Inspection on 15/12/05 for 151 Tunbury Avenue

This inspection was carried out on 15th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

151 Tunbury Avenue 20/01/10

151 Tunbury Avenue 01/10/07

151 Tunbury Avenue 11/07/06

151 Tunbury Avenue 28/06/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 151 Tunbury Avenue 151 Tunbury Avenue Chatham Kent ME5 9HY Lead Inspector Sue McGrath Unannounced Inspection 15th December 2005 10:00 151 Tunbury Avenue DS0000064404.V274431.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 151 Tunbury Avenue DS0000064404.V274431.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. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 151 Tunbury Avenue Address 151 Tunbury Avenue Chatham Kent ME5 9HY 01622 769100 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) MCCH Society Limited Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: 151 Tunbury Avenue is one of a number of homes managed by MCCH Society Ltd. This organisation took over the management of this home on 1st April 2005. The home offers 24-hour care for service users with a learning disability. It is located within a pleasant residential area. It is a large detached bungalow with shops and local amenities close by. The home benefits from transport that is shared between several homes from that group. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection under the terms of the Care Standards Act 2000 and was carried out by one inspector who was in the home from 09.30 to 13.30 on the 15th December 2005. At the beginning of the inspection no permanent members of staff from the home were on duty, only bank staff were present. The inspector contacted the Registered Manager who arrived soon after the call. As this report was made following an unannounced visit and may not cover the standards in sufficient depth for the reader to make a judgment about the home, it is recommended that a copy of the last announced inspection report dated 28th June 2005 be also obtained. What the service does well: What has improved since the last inspection? What they could do better: The main area of concern was the number of hours the Registered Manager was spending managing the home. The majority of the issues raised in the report were as a direct result of lack of management control. The organisation is strongly advised to make a decision over the future role of the Manager within their organisation. Whilst the Commission totally accepts that it is normal practice for employees to seek promotion it must be the case that the 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 6 first priority of any Registered Manager must be the home for which he/she is registered. 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. 151 Tunbury Avenue DS0000064404.V274431.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 151 Tunbury Avenue DS0000064404.V274431.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): 1 and 5 Prospective residents are not currently provided with the information they need to make an informed choice about moving into the home. The written statement of terms and conditions does not currently protect Resident’s legal rights to occupancy. EVIDENCE: The updated Statement of Purpose was viewed but was found to be inaccurate, as it gave false information regarding the name of the Manager and also listed staff that had left the employment of MCCH. This issue will need to be addressed and an updated, accurate copy sent to the Commission for further inspection. A requirement will be made. Staff were unable to find any written contracts or statements of terms and conditions for any of the residents. A requirement will be made. 151 Tunbury Avenue DS0000064404.V274431.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): No judgements made – see last report dated 28/06/05. EVIDENCE: Standards 6-10 were assessed as met at the last announced inspection in June 05. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 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): No judgements made – see last report dated 28/06/05. EVIDENCE: Standards 11-17 were assessed as met at the last announced inspection in June 05. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home’s inadequate procedures regarding the administration and handling of medication continues to put residents at risk despite this matter being raised at the home’s previous inspection. EVIDENCE: Standards 18, 19 and 21 were assessed as met at the last announced inspection in June 05. Medication procedures were again assessed and although improvements were noted, some areas of the administration caused concern. Medicines were still not being counted in accurately; this meant it was impossible to conduct an accurate audit. This had been discussed at the last inspection. On the morning of the inspection two bank staff were administering the medication, one of which had only started to work for the organisation the previous day. One of the bank staff had completed an accredited training in a previous role but had only returned to the home in November 05. Neither had completed any recent evaluation of their skills and capabilities to administer medications. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 12 The Royal Pharmaceutical Society of Great Britain guidelines state in section 4.7 that the manager/designated person is responsible for signing the exemption declaration on the back of the prescription form on behalf of the service user, if the service user is unable to do this themselves, prior to the prescription being submitted to the pharmacy. This is not happening. The Registered Manager was unaware of both situations until it was pointed out to him. The manager confirmed that none of the permanent members of staff had completed any recognised course in the administration of medications. This will be a requirement. The Registered Manager is reminded that he is responsible for the administration of medication within the home. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 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): No judgements made – see last report dated 28/06/05. EVIDENCE: Standards 22 and 23 were assessed as met at the last announced inspection in June 05. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 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): 27-30 Residents benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. Service users are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. EVIDENCE: Standards 24 –26 were met at the last inspection. The manager discussed plans that had been drawn up to improve the bathroom facilities. The unused shower in the en-suite bedroom was to be adapted and incorporated into the main bathroom to provide a walk in shower for all residents to use. It was proposed that a new Hi/Low bath be fitted to meet the needs of the residents currently in the home. An Occupational Therapist had been involved in deciding what facilities were best provided. The plans had been agreed and the project was awaiting confirmation of funding. It was hoped that the cost would be jointly funded by MCCH and the local PCT. The lounge area was fairly small considering some of the residents were confined to wheelchairs and there would be very limited scope to increase the number of residents at the home. The room designated as the dining room was 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 15 used as the main office, so again this limited the amount of space available for the residents to use. The home did have a garden for the residents to enjoy, but access to it was through one of the residents bedroom. Whilst this is not ideal, procedures were in place to ensure the resident agreed to other residents going through her room. Access to the garden and patio was via a ramp. The garden was large with several mature trees and flowerbeds. The kitchen was modern and well maintained. Plans to update the laundry area were also in hand to ensure that access to the laundry was not through the kitchen as required in Standard 30 of the National Minimum Standards. Hand washing facilities will be required in the proposed new laundry area. The home does not provide a designated staff room. The home was well equipped for cater for the level of disability of the residents with several overhead tracks for hoists in the bathroom, lounge and two of the bedrooms. Other aids include handling belts, slings, zimmer frames, slide sheets and wheelchairs. The home does not have a call alarm system and the Registered Manager will be required to risk assess this. A copy of this risk assessment must be supplied to the Commission. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 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): 33, 34, 35 and 36 The care of residents is compromised because of the home’s lack of permanent staff. The care of residents is compromised and they may be put at risk because of the lack of mandatory training provided for staff. EVIDENCE: The home has lost several staff recently and this has made covering the rota very difficult. The Registered Manager confirmed that new staff were currently being employed and it was hoped they would be starting in the new year. Currently the home is understaffed. The organisation had a robust procedure in place and this had been followed to ensure appropriate staff were employed. Staff files were in a locked cabinet and no one, including the Registered Manager, had access to the keys. Therefore staff files could not be examined. It will be a recommendation that all senior staff have access to keys. A system must be put in place to ensure the keys are kept safely on the premises at all times and not taken home by staff. Individual training matrixes were available but had not been completed for the majority of the staff. Moving and Handling training for several staff were out of date. It was difficult to assess what training had been completed. The Registered Manager must ensure these records are updated and any required mandatory training required be arranged. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 17 Currently staff were supervised by an acting manager who had completed a delivering supervision course. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 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): Residents are at risk from a lack of management control within the home. Current arrangements were not sufficient to fully protect the health, safety and welfare of residents and staff. EVIDENCE: As stated in the last report the Registered Manager is not spending sufficient time in the home to manage it efficiently. This is because he has been promoted to Service Co-ordinator. The organisation must decide which post is to be substantive because the home and its residents are suffering from a lack of management control. Issues with the staffing arrangements and the medication issues highlighted earlier in the report are examples of poor management control. The Registered Manager stated that regular residents meetings were held but when the records were checked, none had taken place for some considerable time. Again this situation is not being managed. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 19 The organisation has many policies and procedures in place, which staff signed to confirm they have read and understood, however the Registered Manager had not signed or dated these as required by Standard 40.6. The registered manager confirmed that residents can have full access to their own records but in reality only one of the residents actually asks to see her own records. These are made available to her. On inspection of the maintenance records it was apparent that the hoist servicing was out of date. This meant that all three hoists had not been serviced since March 05 and had been due to be serviced in September 05. The fire alarm system was not being checked weekly, although the manager was not aware of the change in the testing interval. Arrangements were put in place to ensure more regular testing took place. Other fire safety checks, including fire drill were taking place. Fire extinguishers were being checked visually but this was not recorded, it will be recommended that records be kept. The Registered Manager is again reminded that he is responsible for the health, welfare and safety of the residents and staff. The home did not have a current business and financial plan although the Registered Manager did state that work on these documents should be completed by April 06. Adequate insurance cover was in place. 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 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 Standard No Score 1 1 2 X 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 3 28 2 29 3 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X 1 1 1 2 2 2 2 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES 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 YA1 Regulation 4(1)(2) Requirement Timescale for action 31/01/06 2 YA20 13(2) 3 YA33 18(1)(a) The registered person shall compile an accurate and up to date written Statement of Purpose. Copy to be provided to the Commission by 31/01/06 The registered person shall make 31/01/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This requirement is carried over from the last report and must be addressed urgently. Action plan by 31/01/06. The registered person shall, 31/01/06 having regard to the size of the care home, the statement of purpose and the needs of the service users, ensure that at all times suitably qualified, competent and experienced staff are working at the care home in such numbers as are appropriate for the health and welfare of service users. This requirement is carried over from the last report and must be addressed urgently. DS0000064404.V274431.R01.S.doc Version 5.1 151 Tunbury Avenue Page 22 Action plan by 31/01/06. 4 YA37 9 The Registered Manager must spend sufficient time in the home to discharge his responsibilities as Registered Manager. The registered person shall ensure that all equipment provided at the care home is maintained in good working order. The registered person shall ensure that the staff employed by the home have training appropriate to their work they are to perform - in that all staff must be fully up to date with all mandatory training needs 15/12/05 5 YA42 13(4)(5) 15/12/05 6 YA35 18(c) 31/01/06 7 YA5 5(c) 8 YA20 18(1)(c) 9 YA29 23 (2)(n) Action plan required by 31/01/06 The registered manager 31/01/06 develops and agrees with each service user and or their representative, a written and costed contract/statement of terms and conditions between the home and the service user. Staff who administer medication 31/01/06 must complete an accredited training course. Action plan required by 31/01/06 The registered manager is 31/01/06 required to assess the risk of not having an emergency call system in place. The risk assessment to be supplied to the Commission by 31/01/06. ( 29.2vi) 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 23 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. 2 Refer to Standard YA40 YA39 Good Practice Recommendations It is recommended that the registered manager signs and dates all policies and procedures. It is recommended that there is an annual development plan for the home, based on a systematic cycle of planning-action-review, reflecting the aims and outcomes for the service users. It is recommended that a system must be put in place to ensure the keys are kept safely on the premises at all times and not taken home by staff. It is recommended that the visual checking of the fire extinguishers be recorded. 3 4 YA41 YA42 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 151 Tunbury Avenue DS0000064404.V274431.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!