Inspection on 25/01/06 for 19 Fairview Road

This inspection was carried out on 25th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

19 Fairview Road 29/01/09

19 Fairview Road 02/02/07

19 Fairview Road 04/10/05

19 Fairview Road 03/03/05

19 Fairview Road 10/08/04

19 Fairview Road 05/03/04

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 Fairview Road (19) 19 Fairview Road Vange Basildon Essex SS14 1PW Lead Inspector Claire Brookes - Nandara Unannounced Inspection 25th January 2006 12:35 Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 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 Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 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. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fairview Road (19) Address 19 Fairview Road Vange Basildon Essex SS14 1PW 01268 527840 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) Mosaic Essex Mrs Ann Sesay Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 04/10/05 Brief Description of the Service: The home is situated in a busy residential area of Vange. The interior of the house is well decorated, and homely. The lounge has patio doors that open out on to a large, well-maintained garden at the rear of the building - which the residents themselves take great pride in. The home is walking distance from local amenities, and a short bus journey away from a large market and shopping complex. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. On the inspector’s arrival at the home, there were two residents and one member of staff present. The inspection included time spent talking to the residents of 19 Fairview Road, and a complete tour of the house and garden took place. What the service does well: 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. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 6 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 Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 7 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): 2&3 The residents’ needs and aspirations are usually valued. There is some doubt however, over one resident’s suitability for the home and whether the service can cater for his challenging behavioural needs. Not all of the residents’ assessments contain detailed information. EVIDENCE: Individual support plans list the residents’ individual difficulties and needs. These are reviewed on a regular basis. The home has aims and objectives for each resident in place, to aid the staff to support the residents’ in their everyday lives. The home had failed to adequately assess the needs of one resident, in order to protect others from his aggressive behaviour. Resident likes and dislikes are generally documented clearly, but some support plans are lacking in detailed information. 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. Person centred planning is used effectively and photographs of each person have been used to tell their own story, and to illustrate what the residents’ prefer in their every day lives. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 8 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): These standards were not assessed on this occasion. EVIDENCE: Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 9 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 provides most of its residents’ with a variety of activities, but some are not being supported to pursue enough interests outside of the home. The residents are offered a good range of wholesome and healthy meals, which they are able to choose for themselves. EVIDENCE: The residents’ each have an “Annual Diary” kept in their care plan, which lists all of the activities that the individual has participated in. Activities are arranged according to individual preference, as well as activities for the whole group. Some residents go on activities most days of the week. They attend local cookery courses and go to art clubs, but others whose interests are slightly different are only being given limited opportunities outside of the home. One resident’s only activity is volunteering one morning a week at a local charity shop. She told staff in the presence of the inspector: “… really I’d like to help-out more in the shop”. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 10 The residents attend appointments in the community with hairdressers and chiropodists, as well as visiting the local shopping centre and other local places of interest. 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. The home keeps a good stock of foods, so that the residents can choose their own meals on a daily basis. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 11 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): 19 The home actively supports its residents to improve the state of their health. EVIDENCE: The home has one resident who is a smoker. He has recently been encouraged to smoke outside, and as a result has significantly reduced the daily amount of cigarettes that he consumes. Staff told the inspector that they are keen to continue with the support this resident needs, in order to maintain the reduction in his cigarette intake. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 12 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 The home has clear guidance and advice contained within its protection and complaints policies and procedures. EVIDENCE: The home has a complaints book, which records any complaints and subsequent action taken. All staff have read the homes’ abuse policy and protection guidelines, which are reviewed on an annual basis. The manager has had training for Protection of Vulnerable Adults, and all staff attend Adult Protection training yearly. The complaints policies give clear guidance on the procedures to follow when a resident / their representative or a staff member wishes to make a complaint. Both the homes’ protection policy, and complaints guidelines contain details of how to contact the Commission for Social Care Inspection. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 13 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): 30 The home is clean and hygienic, and has found a successful way to ventilate the dinning room where residents are able to smoke. EVIDENCE: Since the last inspection a de-humidifier has been purchased and placed in the dinning room – which is the allocated area for smokers. This has helped eradicate the tobacco odours from the room, and it now smells pleasant and clean. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 14 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, 33, & 35 Recently, the home has not always had sufficient levels of staff on rota to effectively care for the residents’ and their needs. The home offers its staff a good mandatory training package and the opportunity to undertake the NVQ level 3. However, clear records of who has attended the basic training are not being kept. EVIDENCE: There have been several occasions where only one member of staff has been on the rota for the homes’ late shift. Duties on this shift include cooking hot meals for the residents’ and clearing-away after the days activities. The home cares for four residents with varying levels of need. Two can be especially challenging and can require a lot of support throughout their everyday lives, which a lone member of staff is not able to give. The home has a 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. The home offers its staff mandatory and supplementary training courses throughout the year, but does not have a comprehensible system in place for keeping records of what training has been completed. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 15 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 & 42 Proper procedures are not being carried out when an incident involving the residents’ occurs. Staff are not always being correctly informed by the homes’ manager, of how to notify the necessary authorities in the event of incidents’ occurring. Hazardous chemicals (COSHH) are not always being stored safely. EVIDENCE: The inspector found that there have been four occasions in the last six months where one resident’s behaviour has become significantly more challenging. Although the staff involved had documented the episodes in the homes’ incident book, they had not informed The Commission for Social Care Inspection. Staff in the home had been misinformed as to how they ought to be recording such information, and on what procedures to follow there after. There is a cupboard in the kitchen containing cleaning materials and chemicals (COSHH). This cupboard was not locked, allowing access to potentially harmful substances. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 16 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 2 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 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X X X X X X 1 1 Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 YA3YA2 Regulation Requirement Timescale for action 25/03/06 2 YA12 3 YA33 4 YA35 5 YA42 14(2)(a)(b) The registered person must ensure that the assessment of a service users needs is kept under review and revised at any time when it is necessary to do so having regard for any change of circumstances. 16(2)(n) The registered person must ensure that all residents are given the opportunity to regularly take part in a variety of age, peer and culturally appropriate activities. 18(1)(a) The registered person must ensure that at all times staff are working at the care home in such numbers as are appropriate for the health and welfare of service users. 24(1)(a)(b) The registered person must ensure that the home has a training & development plan and designated person with responsibility for the training and development programme. 13(4)(a) The registered person must ensure compliance with the Control of Substances Hazardous to Health Regulations 1999. DS0000018057.V278867.R01.S.doc 25/03/06 25/03/06 25/04/06 25/03/06 Fairview Road (19) Version 5.1 Page 18 6 YA37 17(2)Sch4 37(e) The registered manager must ensure that the home notifies the commission of any event in the care home which adversely affects the well-being or safety of any service user. 25/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA2 Good Practice Recommendations It is recommended that the residents needs assessments be reviewed to ensure that they each contain equal amounts of detailed information. Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 19 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 Fairview Road (19) DS0000018057.V278867.R01.S.doc Version 5.1 Page 20 - 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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