Inspection on 28/09/07 for 19 Church Road

This inspection was carried out on 28th September 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

19 Church Road 07/02/06

19 Church Road 05/07/05

19 Church Road 10/11/04

19 Church Road 20/07/04

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

CARE HOME ADULTS 18-65 19 Church Road Clacton on Sea Essex CO15 6AP Lead Inspector Neal Cranmer Key Unannounced Inspection 28th September and the 9th October 2007 10:00 19 Church Road DS0000054624.V353872.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 19 Church Road DS0000054624.V353872.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. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 19 Church Road Address Clacton on Sea Essex CO15 6AP 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) 01255 479926 The Regard Partnership Ltd Mrs Elizabeth Anne Barfield Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 3 persons) 5th October 2006 Date of last inspection Brief Description of the Service: 19 Church Road is an adapted property situated within walking distance of Clacton town centre and the local amenities that the town has to offer. The home provides single room accommodation with two bedrooms situated on the first floor. Communal areas consist of a lounge, dinning room and activities room. The home provides an enclosed garden to the rear of the premises. The home is situated providing easy access to the local bus route. Fees for staying in the home range between £900.00 to £1,150.00 per week, and additional charges are made for hairdressing and toiletries. This information was provided by the registered manager during the course of the inspection. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows a key inspection of 19 Church Road that included an unannounced visit to the service on the 28th of September and 9th of October 2007. The judgements made within this report are based upon evidence from the site visit, along with information submitted by the service since the last inspection. The manager and their deputy were available throughout both days of the inspection, and took an active part in the inspection process. The visit to the home included an environmental tour, discussions with people living at the home, the manager and their deputy. Records were sampled and included how people living in the home were supported and how staff were recruited and trained. What the service does well: What has improved since the last inspection? At the last two inspections of the home, no residents were living at the home, therefore it is not possible to comment on this section of the summary. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 19 Church Road DS0000054624.V353872.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 19 Church Road DS0000054624.V353872.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 adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents cannot always expect their needs to be appropriately assessed prior to admission to the home. EVIDENCE: The home prior to this inspection had been vacant for a considerable period of time, and the recent admissions to the home were made on the basis of an emergency. Although the home has a detailed admission process, on this occasion due to the urgency of the admissions this was not followed resulting in the admission of a person whose needs the home is not registered to meet. This matter was discussed with the registered manager at the time of the inspection, who recognised their error, however the manager has since taken steps to have an Occupational Assessment carried out on the home to assess how the home maybe adapted to meet the needs of the resident. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 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. 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. People living in the home are supported to be involved in decisions about their lives, and play an active role in their care planning. EVIDENCE: All three of the care plans of the people living in the home were sampled, as mentioned previously all of these people had only recently been admitted to the home. Therefore the home was at the time of the inspection still following the previous care plans from the peoples previous home, although they had already commenced the reviewing process, and had started to collate their own information. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 Page 10 Observation of interactions between staff and people living in the home indicated that people are assisted and supported to make choices about their day-to-day lives, this was witnessed through the interactions observed during breakfast. Discussion with the registered manager confirmed that the home does access advocacy services on behalf of the people living in the home, two advocates were due to visit the home on the day of the inspection. Sampling of care plans evidenced that risk assessments were in place, designed to enable people to maximise their independence. Risk assessments were in place relating to the following areas, Mobility, medication administration and personal care, each of the assessments identified the nature of the risk, who the risk may have an impact on, and the steps taken to minimise the risk. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 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. People living in the home are supported to make choices, and are assisted to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: As mentioned in both of the above two sections all three people are newly admitted to the home, and none of them are currently in any paid or voluntary employment. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 Page 12 Sampling of activity records showed that people were involved in the following daytime activities, shopping, going out for walks, visiting friends at the home’s sister home around the corner and attending a local activities club In addition to the above activities that people are currently involved in plans are in place to explore arts and crafts classes, lunch clubs and college classes. All three people are on the voter’s electoral role. The home has an open door policy on the receiving of visitors, and viewing of the visitor’s book for the home indicated a range of visitors visiting the home. Discussion with the managers indicated that one persons relative has recently re-established contact with their relative after many years of having little or no contact. Examination of records showed that the home operates a four weekly rotational menu. Samples of menus seen showed that a varied diet was provided with all nutritional needs being met. The menus provided were presented in a pictorial format to assist the people living in the home to make a choice. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of people living in the home are based on their individual needs, and the principles of respect, dignity and privacy were put into practice. People living in the home were not adequately protected by the home’s practice around administration of medicines. EVIDENCE: Observation of the interactions between staff and people living in the home, indicated that staff were respectful of peoples dignity and privacy, staff were polite and respectful whenever they were speaking to people, and the responses received were happy and cheerful, staff spent time speaking to the people living in the home and not exclusively with each other. Discussion with staff indicated that, times for getting up and going to bed were flexible. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 Page 14 The care plans sampled clearly identified the individual’s needs, as well as the choices made as to how these needs were to be met. Care plans were well detailed, and were under review at the time of the inspection visit, this review process was on going to take account of the changing needs of the individuals. The services of healthcare professionals such as community nurses, occupational therapists, physiotherapists and dieticians were accessed as necessary, evidence of professional input into the home was seen in the care plans. At the time of the inspection there was no storage facility in the home for peoples medication, although a medication cabinet was on order and awaiting delivery, therefore at the time of the inspection medication was being transported in a backpack from the home’s sister home around the corner. The registered manager explained that this arrangement was a short term interim measure. This practice should cease as a matter of urgency, as it may pose a risk to peoples health and safety. The home does not retain any controlled medicines, and all staff administering medicines have received training. Records sampled on the day of the inspection were all in order. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 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. 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. People living in the home can expect their views to be listened to and acted upon and to be protected from harm and or abuse. EVIDENCE: There have been no complaints made in respect of the service since the last inspection, and the home has in place a robust complaints procedure that included the contact details for the Commission for Social care Inspection. The procedure was written in an easy read format for ease of use by people living in the home, and a copy was posted on the home’s notice board, in addition to this a copy was placed in each persons plan of care. There has been one adult protection Referral made by the home since the last inspection visit this referral was referred appropriately to the relevant agencies. Staff in post have received training in adult protection, and provision will be made for those staff appointed to receive the training once they are in post. Both fulltime staff have been appropriately checked for employment, and although there is currently a high usage of agency staff, seven staff have been appointed and are awaiting Criminal Records Bureau (CRB) clearance. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home, although safe, comfortable and well maintained was not appropriate to the needs of all of those in residence. EVIDENCE: The environmental tour of the premises showed the home to be homely, generally well maintained and decorated. Individual bedrooms were appropriately furnished and equipped to meet the needs of the people in residence. Furnishings and fittings in the home were of a good quality and were domestic in nature. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 Page 17 However not all communal areas were easily accessible to all of the residents accommodated, it was with this fact in mind that the Occupational Therapist assessment was requested by the registered manager. The building was in keeping with the local community and provided easy access to local facilities. The home’s laundry facility was housed in a purpose built outhouse, which although adequate, would benefit from being incorporated into the home, this may help alleviate problems with transporting laundry through the home, as egress can only be made via doors from the dinning room or one of the bedrooms, it would furthermore remove the inconvenience of carry laundry out into the open during inclement weather. On the day of the inspection the home was clean and tidy, and was free of any unpleasant odours. 19 Church Road DS0000054624.V353872.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. Staff employed in the home are appropriately trained and skilled to meet the needs of the people living in the home, and people were supported by the home’s recruitment process. EVIDENCE: Examination of staff records, as well as discussion with the registered manager and staff provided evidence that care staff had a good understanding of their roles and responsibilities and that they were qualified and competent. Records sampled on the day of the inspection showed that staff had received induction and mandatory training, which included, fire awareness training, health and safety, manual handling, first aid, food hygiene, abuse awareness and medication administration. Examination of staff rotas showed that staff were employed in sufficient numbers to meet the needs of those living in the home. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 Page 19 The home’s recruitment records provided evidence that the home’s recruitment policies and procedures were robust and effective, records sampled all contained copies of the following documents, application forms, copies of two written references, Criminal Records Bureau Checks (CRBs), evidence of induction, supervision and training and development. 19 Church Road DS0000054624.V353872.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. The management and administration of the home is good, and there is an effective process in place for addressing issues of quality. EVIDENCE: The home is managed in an open and transparent manner, by a manager who has many years of experience in the field of learning disabilities and who holds an NVQ level 4 award in management. The home’s quality assurance process is managed at corporate level and included the use of questionnaires to a range of interested stakeholders including those living in the home, staff, relatives and visiting professionals. 19 Church Road DS0000054624.V353872.R01.S.doc Version 5.2 Page 21 In addition to this regular Regulation 26 visits are undertaken by a responsible individual to monitor the effectiveness of the service. Sampling of a range of the home’s safety certificates indicated that the home has in place safe working practices, which protect both the people living in the home as well as staff. 19 Church Road DS0000054624.V353872.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 2 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 2 25 X 26 X 27 X 28 X 29 X 30 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 x 19 Church Road DS0000054624.V353872.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. 1. Standard YA2 Regulation 14 Requirement Timescale for action 31/12/07 2. YA20 13 (2) 3. YA24 23 (2a) The home must ensure that the needs of all prospective residents are appropriately assessed prior to any admission to the home. This is to ensure that only people whose needs the home is able to meet are admitted. The home must make provision 31/12/07 for the safe storage of resident’s medication. This is to ensure that people living in the home are adequately protected. The home’s environment must 31/12/07 be laid out and equipped to meet the needs of all of the residents in residence. 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 YA30 Good Practice Recommendations It is recommended that consideration be given to how the laundry service at the home could be better incorporated into the home. (refer to comments in outcome group). DS0000054624.V353872.R01.S.doc Version 5.2 Page 24 19 Church Road Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 19 Church Road DS0000054624.V353872.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!