Inspection on 05/07/05 for 19 Church Road

This inspection was carried out on 5th July 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

19 Church Road 28/09/07

19 Church Road 07/02/06

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 Announced 5 July 2005 th 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 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 Stationary 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 I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 19 Church Road Address Clacton on Sea Essex CO15 6AP Telephone number Fax number Email 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 Limited Mrs Elizabeth Anne Barfield Care Home 3 Category(ies) of LD Learning Disability registration, with number of places 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 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) Date of last inspection 10-11-2004 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 so as to have easy access to the local bus route. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place on the 5th July 2005, lasting 5.5 hours. The inspection process included discussion with two service users, although this was quite limited. However, observation of the service users during the course of the day indicated that they appeared relaxed and at ease in their surroundings. Discussion also took place with the manager and two members of staff. Tour of the premises included viewing of service users’ bedrooms, bathing and toilet facilities, as well as the rear garden area. A range of documentary evidence was also sampled during the course of the inspection. Twenty-two of the forty-three standards were inspected; of these fifteen were met, with the remaining seven being partially met. The home was transferred to the Commission’s predecessor under transitional arrangements and was thus only just borderline in terms of complying with the environmental standards; subsequently the home is scheduled to shortly undergo complete refurbishment to current required standards. What the service does well: Service users are supported in a small homely run service. Environmentally the service only just meets National Minimum Standards. This is, however, recognised and as a result the service is shortly to undergo total refurbishment to address this matter. Service users are supported by a consistent team of staff who have known them for a number of years, and who understand their needs well. Staff receive formal supervision which they felt to be appropriate to enable them to carry out their duties appropriately. During the course of the inspection service users were witnessed to be spoken with in an appropriate style and were consulted on all aspects of the running of the home. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 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 standard(s) 1 and 3. The homes Statement of Purpose was deemed to be in order. Contracts of residency were generally speaking in order. EVIDENCE: The home’s Statement of Purpose was viewed and found to comply with regulatory requirements. As mentioned in the summary of this report, the home is scheduled to undergo complete refurbishment in the very near future; for this reason the contracts of residency have remained unamended. However, the manager stressed their intention to review the contracts of residency upon completion. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 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 standard(s) 8. Service users are supported to participate in the running of the home to the best of their abilities. EVIDENCE: Service users’ files sampled contained evidence of service users being supported to participate in the day-to-day running of the home, e.g: • • • • Cleaning of their rooms Changing of bedclothes Assisting with shopping Assisting in the kitchen The home holds periodic meetings to which service users have access. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 10 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 standard(s) 13 and 14 and 17. Service users involvement/access to community based activities is limited. Service users are provided with a healthy diet. EVIDENCE: Care plans sampled evidenced that the home had further explored opportunities for service users to participate within the community. Activityrecording sheets have now been implemented, which evidenced attendance at: • • • • Busby club Family support centre Central base College 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 11 The home’s duty rota was sampled, and indicated 2 members of staff on duty Monday to Friday, with the manager working 9-5 in a supernumerary capacity. The three weeks worth of rotas sampled all indicated only one carer per shift over the weekends which was confirmed by the manager. Subsequently, opportunities for accessing community based activities at the weekend was virtually non-existent. The home has four-weekly rotational menus which were sampled and deemed to be varied and nutritious. Menus indicated that meals are provided three times daily, at least one of which was cooked. On the day of the inspection one service user was witnessed leaving for college with a packed lunch. Discussion with another service user evidenced that they found the food provided by the home to be nice. They also stated when asked that the meals were more than adequate in terms of quantity. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No standards from this section were inspected on this occassion. EVIDENCE: 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Both the homes Complaints and Adult Protection Policies are corporately developed documents which were deemed to be robust. EVIDENCE: The home’s Complaint Procedure was robust in terms of protecting service users. No complaints have been received by the home or the Commission for Social Care Inspection since the last inspection. The home has Adult Protection and Whistle Blowing Policies, both corporately developed documents, which are robust in terms of protecting Vulnerable Adults. To date staff at the home have not received training in this area, although the manager stated that it is scheduled. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28, and 30 The home is only just borderline in terms of meeting the environmental National Minimum Standards. . EVIDENCE: As mentioned previously within this report, the environmental standards are barely met. However, it is recognised it is the intention of the organisation to totally refurbish the home. Tour of the premises evidenced them to be safe and accessible to service users. Toilet and bathroom facilities were just adequate. On the day of the inspection the home was bright and cheery. Service users’ rooms viewed were seen to contain all of the furniture required under Standard 26. The home has adequate indoor communal space to which service users were seen to have access. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 15 The kitchen is domestic in nature and was adequate to meet the needs of the service users. Although the laundry facility had everything necessary to fulfil its role and meet the needs of the service users, it was clearly in urgent need of refurbishment as it is barely adequate and just about complies. On the day of the inspection the home was found to be clean and tidy and free from any offensive odours. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34 and 36. Service users have been supported by the same team of staff for a long time who understand their needs well. The homes recruitment practices continue to require further development to ensure that service users are adequately protected. Staff receive adequate levels of supervision. EVIDENCE: Turnover of staff at the home remains low; the home does not use agency staff. Staff providing personal care to service users are all aged over 18, and those left in charge of the home are all aged over 21. As mentioned previously, staffing levels require reviewing urgently to find a way to increase the staffing levels of the home at weekends to facilitate activities. Three staff files were sampled in respect of the home’s recruitment processes; one omission was noted in respect of the documentary evidence required under Regulation 19, Schedule 2 of the Care Homes Regulations. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 17 Discussion with staff and the manager evidenced that formal supervision is provided four-weekly; this was supplemented by viewing records contained in staff files. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,41 and 42.and 43. The manager is pursuing the Registered Managers Award. The ethos of the home is one of openess and inclusiveness. Service users interests are protected by the homes policies and procedures. A business plan for the home has yet to be developed. EVIDENCE: The manager does not currently hold the Registered Managers Award, although it is in the process of being pursued. The manager does, however, have extensive experience of working in the care sector. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 19 Discussion with members of the staff team indicated that they felt the management team to be open and approachable and that they provided a clear sense of leadership and direction. Records required by regulation for the protection of service users were seen to be in order. The following safety certificates were sampled and seen to be current: • • • • • Gas safety certificate Electrical installation certificate Record of fire drills Record of hot water checks Cold water tank disinfection certificate. The manager spoke of being in the process of developing a business plan for the home. The home’s certificate of public liability insurance was seen to be displayed and was current. 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 20 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 3 x x x 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x x 2 2 x x 3 Standard No 31 32 33 34 35 36 Score x x 2 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 19 Church Road Score x x x x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 3 2 I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5 Requirement The Registered Person must ensure that service users contracts of residency, specify their room occupancy. (Previous timescale of End of December 2004 not met) This is a repeat requirement. The Registered Person must further develop records of service users activity interests, and use these to enhance the quality of community participation. Linked to this is the need to review staffing levels at weekends. The Registered Person must ensure that service users are protected from the risk of suffering possible harm or abuse. This relates specifically to the need for all staff to receive trainning in the Protection of Vulnerable Adults. The Registered Person must ensure that appropriate arrangements are in place to enable service users to engage in local social and community activities. This relates to the staffing levels of the home at weekends. Timescale for action End of December 2005 2. YA13,14 and 33 16 End of December 2005 3. YA23 13 (6) End of August 2005 4. YA33 16 (m) End of August 2005 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 22 5. YA34 19 6. YA43 25 The Registered person must ensure that documents pertaining to the recruitment of staff are maintained as per the requirements of Schedule 2 of the Care Homes Regulations. (Previous timescale of End of December 2004 not met). This is a repeat requirement.. The Registered Person must ensure that a current business plan is available for inspection. (Previous timescale of the Endo of January 2005 not met). This is a repeat requirement. End of August 2005 End of December 2005 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 Good Practice Recommendations 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 19 Church Road I56-I05 S54624 19 Church Road V228214 AI 050705 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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