Inspection on 27/09/06 for 22 Sandown Road

This inspection was carried out on 27th September 2006.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 22 Sandown Road Billingham Stockton-on-Tees TS23 2BQ Lead Inspector Derek Stow Key Unannounced Inspection 27th September 2006 02:15p 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 22 Sandown Road Address Billingham Stockton-on-Tees TS23 2BQ 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) 01642 365377 01642 360988 Saint John of God Care Services Mrs Kay Mildred Waite Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the first inspection since the change in the name of the organisation to St John of God Care Services was registered with The Commission For Social Care Inspection on 4th September 2006. Brief Description of the Service: 22 Sandown Road is a single storey, bungalow style care home providing residential care, without nursing, for nine adults who have Learning Disabilities. The communal areas of the home are: a spacious lounge, a large dining room, a quiet lounge and a sensory room. There is domestic style kitchen and laundry that are available to residents, depending on residents skills and abilities. All accommodation within the home is for single occupancy. No bedrooms have an en-suite facility but there are communal baths, showers and toilets around the home. Bedrooms are personalised for the individual needs of residents. The gardens are accessible to residents; there is a designated patio area with a pot plants and seating. The entrance to the home also has pot plants and hanging baskets giving a welcoming first impression. The home is located near to Billingham town centre where there are shops and leisure facilities. Nearby there are churches and pubs. A bus route, to Middlesbrough and Stockton, is close to the home. 22 Sandown Road have a minibus and a people carrier to use as transport for the residents. Cost of service at 22 Sandown Road. On the date of this inspection the fees for care ranged from £851 to £2261-05 per week. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection at 22 Sandown Road was unannounced and took eight hours spread over three visits including one visit when the inspector shared an evening meal with eight of the residents and seven staff. Owing to the level of disability of the residents they could not be consulted, but the inspector observed how they related to staff. Account was also taken of comments from relatives and professionals survey questionnaire as well as a visiting health professional at the time of inspection. A day was spent talking with the manager, examining records and included an inspection of the building. The inspection also took account of information gathered about the service over the year including a pre-inspection questionnaire completed by the manager. This inspection looked at those standards, which the Commission for Social Care Inspection regard as Key minimum standards. The details of any issues identified as requiring action together with recommendations for improvement are to be found at the back of this report. What the service does well: What has improved since the last inspection? Since the last inspection the service has improved the staff records, fire training and records, the quality assurance systems and the electrical wiring has been tested. A policy relating to death and dying has also been developed. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome group of standards is “good”. This judgment has been made from evidence gathered both during and before the visit to this service. New and current residents needs and aspirations are assessed. EVIDENCE: Eight of the nine residents at Sandown Road have lived there for between eight and eleven years. Only one resident has been admitted in the last year. The Manager and staff spoken with said that they are aware of the need to obtain detailed information about the needs and aspirations of the residents. The files of two residents were looked at in detail and both held a great deal of detailed assessment information including multi-disciplinary care management assessments obtained prior to admission. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome group of standards is “good”. This judgment has been made from evidence gathered both during and before the visit to this service. The needs and wishes of the residents are assessed in a way that involves them and their families and advocates, as much as is possible to ensure that what happens is what they want. The residents are supported in having as independent a life as is possible with appropriate risk assessments in place. EVIDENCE: The two residents files which were looked at showed good, clear evidence of detailed planning to develop an individual Life Plan covering eight aspects of living. These were agreed and signed by relatives or advocates who are also involved in reviews at least twice a year. Each resident has an appointed key worker who has a special responsibility to ensure needs are met in consultation with the resident. Detailed risk assessments were also in place for each resident. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 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 the following standard(s): 11,12, 13, 14,15, 16, 17 Quality in this outcome group of standards is “good”. This judgment has been made from evidence gathered both during and before the visit to this service. There are many and varied opportunities for personal development, social, learning and leisure activities for the residents who live at Sandown road, the majority of which take place within the local community. Contact with family and friends is encouraged and supported. The residents enjoy a varied diet, which meets their needs and wishes. EVIDENCE: All nine residents attend day resource services and in addition each person has an individually based diary of activities in the community. There is clearly written as well as a great deal of photographic evidence of activities such as horse riding. Swimming, boating in the Lake District as well as annual holidays in France and America. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 11 The home has the use of two vehicles to meet the transport needs of the residents and family and friends are encouraged to maintain contacts. A good standard of evening meal was shared with the residents and staff and observations confirmed that staff are fully committed to the very highest standards, values and principles of service. All staff are trained in food hygiene and nutrition. Residents’ likes and dislikes in all aspects of life are known and respected by the staff and are recorded. A picture menu is also available to assist in the choice of meals. Residents are encouraged to participate in household tasks as far as each individual. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 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 the following standard(s): 18, 19, 20 and 20. Quality in this outcome group of standards is “good”. This judgment has been made from evidence gathered both during and before the visit to this service. Service users receive personal support in a way that is identified that they prefer and enjoy. The healthcare needs of the service users are assessed and met and residents are protected by the home’s policies and procedures for dealing with medicines. The home has developed a policy relating to death and the care of the dying. EVIDENCE: The care plans examined were clear and detailed and identified the needs of the residents and what action should be taken to meet each individuals needs. There is evidence of good links and support from a range of healthcare professionals and on the day of inspection one health care professional spoken with said that they have high regard for the service and the staff team at Sandown Road. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 13 All staff that give residents medication are trained and two staff always do this together in line with the homes policy. The medication and records that were checked were satisfactory but in discussion with the manager it is recommended that for all non-monitored dosage medicines there is a written start/opening date on bottles/packets to create a clear audit trail. The policies should be further developed to deal with ageing and illness. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 14 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 and 23 Quality in this outcome group of standards is “good”. This judgment has been made from evidence gathered both during and before the visit to this service. The staff and manager at Sandown Road respond positively to the feelings and views of service users and relatives and service users are protected from abuse. EVIDENCE: The Home has a complaints policy and procedure in place, which includes a picture version, which some residents with a learning disability may be able to understand. No complaints have been recorded at the Home since the last inspection and a recent survey showed that relatives were all aware of the procedure. The policy and procedure should now be updated to make it clear to residents and relatives that the responsibility to receive, resolve and investigate complaints is with the management of the Home and those agencies such as Social Services and Primary Care who contract or commission services on behalf of individual residents. The Commission for Social Care Inspection is primarily a regulator of services and not a complaints investigation body. However residents, relatives and members of the public can still report any concerns about the running of a particular service to the Commission who will consider the issues and whether the service is meeting the required standards and regulations. The protection of vulnerable adults policy and procedure is in place and Staff spoken with during the inspection all knew what to do if they suspected abuse of residents and had undertaken training. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 15 In discussion with the manager it is recommended that a short in-house procedure be developed for quick reference detailing the contact telephone numbers as well as the dos and don’ts on receipt of an adult protection concern. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome group of standards is “Adequate”. This judgment has been made from evidence gathered both during and before the visit to this service. The residents who live at Sandown Road live in a homely, comfortable and safe environment, which is clean and hygienic. EVIDENCE: A detailed tour of the building took place with the manager. All areas were observed to be very clean, well decorated and furnished to a high modern standard. Anti bacterial hand wash was also available to minimise infection. Residents bedrooms examined were well furnished, individually decorated and personalised in line with the residents /relatives wishes. The building is maintained by the local Council and the following maintenance issues were noted which require action. In one of the bathrooms there were exposed wires and broken pipe work coverings. A soap dispenser needs to be fitted to the wall and in the dining room a light fitting needs fixing. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 17 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, 34, 35 and 36. Quality in this outcome group of standards is “good”. This judgment has been made from evidence gathered both during and before the visit to this service. Residents are supported and protected by appropriate numbers of satisfactorily recruited and trained staff who receive regular supervision and appraisal. EVIDENCE: The staff group at Sandown Road benefit from a range of training opportunities and it is to be commended that over 95 of staff are qualified to NVQ level 2 or above. A group of staff were spoken with during an evening meal and they all confirmed that they are supported with regular training, supervision every two months and appraisal twice a year. Staff had undertaken training in relation to the protection of vulnerable adults. The staff files were examined for the last three staff recruited and they were well organised and held the evidence necessary in law to ensure identity, as well as two references and criminal record checks. Training records and a training matrix covering all mandatory training was in evidence. Some staff suggested that they receive some specialist training in relation to Epilepsy and the manager has this in the training plan for the coming year. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 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 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): 37,39 and 42. Quality in this outcome group of standards is “good”. This judgment has been made from evidence gathered both during and before the visit to this service. The residents who live at Sandown Road benefit from a service, which is well managed and run with their interests, health, safety and welfare being promoted and safeguarded. EVIDENCE: The Manager is experienced and holds the Registered Managers Award, Certificate in Management Studies and Advanced Care Management. Several quality assurance systems are in place focussing mainly on care planning; review; regulation 26 visits; involvement of relatives; advocates; annual survey and the Annual Mission plan. The manager presented an excellent survey questionnaire, which had recently been returned from relatives, advocates and involved professionals. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 19 The Manager said that this would be analysed with the findings put in to the annual action plan. The survey showed a very high level of satisfaction with all aspects of the care service provided at Sandown Road and could only be improved upon by asking people if they had any additional comments or suggestions to improve the service. A number of health and safety records were examined to confirm that up to date maintenance/checks and records were in place relating to hot water temperatures, electrical wiring, fridge temperatures, environmental health, as well as fire training, fire drills and legionella. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 3 X 3 X X 3 x 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 23 Requirement The maintenance work in the bathroom and the dining room must be addressed Timescale for action 31/12/06 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 2 3 4 Refer to Standard YA20 YA21 YA22 YA23 Good Practice Recommendations It is recommended that the manager develop a clear audit trail for all non-monitored dosage system medicines. Develop policy relating to illness and ageing. Update the Complaints policy/procedure. A short in-house procedure should be developed in support of the adult protection policy. 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 22 Sandown Road DS0000068420.V313357.R01.S.doc Version 5.2 Page 23 - 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. 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