Inspection on 29/06/06 for 18 Bellmaine Avenue

This inspection was carried out on 29th June 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

18 Bellmaine Avenue 16/05/07

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

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 Claire Brookes - Nandara Key Inspection 29th June 2006 14:00 Bellmaine Avenue (18) DS0000018096.V295834.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.V295834.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.V295834.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@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.V295834.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 19/12/05 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.V295834.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during an afternoon in June. On the inspectors arrival there were two staff on site, as well as the providers’ registered care manager. One staff member was preparing the residents’ evening meals. The residents were all at home for the evening. The inspection included spending some time with the residents and staff, as well as a tour of the entire building and garden. This report contains 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: It would be better if the home ensured that the residents are kept properly supervised at all times. On the day of the site visit the inspector was granted access to the property by a resident, who was unsupervised, and had walked out of the front door and along the home’s front garden, to beckon the inspector in. Once inside the home, the inspector had to find staff, (who were in the kitchen, lounge and upstairs) in order to inform them of the incident. Bellmaine Avenue (18) DS0000018096.V295834.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. Bellmaine Avenue (18) DS0000018096.V295834.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.V295834.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bellmaine Avenue provides its residents with a well presented and user friendly Service User Guide. The residents’ needs and aspirations are valued, and the home assesses these in a very effective way. EVIDENCE: The home has produced a very thorough Service User Guide, which is available to all current and any prospective residents and their representatives. 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 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…” Bellmaine Avenue (18) DS0000018096.V295834.R01.S.doc Version 5.2 Page 9 The individual support plans also document the residents’ progress towards achieving their goals, and any positive changes that occur in their lives as a result. Bellmaine Avenue (18) DS0000018096.V295834.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are well organised, detailed and take the changing needs and personal goals of the residents into account. 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 risks within their everyday lives. 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 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 Bellmaine Avenue (18) DS0000018096.V295834.R01.S.doc Version 5.2 Page 11 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.V295834.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. 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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 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. Bellmaine Avenue (18) DS0000018096.V295834.R01.S.doc Version 5.2 Page 13 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 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.V295834.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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.V295834.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. Bellmaine Avenue (18) DS0000018096.V295834.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has it’s own complaints book, which is designed in a suitable format. All staff have read the homes’ abuse guidance policy and protection guidelines. The manager has had training for Protection of Vulnerable Adults, and all staff attend Adult Protection training on an annual basis. The complaints policies give clear guidance on the procedures to follow when a resident (and their representative) or a staff member wishes to make a complaint. Bellmaine Avenue (18) DS0000018096.V295834.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe, homely and decorated to a good standard. Resident’s bedrooms suit their individual requirements. The home is clean and hygienic. EVIDENCE: The individual bedrooms within the home are well decorated and comfortable. The residents have been 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. Bellmaine Avenue (18) DS0000018096.V295834.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 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. 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 mandatory and supplementary training courses throughout the year. The home’s manager organises staff training according to the staffs’ needs and up-date requirements. She keeps a thorough matrix of past, current and future training course dates to ensure where practicable that no training is overdue. Bellmaine Avenue (18) DS0000018096.V295834.R01.S.doc Version 5.2 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, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is, on the main part, well organised and efficiently run. The health, welfare and safety of the residents is usually of paramount importance to the home, however on the day of the site visit, the inspector was witness to an incident where a service user went off the premises without the knowledge of the staff. 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 home provides questionnaires to the residents and their representatives, staff and other professionals asking for their opinions on the quality of the Bellmaine Avenue (18) DS0000018096.V295834.R01.S.doc Version 5.2 Page 20 service. The results of the questionnaires are compiled into an annual report, and the findings are used as part of the service’s ongoing monitoring and improvement action plans. 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 there were 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. On the day of the inspection, an unsupervised resident had unlocked the front door and left the building. She approached the inspector and lead her by the hand into the home, where upon the inspector had to shout to draw the attention of staff who were elsewhere in the house. The home has a risk assessment in place regarding this residents like of meeting people at the front door and “welcoming them to her home”. However the homes’ manager was reminded of the potential dangers of allowing this practice to continue; as the resident has an extremely limited sense of danger and is non-verbal, if she were to continue to invite unannounced visitors into the home, she and the other highly vulnerable residents could be at great risk from intruders in the future. Bellmaine Avenue (18) DS0000018096.V295834.R01.S.doc Version 5.2 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 Standard No Score 1 3 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 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTH3CARE SUPPORT3 Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 2 X Bellmaine Avenue (18) DS0000018096.V295834.R01.S.doc Version 5.2 Page 22 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. 1 Standard YA42 Regulation 13(6) Requirement The registered manager must ensure the health, safety and welfare of service users and staff. The registered manager must make arrangements to prevent service users being harmed or being placed at risk of harm. This relates to the risk of service users being able to leave the building unsupervised, and allowing possible intruders to enter. Timescale for action 29/08/06 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 Bellmaine Avenue (18) DS0000018096.V295834.R01.S.doc Version 5.2 Page 23 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 Bellmaine Avenue (18) DS0000018096.V295834.R01.S.doc Version 5.2 Page 24 - 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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