Inspection on 08/11/05 for 17 Gordon Road

This inspection was carried out on 8th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 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 01/03/06

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 8th November 2005 14.20 Gordon Road (17) DS0000018111.V261761.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.V261761.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.V261761.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.V261761.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 14/02/05 Brief Description of the Service: 17 Gordon Road provides care and accommodation for three adults with a learning disability. The homes’ 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 service users and a sleeping in room for staff. Gordon Road has a reasonable sized and secluded garden to the rear of the house, which all service users 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. Service Users 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.V261761.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 two and a half hours. Opportunity was taken to examine records and policies, a care plan and staff files. The service users were observed within the home. During the course of the inspection the acting manager and one member of staff were spoken with. What the service does well: What has improved since the last inspection? Since the last inspection the acting manager has located the homes’ copy of the Royal Pharmaceutical Society’s The Administration and Control of Medicines in Care Homes and Children’s Services and was able to locate it easily. The acting manager has placed a thermometer in the medicine cupboard to monitor the temperature and ensure it does not exceed 25 degrees C. The acting manager started training towards NVQ4 in September 2005. The Commission has received the acting managers’ application for registration as manager. Gordon Road (17) DS0000018111.V261761.R01.S.doc Version 5.0 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. Gordon Road (17) DS0000018111.V261761.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.V261761.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): 2, 3 and 5 The home has had no new service users for approximately eighteen years. There is a Mosaic Homes pre-admission assessment in place, and a threemonth trial period. Contracts were comprehensive. EVIDENCE: The acting manager stated that there have been no new admissions to the home, but that she is aware of pre-admission assessments and that there is a generic Mosaic Homes policy in place. With regard to trial visits there is a Mosaic Homes policy in place at the home. Service user contracts are held in their care plans. In the sample care plan inspected this was comprehensive and an assessment that the service user was unable to sign the agreement was kept alongside it. Gordon Road (17) DS0000018111.V261761.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, 7, 9 and 10 Care plans are detailed and informative but there are some gaps in the information recorded. Service users are supported to make decisions about their lives. Service users are encouraged to take appropriate risks in relation to their independence. Confidentiality is respected within the home. EVIDENCE: One care plan was sampled during the inspection. This was completed in detail and reviewed on a six monthly basis. The care plan contained information regarding the service user’s history, medical history, health needs and contact with specialists including any recommended action or outcomes. The assessment of the service users abilities was thorough and service user support plans were comprehensive and instructive. It was positive to note that a person centred ‘Who Am I?’ plan was also included. The care plan did not however reflect recent changes in information in relation to the service users activities. The acting manager stated that service users tend to make decisions about their lives informally usually at the dinner table during discussion. Decisions Gordon Road (17) DS0000018111.V261761.R01.S.doc Version 5.0 Page 10 are recorded in care plans i.e. one service user was asked whether she wanted the key to her room and decided to keep it in the office as a personal choice. Decisions made on the service users behalf i.e. in relation to safety issues, are also recorded in the care plan. The service users within the home are encouraged to take responsible risks. Formal day care services have recently been cut and the acting manager stated that all service users are re-learning how to access the community i.e. how to use escalators safely. This information was not recorded in the care plan that was sampled. Confidentiality was discussed with the acting manager who stated that service users can talk to members of staff at any time and that all staff are aware of the Data Protection Act 1998 and confidentiality issues. One service user will ask to speak with his key worker, and either the office or the service user’s bedrooms are available for privacy. The home has a policy regarding confidentiality. Gordon Road (17) DS0000018111.V261761.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Family links are encouraged and maintained within the home. EVIDENCE: The acting manager stated that family relationships within the home are good and that all three service users maintain links with their family i.e. the home recently held a birthday party for one service user and her family attended; another service user goes to visit his mum and brother one weekend, and they are collected to visit him the following weekend; the third service user has a brother who telephones and drops in to the home on an informal basis. There is a relatives meeting planned for 17/11/05, and relatives’ views are sought by Mosaic Homes in their quality monitoring. Gordon Road (17) DS0000018111.V261761.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): 19 and 21 Service users physical and emotional needs are identified and reviewed. The issues of aging, illness and death are dealt with sensitively. EVIDENCE: All service users have a yearly health check and information relating to this is recorded in their individual care plans, along with any recommended actions. In the care plan sampled, a variety of healthcare professionals were seen to be involved with the service user and the required outcome was detailed appropriately, as was any support required by the service user. The service users’ talking, listening, spiritual, emotional and communication needs were identified within the care plan sampled as was any support needed i.e. one service users need was identified as requiring support to attend any external appointments. The acting manager stated that each service user has a plan for the event of their death, which is formulated with both service user and family member involvement. This was not seen in the service user care plan sampled during the inspection. Gordon Road (17) DS0000018111.V261761.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): 23 Arrangements for protecting service users are in place within the home. Staff training in the protection of vulnerable adults is inadequate. EVIDENCE: There is a policy in place within the home regarding the protection of vulnerable adults. One member of staff spoken with stated that she had completed training in the protection of vulnerable adults and knew the procedure regarding any alleged POVA incident. The acting manager stated that all members of staff have received mandatory POVA training a number of times, however she did acknowledge that was currently out of date and that she would take action regarding this. There is a whistle blowing policy in place within the home and all staff have access to all policies and procedures. Gordon Road (17) DS0000018111.V261761.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): Not inspected. EVIDENCE: Not inspected. Gordon Road (17) DS0000018111.V261761.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): 31, 32, 34, 35 and 36 The staff team within the home have clearly defined roles however mandatory training updates are not adequate. The recruitment practice within the home is not robust. The individual needs of service users within the home are met effectively, however staff training is not updated. The staff team within the home appear well supported but supervision is irregular. EVIDENCE: Two staff files were sampled, as were two supervision records and one stafftraining folder. A job description was held in one staff file, which clearly identified the staff members role and responsibilities within the home. It was positive to note that three members of the staff team have completed their NVQ 3 and that the newest member of staff is currently undertaking the qualification. The acting manager started the NVQ4 in September 2005. There are no newly recruited members of staff in the home, but one member of staff transferred from another Mosaic home two years ago. Most members of staff have been working at the home for a long time. One staff file demonstrated that there is comprehensive staff training in place, however there was no evidence to suggest recent mandatory training updates. i.e. the last POVA training completed in one of the staff files seen was 10/07/03. Gordon Road (17) DS0000018111.V261761.R01.S.doc Version 5.0 Page 16 There were gaps noted in the recruitment process within the home. One staff file had a CRB check from an organisation other than Mosaic homes and there were unexplained gaps in employment history from 1989 to 1996. The staff-training file inspected was not well organised or up to date. It was positive to note a comprehensive induction process had been undertaken with the newest staff member and both induction and probationary reviews were recorded in a satisfactory manner. It was also positive to note that a copy of the homes’ supervision policy was contained within the staff supervision files. In one file inspected, supervision records were seen to be regular on a monthly basis, with thorough recording. In the second file, supervision was irregular with one four-month gap noted and one two-month gap noted. Gordon Road (17) DS0000018111.V261761.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, 38, 39 and 40 The home has a good standard of care and is in the main part well run, but would benefit from greater organisation of training needs. The acting manager has an inclusive approach to management. Quality assurance practices are well managed. Policies and procedures are comprehensive. EVIDENCE: The acting manager at the home has sent in an application for the Registered Manager position to the Commission and has previous management experience. The management approach within the home is inclusive. One member of staff spoken with said that she finds the acting manager supportive and that she can air her views and is able to state her feelings in supervision. The acting manager said that she likes to consider the views of service users and staff in the decision making process. She added that she is aware that the final decision rests with herself as the manager. Gordon Road (17) DS0000018111.V261761.R01.S.doc Version 5.0 Page 18 The acting manager has drawn up a quality monitoring monthly matrix where she can record responses from service user, relative and staff surveys. She explained that these are the responsibility of Mosaic Homes’ head office, who send out the surveys, review the outcomes and feedback information at team briefs and managers meetings. A comprehensive file of Mosaic Homes policies and procedures were seen, which also contained a dated record of the staff who had read specific policies and when. Gordon Road (17) DS0000018111.V261761.R01.S.doc Version 5.0 Page 19 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 3 X 3 3 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gordon Road (17) Score X 3 X 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X X X DS0000018111.V261761.R01.S.doc Version 5.0 Page 20 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. 1. Standard YA6 Regulation 15 (1) and (2)(b)(c) Requirement The registered person must ensure that care plans record how the service user’s needs are to be met in respect of health and welfare. The registered person must ensure that the service user’s plan is kept under review and is revised accordingly. This is in relation to recording service users’ changes of need as they occur and to making their last wishes available within individual care plans. The home must ensure that full and satisfactory information is available prior to a person being employed. This is in relation to current CRB checks and unexplained gaps in employment history. The home must ensure that persons employed at the care home receive training appropriate to the work they perform. This is in relation to mandatory Gordon Road (17) DS0000018111.V261761.R01.S.doc Version 5.0 Page 21 Timescale for action 01/01/06 2. YA34 19(5)(d) and Sch 2 01/01/06 3. YA35 18(c)(i) 01/01/06 4. YA36 18(2) training that is currently out of date. The home must ensure that the staff team are appropriately supervised. This is in relation to the irregularity of some supervision. 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gordon Road (17) DS0000018111.V261761.R01.S.doc Version 5.0 Page 22 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.V261761.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. 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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