Inspection on 19/12/05 for 18 Bellmaine Avenue

This inspection was carried out on 19th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 16/05/07

18 Bellmaine Avenue 29/06/06

18 Bellmaine Avenue 13/09/05

18 Bellmaine Avenue 16/12/04

18 Bellmaine Avenue 19/08/04

18 Bellmaine Avenue 22/03/04

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 Bellmaine Avenue (18) 18 Bellmaine Avenue Corringham Essex SS17 7TB Lead Inspector Sarah Buckle Unannounced Inspection 19th December 2005 12:30 Bellmaine Avenue (18) DS0000018096.V273077.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 Bellmaine Avenue (18) DS0000018096.V273077.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. Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 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@masaichomes.co.uk Mosaic Essex Mrs Cheryl Edwards Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Bellmaine Avenue (18) DS0000018096.V273077.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 three persons to be accommodated at any one time Date of last inspection 13th September 2005 Brief Description of the Service: 18 Bellmaine Avenue provides accommodation and personal care for three adults who have learning disabilities. The home is managed by the organisation Mosaic Essex. 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. Bellmaine Avenue (18) DS0000018096.V273077.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 and a half hours. Opportunity was taken to examine records and policies, a care plan and staff files. A tour of the building was undertaken and residents were observed within the home environment. During the course of the inspection the manager was spoken with in some depth. What the service does well: What has improved since the last inspection? Since the last inspection the home has tightened its recruitment procedures, to ensure that evidence of CRB checks is available. The home’s policies regarding Abuse and Protection now have the appropriate CSCI information contained within them and the home manager has drawn up a file sheet to list all resident and family contact. The registered manager completed her NVQ4 in March 2005. Bellmaine Avenue (18) DS0000018096.V273077.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. Bellmaine Avenue (18) DS0000018096.V273077.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 Bellmaine Avenue (18) DS0000018096.V273077.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): 5 Written contracts are of a good standard. EVIDENCE: One care plan was sampled and the residents’ contract was contained within it. The contract was a Mosaic Homes Licence Agreement and it was accompanied by an assessment to state that the resident was unable to understand the content of the agreement and would not therefore be able to sign it. It was positive to note that a copy of ‘The Tenant’s Guarantee’ was filed alongside the agreement, as was an Appendix listing what the resident’s rent covered, and what it did not. All of the residents within the home have lived there since 1998. There have been no new admissions since that time. Bellmaine Avenue (18) DS0000018096.V273077.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, 8 and 9 Individual care plans were well organised, detailed and personal to the individual resident. Residents are supported to make decisions about their daily lives and to have input into the running of the home. Residents are supported to take appropriate risks as a means of promoting independence. EVIDENCE: One care plan was sampled and looked at in detail. This was separated into two files, one being a care file and the other a support file. The care file contained personal details and profile, medical history, GP and other specialist visits, specialist reviews and medication reviews. It also contained a thorough ‘Service User’s Assessment of Abilities’ and the resident’s contract. All of the required information was contained within the plan in a clear and organised manner. The support file contained Thurrock Council ‘Community Care Summary of Needs and Care Plan’ and a ‘Disability Team Core Assessment’, both of which were completed on 19/10/05. Support plans were detailed and instructive and specified the identified needs of the individual resident along with any support needed. Changes in need were reflected within the plans i.e. within one residents’ support plan regarding accessing the community it stated, “I have Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 10 lost my Day Services at Benton’s Farm. I feel that this has not affected me, I meet up with friends from other homes for a rambling club and I now go swimming one more time during the week”. One resident’s support plan stated “I can make myself understood by either using objects of reference or by taking hold of my staff’s hand and leading them to whatever I want”. Support plans were reviewed regularly either three or six monthly. Alongside this there were weekly key worker reports and four weekly key worker reports. It was positive to note that these reports were tied in directly to the resident’s individual support plan and that each month, the weekly reviews and daily notes for the resident were filed alongside the four weekly report, offering a clear and organised means of gauging any changes in need. ‘House Meetings’ are held within the home on a monthly basis and key workers are present at these meetings to act as advocates on behalf of the residents. Risk assessments were comprehensive, instructive and regularly reviewed. The care plan sampled demonstrated that the individual resident was supported to take risks to maintain an independent lifestyle i.e. one risk assessment was in relation to swimming, and it outlined possible hazards, control measures and a risk evaluation. One identified hazard was noted as ‘drowning’ and the control measure stated that two staff members would support the resident when she went swimming. The latest review stated that the resident was now able to go swimming with just one staff member as her behaviour had improved. Although this information was reflected in the review section of the risk assessment, it was not altered on the risk assessment form. This was also the case in relation to the risk assessment regarding accessing the community. Bellmaine Avenue (18) DS0000018096.V273077.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): 11, 12, 13, 14, 15 and 16 Residents within the home are encouraged in areas of personal development and supported to take part in age appropriate activities, to access the local community and to partake in leisure activities of their choice. There is positive family involvement for those residents with relatives. The rights and responsibilities of residents within the home are both recognised and respected. EVIDENCE: One resident within the home was seen to have had input from both a Behavioural Nurse and a Speech Therapist. She also had a bag of photographs of people and objects to aid communication, which were well used. At the time of the inspection, one resident was out doing the Christmas shopping with staff members. It was noted in her care plan under ‘Usual Opportunities’, that she was involved in the weekly shop for provisions, and the weekend shop for extra items. The activities that residents were involved in included hair appointments, meals out, visits to Burger King with the Monday Club, birthday parties, swimming and rambling. One resident had regular contact with her family and all of these visits were listed separately to her regular activities. Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 12 Within the care plan sampled was an ‘Infringement of Service User’s Rights’ form, which detailed areas where an individual residents rights were restricted i.e. safety gates were fitted at the top and bottom of the stairs for the safety of residents. This document was completed on 16/06/05 and reviewed on 16/12/05. Members of staff were observed to interact in a friendly and caring manner with the residents at the home. Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 The assessment of residents’ abilities clearly demonstrates that their personal, physical and emotional support needs are met. Medication is well managed. EVIDENCE: The residents at Bellmaine Avenue each have a designated 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. Within the care plan sampled, the assessment of residents’ abilities clearly and thoroughly outlined the needs of the resident and the support they required i.e. one area of the assessment stated “I can wash my own face but I do like encouragement from my staff, to show that I am doing it correctly” and the support offered stated “I like my staff to encourage me and praise me when I am doing it correctly. I have to be supervised at all times, so I keep my face nice and clean”. During the course of the inspection, a chiropodist was attending to the residents. A full record of health specialists involved with the residents was contained within the care plan. On the first page of the care file in the care plan inspected there is a section containing relevant information in relation to the individual resident. This Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 14 outlines any difficult behaviour’s, actions that may be displayed and diagnostic reasons for this. The support plan outlines strategies for managing such behaviours, including the use of reactive strategies and interventions, such as reassurance or taking the resident to a quiet area. Medication within the home is well managed and staff undertake medication training. There is a PRN protocol in place, which is signed by staff as they read it to demonstrate that they are aware of the guidelines. A thermometer was in place within the medicine cupboard. The home manager explained that one member of staff remains responsible for the ordering of medication for the duration of a year. A homely remedies policy was in place as were resident consent forms, stating that they were unable to give their consent for medication to be administered. Clear photographs of each resident were in place in front of the MAR sheet relevant to themselves. The MAR sheets were clearly recorded and signed by staff members, and no omissions were noted. Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home has procedures in place to ensure a safe environment for the residents. EVIDENCE: The home has clear policies and procedures in relation to adult abuse and complaints. The CSCI address is now contained within these policies. It was positive to note that there was a section of ‘No Secrets’ in pictorial form contained within the residents’ care plan seen. Staff members receive training in all core areas, and the registered manager stated that POVA issues played a large part in the induction programme. The Accident and Incident book was looked at, and it was positive to see a matrix in the front of the book highlighting any residents who had been involved in accidents, where this had happened and when. The manager explained that she devised this as an overview. It was seen that only a few accidents had occurred over the period of 2005. Where an accident had occurred it was recorded both on the matrix and on an accident form. The accident book was well organised. Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 16 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, 25, 28 and 30 The home was safe, homely and in the main part decorated to a good standard. Resident’s bedrooms suited their individual requirements. The home was clean and hygienic. EVIDENCE: Bellmaine Avenue was, in the main part, decorated to a good standard and had a homely, relaxed atmosphere. The home was in keeping with the local community. The residents’ bedrooms were individual and personalised and each resident had their own room. The living room was spacious, comfortable and had patio doors out onto the garden. The dining room was adequate, but in need of some redecoration, as damage was noted to some paintwork. The home was clean and free from odours. Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 17 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, 33, 34, 35 and 36 The staff at Bellmaine Avenue offer a skill mix and are well qualified and effective. The recruitment procedure at the home is robust. Staff are regularly supervised. EVIDENCE: Three staff files were seen during the inspection. These were all thorough and well organised. Job descriptions were kept by each member of staff and this was recorded on their file. The registered manager stated that there is a good mix of staff in terms of age and that the team is small and has a good rapport. Of the eight members of staff at the home one member of staff has completed the NVQ3, four members of staff have just started the training with Impact Training and two members of staff are completing NVQ3 with VTS. The registered manager completed her NVQ4 in March 2005. It was positive to note that members of staff recruited during 2005 have completed a large amount of core training and some specialist training. All the required information in relation to the recruitment process was contained within the staff files, including proof of identity, photograph, application forms, two references, CRB checks and some evidence was seen of POVA First checks. Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 18 In the staff files sampled all the staff were supervised on a regular basis, mostly four-weekly. The information arising from supervision was detailed and clearly recorded. Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 19 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. The home is well organised and efficiently run. The health, welfare and safety of the residents is proactively sought. EVIDENCE: The registered manager has completed NVQ4 as well as a variety of other training during 2005. 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 paperwork within the home is well organised, clear and detailed. Records are well kept and reviews are regularly completed, within the required time frame. A variety of records pertaining to health and safety were seen during the course of the inspection as were a variety of certificates regarding the servicing of equipment. All of those seen were checked regularly, recorded with adequate detail and in date. These included a gas safety record of service Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 20 dated 05/08/05, Essex Fire Protection checks on fire extinguishers and fire alarms, dated 23/11/05; electrical installation was last tested on 09/03/01; the fire alarm testing record was completed weekly and there were clear records of a weekly fire drill. Water temperatures and clinical equipment are checked weekly, and the temperature of the fridge, the freezer and the home are checked and recorded daily. Samples of staff files were seen, and the two newest recruited staff members have completed most of the mandatory training. One staff member, who began employment in September 2005 has completed Boots medication training, Induction, Food Hygiene, First Aid, Manual Handling, Personal Safety and POVA. The registered manager stated that this staff member’s fire safety training is due to be booked for the beginning of next year. Another staff member had completed the same kind of core training, and had also completed a course in communication, confusion and dementia and support planning. Bellmaine Avenue (18) DS0000018096.V273077.R01.S.doc Version 5.0 Page 21 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 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bellmaine Avenue (18) Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 4 X X X X 3 X DS0000018096.V273077.R01.S.doc Version 5.0 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations The home must ensure that information regarding a residents’ change of need is recorded on the risk assessment and not just on the risk assessment review form. The registered manager must ensure that the dining room is decorated to repair the damaged paintwork and to make it feel more homely for the residents. 2. 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