Inspection on 22/07/05 for 2 Herondale

This inspection was carried out on 22nd July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

2 Herondale 28/08/07

2 Herondale 03/08/06

2 Herondale 30/11/05

2 Herondale 21/02/05

2 Herondale 16/08/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Herondale(2) 2 Herondale Basildon Essex SS14 1RR Lead Inspector Trevor Davey Unannounced 22 July 2005 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. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Herondale (2) Address 2 Herondale Basildon Essex SS14 1RR 01268 523399 01268 523399 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) MCCH Society Limited Mrs Diane Patricia Watts CRH Care Home 8 Category(ies) of Mental Disorder (8) registration, with number MD(E) Mental Disorder - over 65 (8) of places Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Personal care to be provided for adults with a mental disorder aged 18 to 65 years (MD). 2. Personal care to be provided for adults with a mental disorder aged over 65 years (MD) Elderly. 3. Total number of places not to exceed eight. Date of last inspection 22nd February 2005 Brief Description of the Service: 2 Herondale is registered to provide personal care and accommodation to a maximum of eight adults with a mental disorder. This includes residents aged 18 to 65 years as well as older people over 65 years of age. This does not include people who may have dementia or learning disability. The home is a modern purpose built premises set in a residential area of Basildon. The accommodation is on two floors with eight single bedrooms some of which,are on the ground floor. Residents have use of the lounge, separate dining room, quiet/smoking room, laundry and kitchen. There is a shaft lift access between the ground and first floors. The home has a garden to the rear and adequate parking to the front. It is also close to local shops and Basildon town centre can be reached on foot or by public transport. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 22nd of July 2005 lasting 5¼ hours. The inspection process included discussions with four staff and four residents. The manager was off-duty and senior support workers were covering the shifts for the day. A tour of the premises took place and a sample of policies and records were inspected. Twelve standards were covered and requirements and recommendations are listed at the end of report. What the service does well: What has improved since the last inspection? Since the last inspection, a number of staff have attended refresher courses on the administration of medication and others are to attend in September. The management have also made improvements in the way drugs are administered in the home. Following a requirement from the last inspection, the Prevention of Vulnerable Adults Procedure has been updated to include the essential agencies to be notified when reporting incidents of this nature. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 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. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.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 Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.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) 2 The Homes admission and assessment procedure takes into account individual aspirations and needs to ensure placements are suitable. EVIDENCE: Some of the residents spoken to stated that staff were very supportive and discussed with them any concerns and changes regarding their daily routines and that they were involved with the updating of care plans. There was evidence to show that the staff team had discussed and made provision for residents to fulfil particular interests and leisure activities as well as meeting friends and family. Specific arrangements had been recorded on care plans and risk assessments included where necessary. There was evidence that ongoing consultation with residents on a one-to-one basis was taking place and they were given the opportunity of influencing changes in the day-to-day running and routines of the home. Residents confirmed that staff were involved in accompanying and supporting them in their daily activities both in the home and in the community. Details of support provided was recorded in the personal care records. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.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) 9 Residents are supported in following an independent lifestyle and risk assessments are drawn up as required. It was not always clear if risk assessments had been regularly updated to take account of changing circumstances. EVIDENCE: From the sample checks made, care plans were in place but it was not always clear from some of the records, if these and the risk assessments had been updated. In some cases records had been ticked for reviews and not dated or signed by members staff concerned. Other risk assessments had been reviewed each month and monthly evaluation sheets completed. A consistent recording procedure should be in place to ensure that all residents’ needs are regularly reviewed and risk assessments updated as appropriate. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.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) x EVIDENCE: Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 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 standard(s) 18,19 & 20 The home was able to demonstrate that the holistic needs of residents were being met and supported in accordance with individual preference. EVIDENCE: From sample checks made, personal records showed where specialist appointments had been made with other health care professionals and the outcome of these meetings. The community psychiatric nurse visits the home and gives regular support as required. The philosophy of the home is very much one where staff discuss and involve residents in decision-making on a day-to-day basis with the key worker or in group meetings to ensure their individual views and choices are respected. At the time of inspection, none of the residents were responsible for taking their own medication. Improvements have been made to the medication administrative system and two staff carry out an audit of drugs when a handover of shift takes place. Five staff completed a medication refresher course in July and others are to attend in September. From the sample checks made, the medication record sheets had been completed in accordance with standard procedures. Protocols were in place where required particularly when residents visited family at weekends. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 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 standard(s) 22 & 23 There is an established complaints procedure of which residents are aware and opportunities made available for their views to be expressed and listen to. A Vulnerable Adults Procedure is in place to protect residents from harm and abuse. EVIDENCE: A copy of the homes complaints procedure is available and is displayed in residents’ bedrooms. No complaints have been recorded since the last inspection. The whistle blowing policy as part of the protection of abuse procedure has been updated since the last inspection. This now includes the essential agencies which must be contacted should any incidents be reported. Residents spoken to, felt confident that they could approach staff should they have any concerns and that they felt safe in the home. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 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 standard(s) 24 & 30 Overall, the home is comfortable, and clean with accommodation suitable for residents needs. Improvements required by the fire officer have not been implemented and renewal of the gas and electricity safety certificates remains outstanding, which means residents’ safety could be at risk. EVIDENCE: There is a homely atmosphere with accommodation and facilities being suitable for residents needs. Previous Commission for Social Care Inspection reports have identified items of maintenance and in particular, the need to upgrade the fire precautions, which the fire officer highlighted in his visit to the home on the 21st October 2004 and which was still outstanding when the fire officer visited the premises on the 19th April 2005. This issue together with other items of maintenance have been regularly reported on the monthly visit of the Responsible Individual on behalf of the Registered Provider. The manager of the home has also made regular weekly contact with the Central office of the Registered Provider concerning these issues. A gas safety check was carried out at the home on 30th June 2004, but the safety certificate has never been received. A further annual safety check of the gas services should have taken place at the end of June 2005. The five-year electrical safety certificate also expired in April 2005. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 Page 14 The Inspector made telephone contact on the day of inspection to the central office of the Registered Provider because of concerns regarding the risk to residents health and safety and the long delays which have occurred in completing essential maintenance. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 Page 15 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) 35 Staff are appropriately trained and have suitable experience to meet individual and joint needs of the residents. EVIDENCE: A record of training and courses, which had been completed by staff, was made available for inspection together with certificates of attendance. This included refresher courses in the administration of medication and first aid training. A staff rota was available but it was not possible to check recruitment records as only the manager has access to these and she was off duty at the time of inspection. These will be checked at the next inspection. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 Page 16 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) 39 & 42 Residents’ views are sought and are taken into account in reviewing and developing the practices of the home. Not all health and safety issues are addressed which could leave residents at risk. EVIDENCE: Records of residents’ meetings were made available for inspection and residents were positive and expressed confidence in knowing they could share their opinions and that staff were approachable. Staff could also be approached on an individual basis should they have any concerns. Records were also available of staff ‘away days’ which included discussions on what residents would like in the home including looking at various social and leisure activities. This report has already highlighted concerns under Standard 24 regarding possible risk to the health and safety of residents because of fire precautions, which have not been upgraded, and gas and electricity safety certificates not being renewed. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 Page 17 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Herondale(2) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 1 x I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 Page 18 This 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 24 Regulation 23 Requirement The Registered Person shall after consultation with the fire authority take adequate precautions against the risk of fire including the provision of suitable equipment and making adequate arrangements for the detecting and containing of fires and for the reviewing of fire precautions. This must include replacing seals to all fire doors to ensure that they are effective in accordance with fire officers requirements (this is a repeat requirement). The Registered Person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety and any unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. This includes ensuring that up to date gas and electricity safety certificates are issued. (This is a repeat requirement). The Register Person shall ensure that the assessment of the service users needs is kept Timescale for action 31st August 2005 2. 42 13(4) 31st August 2005 3. 9 15 (2 ) 14 (2 ) 15 September 2005 Page 19 Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 4. 42 23 under review and revised any time when it is necessary to do so having regard to any change of circumstances. This includes updating care plans and risk assessments as appropriate.. The Registered Person shall after 31st August consultation with the fire 2005 authority take adequate precautions against the risk of fire including the provision of suitable equipment and making adequate arrangements for the detecting and containing of fires and for the reviewing of fire precautions. This must include replacing seals to all fire doors to ensure that they are effective in accordance with fire officers requirements (this is a repeat requirement). 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 37 32 Good Practice Recommendations The manager should achieve NVQ 4 in management in care by 2005. 50 of care staff should achieve NVQ 2 or equivalent by 2005. Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 Page 20 Commission for Social Care Inspection Kingswood House Baxer House 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 Herondale(2) I56-I06 S 18053 Herondale V239591 220705 Stage 4_UPDATED3.doc Version 1.40 Page 21 - 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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