Inspection on 16/05/07 for 18 Bellmaine Avenue

This inspection was carried out on 16th May 2007.

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

18 Bellmaine Avenue 29/06/06

18 Bellmaine Avenue 19/12/05

18 Bellmaine Avenue 13/09/05

18 Bellmaine Avenue 16/12/04

18 Bellmaine Avenue 19/08/04

18 Bellmaine Avenue 22/03/04

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Coopers Mill Ltd

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Paradise Lodge

Grangewood

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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 Bellmaine Avenue (18) 18 Bellmaine Avenue Corringham Essex SS17 7TB Lead Inspector Helen Laker Unannounced Inspection 16th May 2007 09:00 Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 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 Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 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. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bellmaine Avenue (18) Address 18 Bellmaine Avenue Corringham Essex SS17 7TB 01375 360788 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) bellmaine@familymosaic.co.uk Family Mosaic Mrs Cheryl Edwards Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 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 three persons to be accommodated at any one time Date of last inspection 29th June 2006 Brief Description of the Service: 18 Bellmaine Avenue provides accommodation and personal care for three adults who have learning disabilities. The homes’ facilities include a lounge, dining area, three single bedrooms and a sensory room and it is situated in close proximity to the main towns of Corringham and Basildon. The home offers off street parking to the front of the house and there is a large well-maintained garden at the rear of the building. The home has a small staff team and the environment is comfortable and homely. The residents within the home access leisure pursuits and community facilities according to their abilities, likes and dislikes. The home has a vehicle, which enables the residents to access the community on a regular basis. The home makes information (including CSCI reports) available to prospective service users via their Service User Guide. The current weekly fee for a placement in this home is £1451.00, with the residents contributing £63.25. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection which took place over one day with one inspector in the home. There was a tour of the premises and grounds and an inspection of records and documentation. Time was spent discussing the care of the six service users, as all were out on the day of inspection. The manager and two members of staff were spoken with. Twenty two National Minimum Standards were inspected on this occasion, Nineteen overall outcomes were met and three requirements are detailed in the full report. Discussion of the inspection findings took place with the manager at the end and throughout the inspection and guidance was given. Further feedback was also received from service users and staff through survey and discussion. Responses have been included in the relevant sections of the report. A preinspection questionnaire was provided on this occasion and other reports and correspondence provided by the staff on duty were used as evidence to inform this report also. This report contains some information similar to previous reports published about this home. This is due to no changes being noted in some outcome groups. What the service does well: What has improved since the last inspection? What they could do better: Staff should pay attention to ensuring two signatures are evident where the transcription of medication instructions take place. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 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 Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Present and prospective service users and their supporters are given adequate information about the home so that they can make informed choices. Each service user has a contract directly with the home if privately placed or a statement of terms and conditions if funded by social services. EVIDENCE: Support plans contain the residents’ individual abilities and needs. These are assessed and reviewed on a monthly basis - or more frequently if required. The home has aims and objectives designed for the staff to support the residents’ in their everyday lives. Resident likes and dislikes are documented in fine detail. For example previously one resident is said to enjoy, “…Closing doors, peaceful walks in her wheel chair, rides in the car and picking tiny bits of cotton or fluff from the carpet – and throwing them over her shoulder…” The individual support plans also document the residents’ progress towards achieving their goals, and any positive changes that occur in their lives as a Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 9 result. One resident has left the home since the last inspection leaving one vacancy. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users know their assessed and changing needs, they can make decisions and participate in all aspects of the home. Each service user has an individual plan and service users are supported to take risks as part of an independent lifestyle via a process of assessment Due to some service users learning disabilities they are only able to make limited decisions but staff facilitate this as much as possible. EVIDENCE: The residents’ care notes are separated into two files; one being a care file and the other a support plan. The care files contain personal details, a profile, medical history, GP and other specialist visits, specialist reviews and medication reviews. They also contain a Service User’s Assessment of Abilities and the resident’s contract. The residents have a series of Care Needs Assessments made, which are contained within their Support Plan. Each assessment consists of an aim, short Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 11 and long term goal for the individual, details of support required, how staff will enable the resident to achieve their goal and a date for which the assessment should be reviewed. Reviews for each of the residents’ needs assessments happen on at least a monthly basis, where it can be decided whether the need has changed, been met, or whether continued support is required. Along with the Care Needs Assessments, residents are also encouraged to be as independent as possible with the support from the staff. The residents at this home are supported to take risks, in order for them to maintain an independent lifestyle. The home has Risk Assessments documented for each resident - for any potentially hazardous activity that they may undertake in their daily routines. Risk assessments are put in place for all aspects of the residents’ lives as appropriate. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are encouraged and supported with opportunities for personal development by way of access to a wide variety of activities and overall their rights and responsibilities are recognised in their daily lives. The home offers its residents’ a wide variety of activities. The residents are offered a good range of wholesome and healthy meals, and mealtimes are shared with staff, to create a warm and homely environment. EVIDENCE: The residents’ each have an “Annual Diary” kept in their care plan, which lists all of the activities that the individual has participated in. Activities are arranged according to individual preference, as well as activities for the whole group and activities arranged jointly between other local homes. The residents are invited to evening meals and parties with their friends at the other homes. They also attend appointments in the community with Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 13 hairdressers and chiropodists, as well as visiting the local shopping centre, and other places of interest such as near by country parks and the seaside. The relatives and friends of the residents are encouraged to visit the home as often as possible. Adequate seating is provided in each individual’s room, and quiet space is made available as necessary for any guests who may visit. Staff will also facilitate family contact outside of the home on request. The home also has a sensory room and a sensory garden is being developed. The care plan has a list of each individual’s “Weekly Opportunities”, which is a daily record of the residents’ every day activities inside and outside of the home. Onsite activities such as relaxing and listening to music in the lounge, or enjoying some time in the garden are also available. The residents are invited to participate in their daily routines where practicable. For example, the more independent residents are encouraged to help at snack time by carrying the empty teacups back to the kitchen. The residents’ weekly menus offer a choice of meals and meal alternatives, which are well nutritionally balanced and healthy. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Arrangements are generally in place to ensure that the health care needs of service users are identified and met. The residents’ all receive good quality care, and the home always aims to meet the residents’ physical and emotional needs. The home has adequate medication policies and procedures in place. EVIDENCE: The residents are all encouraged to be as independent as possible with their personal care, and staff offer minimal intervention whilst supporting the residents’ to meet their healthcare needs. Key workers review the residents’ progress within the home on a monthly basis; a person-centred approach is used. Staff are all familiar with the homes’ medication policies and procedures, and have all received the homes’ mandatory medication training. On completion of this training, the assessor completes an Administering Medication Competency form, which is signed and kept on file. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 15 The residents at Bellmaine Avenue each have a key worker, which helps to ensure continuity of care for each individual. Key workers are responsible for completing weekly and four weekly records relating to the changing needs of each resident as outlined in their support plans. Medication within the home is well managed and staff have undertaken medication training. There is a PRN protocol in place, which is signed by staff to demonstrate that they are aware of the guidelines. Staff should pay attention to ensuring two signatures are evident where the transcription of medication instructions take place. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Bellmaine Avenue has clear guidance for staff contained within its protection and complaints policies and procedures; staff have all received the necessary POVA training to be able to protect the residents from abuse. EVIDENCE: No complaints have been made since the last inspection. The home has an appropriate complaints procedure and record book which is divided into complaint, investigation and outcome. Compliments are recorded also. The home has appropriate Adult Protection and Whistle Blowing policies and procedures and a copy of the Local Authority’s Protection of Vulnerable Adults Procedures. Both polices are discussed with staff during their induction process and training in protection of vulnerable adults is planned for 2007, however the majority of staff in the home have had required POVA training and updates are planned. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 18 Bellmaine Avenue was clean, bright and generally well maintained and provided the service users with homely and comfortable surroundings. Future improvements are planned and some have already been made to the décor of the home. EVIDENCE: The individual bedrooms within the home are decorated and comfortable. The residents are able to personalise their rooms with their own belongings. Their rooms are suitable for their individual needs and lifestyles, and promote their independence. The toilets and bathroom are clean and well maintained, and provide sufficient privacy for the individuals who use them. Shared areas are spacious, clean and well looked after, and complement the residents’ own private rooms. The interior is due to be completely redecorated shortly as is looking a little tired in places. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Bellmaine Avenue offers its staff a comprehensive training package. The procedures for the recruitment and training of staff have safeguards in place to offer protection to people living in the home. The home has an effective and competent staff team. Recruitment for the home is now organised through Mosaic Home’s head office, and no staff recruitment files are kept on site. EVIDENCE: The home has a comprehensive range of policies and procedures in place, which are updated on an annual basis. All staff members sign to confirm that they have read and understood these policies, and the home also offers its staff a wide range of core and supplementary training courses throughout the year. Staff files examined show that appropriate procedures are generally in place for recruitment and contained most or all of the information to meet this standard. Staff files evidenced staff receive individual supervision approximately every two to three months. Annual appraisals have been developed and are being done. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 19 The home’s manager organises staff training according to the staffs’ needs and up-date requirements. A matrix of past, current and future training course dates is kept to ensure where practicable that no training is overdue. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is leadership, guidance and direction to staff and the home has in place practices that promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The inspector previously confirmed the registered manager has completed NVQ4 as well as a variety of other training. This includes courses in training and leadership skills, managing difficult people, introduction to the new health and safety manual, health and safety inspections, COSHH training and Management and Development Training. The home provides questionnaires to the residents and their representatives, staff and other professionals asking for their opinions on the quality of the service. The results of the questionnaires are compiled into an annual report, Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 21 and the findings are used as part of the service’s ongoing monitoring and improvement action plans. This has still to be submitted to the CSCI and documentation is currently being updated. Health and safety records are kept within the home; checked regularly, recorded in detail and up-to-date. These include a landlords’ gas safety record, Essex Fire Service protection checks on fire extinguishers and fire alarms, electrical installation checks, a fire alarm testing record that is completed weekly and clear records of a weekly fire drill. Water temperatures and clinical equipment are checked weekly, and there have been checks on the water system for Legionella. The temperature of the fridge, the freezer and the home are checked and recorded daily. The home has policies and procedures in place covering all aspects of Health & Safety in the home and the manager is aware of her duties regarding Health & Safety in the home, in house health and safety audits are undertaken which is considered good practice. Risk assessments are completed for safe working practices. Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 22 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 X 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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. Refer to Standard Good Practice Recommendations Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Bellmaine Avenue (18) DS0000018096.V342672.R01.S.doc Version 5.2 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. 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