Inspection on 24/08/05 for 2 Emily Jackson

This inspection was carried out on 24th August 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 Emily Jackson 30/07/07

2 Emily Jackson 06/12/05

2 Emily Jackson 21/10/04

2 Emily Jackson 07/05/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 2 Emily Jackson Eardley Road Sevenoaks Kent TN13 1XT Lead Inspector Paul Stibbons Unannounced 24 August 2005 09:30 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. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 2 Emily Jackson Address Eardley Road Sevenoaks Kent TN13 1XT 01732 457284 01732 457284 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) The Avenues Trust Limited CRH Care Home 6 Category(ies) of Physical disability (6) registration, with number of places 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. 6 People with physical disability may also have a learning disability. 2. Care of one Service User over 65 years of age is restricted to one Service User whose date of birth is 31/03/1938. Date of last inspection 21 October 2004 Brief Description of the Service: The home was purpose built in 1995 to six service users with Learning disabilities. Accomodation is single storey and consists of six single bedrooms with en-suite shower and toilet facilities. All bedrooms have a TV point. Apart from the assisted bathroom, bedrooms and communal areas are not connected to an emergency call system. Day space consists of a lounge and separate dining room. There is a small rear garden. The home is situated in a quiet residential area within walking distance of Sevenoaks town centre and main transport systems. There is limited on site parking. The person in charge of day to day running of the home has applied for registration with CSCI. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulatory inspector Paul Stibbons carried out this unannounced inspection from 10.00 hours until 16.30 hours. A tour of the building was conducted and information provided by care staff in the morning and the home’s manager in the afternoon. Various records were viewed and the inspector spoke with two care staff and two service users. What the service does well: What has improved since the last inspection? What they could do better: A more accessible format for recording service users’ daily support requirements would benefit both staff and service users. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 6 Whilst it is commendable that staff care about the visual impact of the home for service users, the time they spend decorating can only impact on time spent with service users. A dedicated maintenance team should be delegated this task within a maintenance schedule. To maintain a satisfactory standard of hygiene the kitchen worktop, which is badly damaged and the refrigerator with a missing door must be discarded or replaced. En-suites in service users rooms have no means for carers to dry their hands. It is recommended that paper towel dispensers or other means are provided for infection control. The service must continue to recruit permanent members of staff to reduce reliance on agency and bank staff. Copies of up to date qualifications and membership of professional bodies must be maintained for individuals who provide a service privately to service users. 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. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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, 2, 3, 5 Service users are provided with sufficient information for them to make an informed choice about the home and whether their needs will be catered for within the service. EVIDENCE: The home conducts a comprehensive assessment of service user needs using a multi-disciplinary approach. These assessments cover health, social, physical and emotional needs. Evidence of assessments is contained within service user support plans along with carer guidance. A letter was seen from a relative of a service user that thanked staff for the standard of care given to their relative. Each bedroom has a service user guide and written contract with terms and conditions of the placement detailing their rights and responsibilities. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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) 6, 7, 8, 9,10 Comprehensive care plans are in place for individual service users and they are encouraged to join in daily household tasks within a risk-assessed framework, service user rights to confidentiality are upheld. EVIDENCE: Individual care plans were comprehensive but bulky and in some areas difficult to follow. Some records were duplicated in other locations. Discussion took place about how support plans could be formatted into a more workable document and used on a day-to-day basis. Care plans were kept securely in the manager’s office. Pictures and symbols within the home help service users communicate and make choices. They are encouraged to participate in household chores and have the use of communal areas where capability allows. One service user regularly visits their friend in the home next door. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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) 11, 12, 13, 14, 15, 16, 17 Service users have the opportunity to participate in a range of activities to meet their spiritual, social and leisure needs. They are supported in maintaining friendships and family contacts and receive a healthy and balanced diet. EVIDENCE: The staff team support service users to attend church and they have access to the hydro-pools at Sevenoaks and Seven Springs at Tonbridge under the guidance of a physiotherapist. Service users, their families and friends recently enjoyed a barbeque in the garden and another, accompanied by live musical bands, has been arranged for September. All service users enjoyed a 7-day holiday at Longleat and some will be taking a second holiday later this year. A four weekly menu was seen that showed that service users receive a healthy and balanced diet based on their likes and dislikes. Staff said that the community dietician has input into these and records were seen that documented the service users’ food and fluid intake. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 11 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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) 19, 20 Service user health needs are fully met and monitored by the multi-disciplinary team. They are unable to administer their own medication and are supported by competent staff using safe procedures. EVIDENCE: Various charts are used for monitoring service users health and care plans showed that referrals had been made relevant professionals when appropriate. A keyworker system supports service users. The manager stated that person centred planning meetings are held quarterly and in-house reviews of individual support plans are six monthly. Medication is stored and administered in line with Royal Pharmaceutical Society guidance and only administered by named staff who have received appropriate training and have been assessed as competent. The district nurse provides training for administering rectal diazepam should service users need this. Records are accurate and are kept securely. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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) 23 Policies and procedures along with staff training protect service users from abuse. EVIDENCE: The home has a “Whistle blowing” policy and all staff have received training on adult protection issues. Staff said they were confident in approaching the manager with any concerns and service users are protected from abuse and neglect through induction training and ongoing supervision. Details of which were seen in staff training files. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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, 29, 30 The service users live in a safe and clean environment with access to adequate personal and communal space. Service users have the specialist equipment they require to maximise their independence. EVIDENCE: The home has a homely and comfortable feel and is adequately furnished to meet the needs of service users. Staff are currently re-decorating the home, but this task should be delegated to a maintenance team. Service user bedrooms reflect their interests and there are many personal possessions on display. All bedrooms have an en-suite toilet, washbasin and shower, have wheelchair access and provide privacy for personal care. There is no facility for carers to dry their hands in these areas and a suitable paper towel dispenser or other means must be installed to minimise the risk of cross infection. Service users have specialist adjustable beds and hoists to maximise their independence and servicing of this equipment was in date. Other than their individual rooms service users have access to a dining room, lounge, visitors room and a garden area. On the day of the inspection the 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 15 home was clean and odour free. However, to ensure standards of hygiene are maintained in all areas, attention must be given to a damaged kitchen worktop and fridge that need repairing or replacing. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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) 32, 33, 34, 35 Service users individual and joint needs are met by a competent and appropriately trained staff team. However, vacancies continue to affect the consistency of care for service users. EVIDENCE: The manager stated that staff receive a comprehensive induction and additional statutory training so that they can carry out their duties effectively. Staff spoken to confirm that, in addition to an induction course, they had received training in manual handling, first aid, adult protection and fire procedures. One senior holds the registered managers award and NVQ3 in care and 5 staff have NVQ3 in care. The staffing level for the service is 14.6 full-time equivalent posts, but is currently running at 8.5. In addition, one member of staff will be leaving in September, which will reduce staffing levels even further. On the morning of the inspection only two members of staff were on duty to care for six very dependent service users. This level of cover at best restricts opportunities offered to service users and at worst has the potential to put them at risk. The home must address staffing levels so that training days, sickness, annual leave etc., does not adversely affect service users. Staff files were not available for inspection as they are held at head office. However, there were out of date copies of membership of a professional body for an Aromatherapist employed 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 17 by the home. For the protection of service users evidence that their qualifications are current must be kept on file. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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, 39,42 Service users benefit from living in a home that is run by a qualified, approachable and competent manager. Service users and their families are consulted on their views and know their opinions are valued. The health, safety and welfare of service users are promoted. EVIDENCE: The home’s manager has successfully completed the NVQ4 in Management and will be starting the NVQ4 in Care late September 2005. An application has been submitted to the Commission for them to be registered, this is currently being processed. Staff said the manager is approachable and fully supports the team. The Trust sends out questionnaires to relatives on an annual basis to obtain feedback on the service. Open invite events are also held to discuss developments within the service. Records of temperatures that food is stored and cooked at were seen. An emergency procedure file covering what to do in the event of fire, missing persons and medical emergencies was also seen. Hazardous 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 19 substances were stored securely. Care plans contained comprehensive risk assessments for manual handling and other activities that service users undertake. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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 3 3 x 3 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 2 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 2 Emily Jackson Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 3 x H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(2) c Requirement Equipment in the home must be maintained and in good working order. The refridgerator in the kitchen must be repaired or replaced to maintain hygienic standards. The damaged kitchen worktop must be repaired or replaced to maintain hygienic standards Suitable arrangements must be made for staff to dry their hands in en-suite and bathroom facilities to prevent the spread of infection. The registered person must ensure sufficient numbers of staff are on duty as are appropriate for the health and welfare of service users Documentary evidence of any relevant qualifications must be kept up to date for persons employed in the home. In this context the external Aromatherapist. Timescale for action By 25 October 2005 2. 3. YA24 YA30 23(2)c 13(3) By 25 October 2005 By 22 December 2005 By 22 December 2005 By 25 November 2005 4. YA33 18(1)(a) 5. YA34 19(1) schedule 2 (4) 6. 7. 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 22 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. 2. Refer to Standard YA6 YA24 Good Practice Recommendations Support plans should be arranged in a more accessible format for staff delivering care. Decoration of the home should be undertaken by a delegated maintenance team and not care staff 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 2 Emily Jackson H56-H06 S23882 2 Emily Jackson V242509 240805 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. 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!