics had been undertaken at induction and updated as required. Specific training in topics relevant to the needs of the service users had also been undertaken. Members of staff confirmed that this training had been provided and that updates in Health & Safety topics are being provided again this year. Members of staff confirmed that the staffing levels in the home are usually sufficient to meet the needs of the service users within the home and to take them out to their individual activities. Staffing records demonstrated that the staff team have remained reasonably stable for some time and only the organisations bank staff or a regular agency is used to cover vacant hours. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 20 The records relating to four members of staff were examined during the inspection. The records demonstrated that the organisation follows a robust recruitment procedure and all staff had had a Criminal Record Check undertaken. Records demonstrated that those members of staff had received regular supervision. Members of staff spoken with confirmed that they receive regular supervision and staff meetings are usually held regularly. There was no evidence of annual appraisals/personal development reviews for these members of staff. The Manager should ensure that these are undertaken. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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 in this outcome area is good. These judgements have been made from evidence gathered both during and before the visit to this service. The home is well maintained and safe for service users. The safety of service users and members of staff is considered and risks minimised as far as possible. EVIDENCE: A new Manager was appointed in May 2006 but is not yet registered with the Commission for Social Care Inspection. Records demonstrated and members of staff spoken with confirmed that training in the Health & Safety topics: Moving & Handling, First Aid, Food Hygiene, Fire and Health & safety is undertaken as part of their induction programme and then updated as required. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 22 Records seen on the day of the inspection demonstrated that annual safety inspections are undertaken on equipment and utility supplies and maintenance systems are in place to ensure the safety of residents. Risk assessments had been undertaken in respect of potential risks to staff or service users when using kitchen equipment for example and other hazards within the home. There is a current liability insurance certificate for the home. Each house has a telephone so that staff can contact each other in each house. The telephone is located on the first floor. After speaking with a member of staff it is recommended however that thought be given to providing some form of emergency alarm system so staff can easily and quickly call for staff from the other house in an emergency. A quality assurance system is in place and provides an organisation service review every 2-3 years. The previous Manager had undertaken a quality assurance exercise last year that obtained views of the service from relatives and professionals who know the service. 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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 X 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 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 3 X X 3 x 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 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. 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. 1 Refer to Standard YA42 Good Practice Recommendations To provide some form of emergency alarm system so staff can easily and quickly call for staff from the other house in an emergency. The Manager should ensure that staff annual appraisals are undertaken. 2 YA36 15-17 Kew Gardens DS0000014276.V290615.R01.S.doc Version 5.1 Page 25 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.V290615.R01.S.doc Version 5.1 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. 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