Inspection on 01/03/06 for 17 Gordon Road

This inspection was carried out on 1st March 2006.

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

The inspector found 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Gordon Road 19/07/07

17 Gordon Road 28/07/06

17 Gordon Road 08/11/05

17 Gordon Road 14/02/05

17 Gordon Road 13/09/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Gordon Road (17) 17 Gordon Road Vange Basildon Essex SS14 1PN Lead Inspector Sarah Buckle Unannounced Inspection 1st March 2006 14:45 Gordon Road (17) DS0000018111.V266245.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 Gordon Road (17) DS0000018111.V266245.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. Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gordon Road (17) Address 17 Gordon Road Vange Basildon Essex SS14 1PN 01268 282777 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) Mosaic Essex Mrs Michelle King Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 3 persons of either sex to be accommodated who have a learning disability. No more than 3 persons to be accommodated at any one time. Date of last inspection 08/11/05 Brief Description of the Service: 17 Gordon Road provides care and accommodation for three adults with a learning disability. The home’s facilities include a comfortable open plan living room, dining room and kitchen. There is also a shower room, an office and a laundry room on the ground floor. Upstairs there is a bathroom, three bedrooms for residents and a sleeping in room for staff. Gordon Road has a reasonable sized and secluded garden to the rear of the house, which all residents can access. The home is situated within walking distance of local shops. Basildon town centre is a short distance away. There is a good bus service in the area. Residents within the home are encouraged to access leisure pursuits and community facilities supported by experienced staff. The home has its own transport available. Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over three hours. Opportunity was taken to examine records, certificates, a care plan and menus. The residents were observed within the home. During the course of the inspection two members of staff were spoken with. What the service does well: What has improved since the last inspection? What they could do better: PRN protocols are not written for all of the ‘as required’ medication. Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 6 Mandatory training is in the process of being organised, but is still out of date in some instances. Some members of the staff team were working excessively long shifts, which could compromise the effectiveness of the staff team and potentially place residents at risk of harm. There is not a procedure in place for all records within the home to be inspected in the absence of the acting manager. The acting manager must ensure that references required by the Commission are forwarded in order to progress her application for registration. 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. Gordon Road (17) DS0000018111.V266245.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 Gordon Road (17) DS0000018111.V266245.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): Not inspected. EVIDENCE: Not inspected. Gordon Road (17) DS0000018111.V266245.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): 6. Individual care plans were of a good standard. EVIDENCE: One care plan was sampled and it was positive to note that it had been updated and re-organised since the last inspection. The care plan was well structured. Support plans were clear, detailed and written in a person-centred manner. These included short and long-term goals and instructive information regarding support required i.e. one support plan concerned with bedroom maintenance had a long term goal of the resident being able to clean her bedroom without any staff intervention. Alongside this plan was a sheet, which broke these tasks into six stages, each of which was ticked by a staff member on completion. Gordon Road (17) DS0000018111.V266245.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, 13, 16 and 17. Residents have opportunities for personal development, to partake in appropriate activities and to access the local community. Their rights and responsibilities are adequately recognised and they are offered a varied and balanced diet. EVIDENCE: Within one care plan sampled there were support plans for activities, which included a cooking activity and a step-by-step guide regarding the support required by the resident to achieve this. Al of the residents within the home accessed the local community college for courses. One resident went to a class called ‘The Strongest Link’, which developed communication skills, another resident went to this class along with a class in English skills and a class in Maths skills and the third resident attended a class in co-ordination skills. One staff member spoken with stated that when the day services closed down, the available courses at local colleges were oversubscribed. She said that this Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 11 year they hope to book places early and subscribe to more courses on behalf of the residents. A weekly opportunities record was examined during the inspection and this demonstrated that residents have access to the local community and are involved in tasks such as house shopping, visiting the bank, going out to Lakeside and to the town centre. The menus were examined and a staff member spoken with stated that all the residents are asked what they would like to eat the on the day before the food is due to be cooked. The menus were seen to be varied and to offer a balanced diet. Gordon Road (17) DS0000018111.V266245.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): 18 and 20 Residents do receive personal support in a way they prefer. Medication is in the main part well managed. EVIDENCE: Daily care notes were examined and demonstrated that residents were supported to make choices and to partake in their preferred occupations. For example, one resident was involved in completing household tasks, going out to do the house shopping, relaxing at home, and completing cooking tasks. During the inspection all three residents were observed making cups of tea as and when they wanted, one resident was offered support to achieve this. The medication file was examined. There were no omissions noted on the residents’ MAR sheets, however, there were three instances of PRN medication and only one protocol had been completed. This was for Chlorpromazine and stated that the protocol was to be implemented and the medication given when the residents “behaviour changes” and to “follow guidelines set”, however there were no guidelines within the file. The protocol had been completed in 2003. There were no photographs of the residents attached to their MAR sheets. Gordon Road (17) DS0000018111.V266245.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 and 23 Resident’s views are listened to and they are protected from abuse and harm. EVIDENCE: There have been no complaints since the last inspection. One staff member was spoken with in relation to POVA. She was able to demonstrate awareness of the procedure to follow in relation to an allegation or the suspicion of abuse. She made reference to the ‘No Secrets’ guidance. Two staff training folders were examined. One of these had evidence of POVA training on 11/03/2004 and the other had completed training in 2003. The staff member spoken with explained that the training schedule for 2006 has just become available and that all staff members will be completing all mandatory training. Gordon Road (17) DS0000018111.V266245.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 and 30. Gordon Road is a safe, homely and clean environment. EVIDENCE: The lounge and dining area of Gordon Road were observed to be well maintained, comfortable and homely. Two of the residents were relaxing and watching TV. The kitchen area was clean and tidy. The home was free from odours. It was noted in the dining room that an area of wallpaper on the ceiling had was hanging down. A staff member explained that this had come loose as the result of a flood in the room above. She recorded the need for this to be repaired in the maintenance book. Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 15 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 Staff files were not available to be inspected. There are not sufficient staff numbers to ensure an effective staff team. Staff training and development has improved but is not satisfactory. Supervision files were not available to be inspected. EVIDENCE: Staff files were not available to be inspected, as the acting manager was not present during the inspection. The staff rota was examined and it was noted that some staff members are working long days and double shifts. In some instances staff members were written into the rota as working an early and a late shift, sleeping in, working an early and a late shift. This constitutes a thirty-one hour shift not including the sleep-in hours, and this was followed by a late, sleep-in and early shift the following day. Some staff members were working sixty hours a week without including sleep in shifts. Training files within the home are more organised that during the previous inspection. A training programme for 2006 was seen and a staff member explained that mandatory training and updates is in the process of being organised for staff members. Two staff training certificate files were examined. The first had evidence of core training, most of which was completed during 2003 and 2004. The staff member had completed training in Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 16 Breakaway and safe escape techniques on 29/07/05 and confusion and dementia on 07/05/05. The second file had evidence of training being completed in 2002 and 2003, and the staff member had also completed Breakaway training 0n 30/09/05. Some core training was still out of date. One staff member spoken with stated that two support workers had recently undertaken Boots medication training and two further staff were booked to complete it on 21/03/05. One other staff member spoken with stated that she had recently completed her NVQ3 and that another care worker was currently in the process of achieving this qualification. The acting manager is undertaking NVQ4. Staff supervision records were not available to be inspected and the acting manager was not present during the inspection, and she holds the key to the filing cabinet. Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 17 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 and 42 Gordon Road is a well run home, however there is still an acting manager in post. Health and safety was well managed. EVIDENCE: Gordon Road is a well run home, however, there is an acting manager currently in post and the Commission are still awaiting references in order to progress her application for registration. Health and safety is well organised within the home, and all the appropriate checks were seen to have been completed i.e. portable appliance testing was completed on 13/06/05; fire extinguisher’s were serviced on 17/11/05; fire alarms and emergency lighting were checked on 14/10/05 and there were two monthly recorded fire drills, with the names listed of those people involved and the time of the drill. Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 18 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 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 1 2 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gordon Road (17) Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 3 X DS0000018111.V266245.R01.S.doc Version 5.0 Page 19 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 YA33 Regulation 18(1)(a) Requirement The acting manager must ensure that there are sufficient numbers of staff working at the home as appropriate to meet the health and welfare of residents. This is in relation to some staff members working long days and double shifts. The acting manager must ensure that all records referred to in Sch3 and Sch4 are available for inspection at all times by any person authorised by the Commission. A person authorised by the Commission may inspect and take copies of any documents or records (except medical). This is in relation to the staff files’ being inaccessible during the inspection. Timescale for action 14/04/06 2. YA34 17(3)(b) 31(3)(b) 31/03/06 Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 20 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 YA20 YA37 Good Practice Recommendations This is in relation to the medication file not containing all the appropriate PRN protocols and not having photographs of residents to identify them. The acting manager must ensure that the relevant references are returned to the Commission as soon as possible in order to progress her application for registration. Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Gordon Road (17) DS0000018111.V266245.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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