Inspection on 17/10/06 for 230a Mountnessing Road

This inspection was carried out on 17th October 2006.

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

Other inspections for this house

230a Mountnessing Road 29/08/08

230a Mountnessing Road 03/09/07

230a Mountnessing Road 03/11/05

230a Mountnessing Road 02/06/05

230a Mountnessing Road 02/11/04

230a Mountnessing Road 25/05/04

230a Mountnessing Road 08/12/03

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 Mountnessing Road (230a) 230a Mountnessing Road Billericay Essex CM12 0EH Lead Inspector Mrs Bernadette Little Unannounced Inspection 17th October 2006 09:55 Mountnessing Road (230a) DS0000015548.V316506.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 Mountnessing Road (230a) DS0000015548.V316506.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. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountnessing Road (230a) Address 230a Mountnessing Road Billericay Essex CM12 0EH 01277 632914 01277 632914 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) Estuary Housing Association Limited Yolanda Inciong Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Nursing and personal care to be provided to 8 service users with a learning disability. Nursing and personal care to be provided excluding any service user liable to be detained under the Mental Health Act 1983. 3rd November 2005 Date of last inspection Brief Description of the Service: 230 Mountnessing Road provided nursing care and accommodation to eight adults with learning disabilities. The home comprises of two semi-detached bungalows with an internal interconnecting door. Each bungalow has its own lounge, dining room, kitchen, shower room with WC, bathroom with WC, sluice and laundry room, as well as for single bedrooms with wash basin. There is a large garden for the use of residents. The home has car parking facilities and is situated within reasonable access to all local amenities and transport links. The weekly fee is £1,627.27 as advised by the pre-inspection questionnaire of June 2006.this document advised that approximate additional charges are made to residents as following: toiletries £20 each per month, activities £20, hairdressing £10 every few weeks, aromatherapy £25 per person, sensory sessions £12 per person, outings at up to £20 per outing and holidays £500 plus depending on venues. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken as part of the key inspection of 230 Mountnessing Road and six hours were spent at the home. Seven residents were living at the home at the time of the inspection and one resident was at an assessment unit. Two qualified nurses in charge of the shifts, two permanent staff and four agency staff were spoken with. A tour of the premises was undertaken and records, policies and procedures were sampled. Records for two residents were case tracked and others were sampled. A pre-inspection questionnaire had been received from the home prior to the site visit and information from this document was also used to inform this report. Feedback and advice was given to the staff in charge of the home during the day. The registered manager was not on duty at the time of the site visit. There were no permanent qualified staff on duty either. The agency staff in charge did not know what, or where, many of the records or documents asked for were, and this was quite difficult for them. Some things may be shown in the report as not being done properly, but it could be that the information that showed that they were, simply was not given to the inspector. Two professional visitors were spoken with. Two comment card/questionnaires were also returned. Information on their comments is contained in different parts of the report. Generally all comments were positive. A random inspection of 230 Mountnessing Rd had also been undertaken on the first of June 2006. A report from this inspection was not published the relevant things are again referred to in this report. What the service does well: 238 Mountnessing Road provides residents with a well decorated and comfortably furnished place to live. Some of the staff knew the residents well, and the things they liked and how they tried to tell us things. Other people who gave information about the home said that they were satisfied with the care provided to the residents, that staff listened to/acted on advice, or passed on important information to them. Other comments included that the home was always clean, that staff spoke to residents with respect and used their names, and that residents always looked clean and well cared for. Professional visitors and relatives said that they felt welcome at the home. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mountnessing Road (230a) DS0000015548.V316506.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 Mountnessing Road (230a) DS0000015548.V316506.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home was available for prospective/users of the service. Information on the terms of their living there was also available for residents. EVIDENCE: The random inspection of June 2006 identified that the Statement of Purpose and Service User Guide that had been provided to the commission and were available in the home needed updating in some areas. Updated copies had not been sent to the Commission. A copy of the Service User Guide available in the home at the time the site visit was dated March 2004. Estuarys most recent monthly regulation 26 report sent to the Commission also identifies that the Service User Guide requires updating. Staff confirmed that there had been no new admissions to the home for some time. Estuary had a clear and detailed admission policy that includes trial visits. This was also confirmed within the Statement of Purpose and Service User Guide. A basic pictorial format ‘ service user contract’ was available on a resident’s file sampled. This had been signed by the registered manager over two years Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 9 previously and so had not been updated. It was noted positively that an independent advocate had also provided written confirmation of the appropriateness of the document for the resident. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provided staff with clear information on how to provide consistent care for residents, supported by risk identification. Staff supported residents to make some choices. Resident individuality was not always shown as fully considered. Residents’ communication methods were known and responded to by staff. EVIDENCE: Care files for two residents were tracked. Both care plans contained a range of aims and objectives with instructions on how staff were to carry out the care. They were supported by risk identification/actions. A limited number of aims in one of the care plans were supported by a pictorial format. It was noted positively that care plans included issues such as communication, medication, finance and relationships, as well as issues of personal care and some information on hobbies and interests and activities of daily living. There Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 11 was no reference to the resident’s religious needs/wishes or their plan/wishes for end of life care. The monthly evaluation sheets on one of the care plans were recorded as having been completed in February, August and September 2006. The latest one was in a large font with pictorial input. Care notes were written regularly, twice daily and at night as a minimum. The care plan folder contained a list of the signatures of staff who had read the care plan since this procedure was instigated at the beginning of September. This contained thirteen signatures, but did not include all of the permanent staff or all the agency staff/nurses in charge at the time of the inspection. Some staff spoken with were clearly aware of residents’ needs and their plan of care. They advised that with the complexity of the needs of some residents it is sometimes very difficult to find ways to offer them real opportunities to make meaningful decisions about their daily lives. Examples of where they try to ascertain wishes and choices by interpreting residents’ responses were given. Staff advised that residents can show if they dont like or want something, for example having had enough food, by facial expression. Residents can also indicate choices by looking at different things. Another resident’s pinching behaviour was advised as their way of telling you they were bored, or their kicking at your foot meant they wanted you to talk to them. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ opportunities to have their individual social/leisure needs met were limited in some aspects. Visitors felt welcomed. Residents were generally provided with a varied diet. EVIDENCE: The inspection questionnaire identifies that one service user attends day services, two attend an evening social club and that other activities include bowling, going to a restaurant or pub or on outings such as the zoo, the beach or shopping. Activities at home include listening to music watching TV, building plastic blocks, sensory sessions, cooking, painting and doing puzzles and beads. A record of the weekly activities/outings for each resident was maintained. This was sampled on the two resident files tracked. In the two weeks prior to the site visit one resident had been to the zoo, had been to a designer village for Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 13 shopping, and had been out for lunch. In-house activities included relaxing in the lounge, watching TV or use of the sensory room. For the other resident it demonstrated that the resident listened to music and looked at books at home, had been to the zoo to an evening music group and also to the Wickford Exchange. The whiteboard in the office demonstrated the plans for each resident for that week. This demonstrated very limited plans for some residents. It was planned that one resident would go out with a named member of staff for a minibus ride on the day of the site visit, however this member of staff was not on duty. At the time of the random inspection in June 2006, it was also confirmed that an activity recorded on the whiteboard to residents had not actually occurred. The sensory therapist was visiting on the day of the site visit. The records of expenditure of residents monies show that residents are routinely charged the same amount for toiletries. It is considered unlikely that all residents always use exactly the same amount of toiletries, this either indicates the practice of shared toiletries, which does not respect individuality, or unfair charging of all residents regardless of how much they use. Estuary act as corporate appointees in relation to all residents finances. Risk assessment also confirms that residents are unable to manage their own medication. Ample food stocks were observed to be available. Residents had pizza for lunch on the day of the site visit and those able to indicated their satisfaction. The nutrition record was maintained and demonstrated that residents generally had a varied diet. However it was noted that some residents had the same cereal almost every morning for three weeks, and staff were advised to reconsider whether this had become habit, rather than appropriate support to exercise choice. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A keyworker system supported some consistency of care and advocacy for residents. Residents were supported to access services to ensure their healthcare needs were met. The management of medication in the home safeguarded residents. EVIDENCE: Staff confirmed that all residents at 230 Mountnessing Road require assistance with all aspects of personal care. The staffing rota and observation of staff on duty at the time of the site visit indicated that residents would have the choice of at least one same sex member of staff to assist with personal care. Care plans identify that each resident has an allocated key worker. On one of the files sampled the key worker was an agency member of staff, who works regularly at the home. Two residents’ care plans sampled included a health-care plan. Records also indicated routine health-care checks such as medication reviews and dental appointments. Weight, bowel and seizure charts were maintained and seen to be up-to-date. Records also showed access for assessments/referral to, for example occupational therapists, continence adviser and physiotherapist. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 15 Discussion took place with a healthcare professional who provided services to the home. This confirmed that any specialist advice offered was incorporated into the service user plan and that staff demonstrated a clear understanding of the needs of service users. There was evidence that assessment was underway for the provision of a specialist bed for an individual resident. Pictorial format information was seen to be available in individual residents’ rooms that instructed on appropriate moving and handling techniques and equipment for that person. An agency staff member spoken to was clearly aware of residents’ individual conditions and needs, including for example epilepsy. Only qualified nurses administer medication. The sample of staff signatures and initials for a medication administration was in the process of being updated. Staff advised that no residents were prescribed controlled drugs. A medication directory and a copy of Estuarys policies and procedures on medication were readily available. The medication administration recording (MAR) sheets were seen to be well maintained, with no omissions and recorded the amount and date of medication received. Some MAR sheets did not contain a photograph of the resident, which is not considered good practice in light of the number of agency nurses working at the home. Protocols for ‘as required’ rectal diazepam had recently been signed as reviewed by a consultant. The protocols identified that this may only be administered by qualified nursing staff. There was no information/evidence available on updated training/competence assessments for staff on medication. Please refer to Standard 6 in the section ‘Individual Needs and Choices’ for information relating to end of life wishes/practices. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would be better protected by evidence of staff training/safe recruitment and a greater staff awareness of appropriate policies and procedures. EVIDENCE: A customer service policy was displayed along with pictorial format information on who to contact with regard to concerns and complaints. The agency staff in charge of the home could not confirm whether any complaints had been received by the home. The pre-inspection questionnaire returned in June 2006 identified that there had been one complaint received by the home during the previous 12 months. No complaints had been recorded in the named complaints book, which had not had any entries for some years. The commission has not received any complaints regarding this home since the last inspection. Both agency nurses in charge of the home stated that they had had training in the protection of vulnerable adults, but did not have evidence of this training. One said that if a concern was reported to them they would listen to both sides, would protect the residents and inform the registered person as soon as possible for advice on what action to take. They confirmed that they had not read the whistleblowing policy and procedure and were advised to do so. They were unaware of where the homes policies and procedures in relation to protecting vulnerable adults were. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 17 A separate file marked protection of vulnerable adults was seen to be available on a shelf. On inspection this referred only to recruitment processes. Another agency staff member provided evidence of training on protection of vulnerable adults but confirmed they were not especially aware of the homes policies and procedures. No evidence of training on protecting vulnerable adults was available for three other agency members of staff on site during the day of the site visit. The inspector noted that Estuary’s policies and procedures on the protection of vulnerable adults were displayed in a plastic wallet on the wall in the office. This also contained guidelines for staff from Essex county council. A signatory listed that had been in place for some two and a half weeks to confirm staff had read the policies and procedures contained three names, including the registered manager. The training matrix provided with the pre-inspection questionnaire in June 2006 identified that some of the permanent staff had not had updated training in the protection of vulnerable adults. The agency staff on duty were unable to advise if any updated training had been provided for permanent staff or who the staff may have been. The pre-inspection questionnaire returned in June 2006 identified that there had been one concern reported under the protection of vulnerable adults guidelines by the home during the previous 12 months. The action taken by the reporting staff and Estuary was prompt and appropriate. The section on Staffing identifies a concern regarding evidence of safe recruitment practices to protect residents. A list of what is acceptable expenditure for residents personal money was provided, which is positive. Those sampled indicated appropriate expenditure, with the possible exception that residents are paying for meals out. This does not correspond with the information provided by Estuary in their information documents for residents about the home that all food/meals are included in the cost of the placement. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises provided a comfortable, clean and pleasant environment for residents. Some aspects did not best protect resident safety. EVIDENCE: Since the last inspection, both lounges had been redecorated, re-carpeted and provided with new curtains, furniture and other homely touches. All bedrooms had individual colour schemes and decorations. They were personalised for example with items that reflected resident interests such as music. Staff confirmed that residents had all the appropriate equipment they required. (See also the section on personal health care and support). The office has also been redecorated and carpeted. The sensory room was cluttered with items that should not be stored there, for example mirrors. All areas were noted to be clean and older free. Water temperatures sampled were satisfactory. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 19 Hazardous items (COSHH) such as slug pellets, aerosol sprays and bath cleaner were noted in different areas and so accessible to residents. The doors to the staff toilets open outward onto the corridors. This was seen to present a risk to residents, two of whom mobilise on the floor. The home has an accessible garden which staff confirmed that residents use, more especially in the warm weather. Some old kitchen cupboards in the garden needed to be removed. A sign was noted to be displayed on those of the dining room advising that they were dangerous and were not to be opened. Staff on duty were unaware of why this was all what action was being taken. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The high use of agency staff does not always provide opportunity for familiar continuity of care to residents. The lack of records regarding safe recruitment practices did not best protect residents. EVIDENCE: The pre-inspection questionnaire identified that none of the care staff had completed NVQ training. At the site visit staff advised that one of the permanent staff members had commenced NVQ 3 training, and the visitors record confirmed that an assessor had visited the premises the previous day. Another staff member communicated that they hoped to also undertake this training once appropriate support could be found to meet their individual need. The most recent Regulation 26 report identified that they were four support worker vacancies and a deputy manager vacancy at the home. The home uses a high level of agency staff and while endeavouring to use regular agency staff, were not achieving this at the time of the site visit. Both the qualified staff on duty and in charge of the home during the day of the site visit had not done shifts there for some weeks previously. On the afternoon shift the Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 21 qualified agency nurse was supported by an agency staff member who had never worked at the home previously, one who had done a very limited number of shifts there and one permanent member of staff. The deployment was not appropriate when the qualified nurse was doing the cooking and agency staff, who barely knew the residents and had not read the care plans, were unsupervised with the residents. There was no evidence available on site that appropriate checks and references had been undertaken on the staff. Two versions of the duty roster were being maintained. They did not correspond with each other. One was accurate as to the staff on duty at the time of the site visit, but did not contain the full name of all staff or show the hours they were to work. The registered manager identifies in the pre-inspection questionnaire that all eight residents are of high dependency. The rosters indicated that the minimum staffing level of one qualified staff and three support staff was maintained during the day, and one qualified staff and one support staff worker at night. The random inspection of this home in June 2006 recommended a review of the staffing levels, following the loss of day services for one resident and the management of issues such as food shopping when two staff remained at home for some hours caring for all eight residents. There was no evidence that any action had been taken relating to this. Staff advised that there was no access available to the staff recruitment files, either for permanent or agency staff, as these were private and locked away. They also advised that there had been no new permanent staff employed. Records for permanent staff had been inspected at the last full inspection. The issue of evidence of appropriate references and checks for each agency member of staff was outstanding at the random inspection and the previous full inspection. Staff training records indicated that there had been recent training updates for example in medication for a nine staff, on epilepsy for six staff, on protection of vulnerable adult for three staff and on dementia for two staff. Other training recorded as planned included on Asperger’s syndrome, communication and risk assessment. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The appointment of permanent qualified staff would support more consistent and effective management of the home for residents. There was a limited system in place to seek the views of residents and their representatives. The internal systems that ensure the safety and welfare of residents were not effectively practised or monitored. The external monitoring of the home by the registered provider was not evidenced as routine or effective. EVIDENCE: The registered manager was not on duty at the time of this inspection. Those spoken with said that the manager is both supportive and approachable. The management situation at the home of the time of the site visit, while meeting the requirements for a qualified nurse, was not best practice, as Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 23 neither of the agency staff in charge had been regular at the home recently. The registered manager does not have the support of the deputy manager currently. The external management of the home had not evidenced (through regulation 26 reports) regular monitoring and support to the home/manager. There was no evidence that Estuary had monitored the staffing situation or taken appropriate action in relation to the staffing levels, staff recruitment and retention, as well staff deployment, although some clearer actions were identified as required in the one recent monthly monitoring report available. The last available minutes of a residents meeting were dated May 2006. These did not present as person centred. A pictorial agenda was seen to be displayed for the next residents meeting to be held in late October. This is a more positive approach. A questionnaire as seen in a resident’s bedroom, however this was dated 2004. No other information was available in the home relating to quality monitoring and quality assurance. The last monthly Regulation 26 report available was dated June 2006. This recorded the previous visit as January 2006. Fire doors were fitted with automatic closures. A letter was noted from Essex Fire authority in July 2006 advising that the home was not complying with the workplace regulations. Staff were unaware what this referred to or whether it had been actioned and there was no indication on the file. Records of water temperature checks were erratic and only recorded the hot water readings. Those recorded for the laundry were not adequate. Records of the fire alarm system were not recorded as being done routinely. Current inspection certificates were available relating to the fire alarm and emergency lighting systems. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 X X 2 X Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The statement of purpose must be updated to be accurate and include all information required by Schedule 1. Care plans to be kept up-to-date and reviewed regularly. The person registered must ensure that residents are enabled to engage in age and peer appropriate fulfilling activities. The person registered must ensure that residents are enabled to engage in appropriate social and leisure activities as identified and planned. The person registered must ensure the safety of residents by ensuring that all staff are trained in the protection of vulnerable adults. This refers to evidence of training being available for all staff working with residents. The person registered must ensure the safety of residents by DS0000015548.V316506.R01.S.doc Timescale for action 15/01/07 2. 3. YA6 YA12 15(2)b 16(2)m 17/10/06 17/10/06 4. YA13 16(2)m 17/10/06 5. YA23 13(6) 01/12/06 6. YA24 13(4) 17/10/06 Mountnessing Road (230a) Version 5.2 Page 26 the safe storage of items that could be hazardous to them. 7. YA24 13(4) The person registered must ensure the safety of residents by putting procedures in place, based on risk assessment, to manage the use of the outward opening doors onto areas where residents mobilise on the floor. The person registered must make arrangements to manage infection control in the home. This refers to ensuring all staff are provided with training, including agency staff. (Previous timescales of 15/08/05 01/12/05 and 1/08/06 not evidenced as met). 9. YA33 17(2)Sch4 The roster to show the full name of all staff and the hours to be worked. (Previous timescale of 01/07/05, 03/11/05 and 01/06/06 not met). 10. YA33 18(1)a A review of the staffing levels must be undertaken to ensure that there are adequate staff on duty at all times to meet residents needs, including social and leisure needs. (Previous timescale of 15/07/06 not met) The deployment of staff must also be evidenced as reviewed. Evidence of the review to be sent to the Commission. The person registered must ensure records are available for inspection in line with regulatory requirements. This includes references being in place prior to DS0000015548.V316506.R01.S.doc 01/12/06 8. YA30 13(3) 01/12/06 17/10/06 15/12/06 11. YA34 17 (2) 17/10/06 Mountnessing Road (230a) Version 5.2 Page 27 employment commencing and complete records for all agency staff working in the care home, to be in place prior to their first shift. Previous timescales of 03/11/05 and 01/06/06 not met. Unable to be inspected on this occasion as access to the records was not available. 12. YA35 18 The person registered must ensure that all staff, including agency staff, are provided with training appropriate to the work they are to perform. (Previous timescales of 15/07/05, 01/12/05 and 01/08/06 not met ). This refers to an up-to-date training matrix that includes all relevant training being maintained, and evidence/access to be available for inspection. 13. YA37 9 & 10 The registered persons must demonstrate that they are carrying on the home with sufficient care, competence and skill. This refers to both the internal and external management of the home being shown to be supported, consistent and effective in relation to the issues identified in the requirement section of this, and of previous inspection reports. 14. YA39 24 The person registered must ensure evidence of a quality assurance and monitoring system, which includes all DS0000015548.V316506.R01.S.doc 17/10/06 15/01/07 15/01/07 Mountnessing Road (230a) Version 5.2 Page 28 aspects of the service . Previous timescales from 03/11/05 not met. 15. YA39 26 The person registered must ensure that visits and reports as required by regulation are undertaken monthly and available in the home for inspection . Previous timescale of 01/06/06 not met. 16. YA42 23(4)d The person registered must make arrangements for all staff to have fire training. Evidence to be available for inspection. Previous timescale of 03/11/05 and 0 1/06/06 not met. 17. YA42 17(2) The person registered must ensure the safety of residents by regular monitoring and management of the safety checks according to their own policies/procedures/risk assessment. This refers to the issues identified in the report for example monitoring of the fire alarm system and the hot and cold water with appropriate actions. 17/10/06 17/10/06 17/10/06 Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 29 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 YA1 Good Practice Recommendations The Service User Guide should be updated to include all relevant and current information. Respect should be maintained and evidenced for resident individuality. This refers to the issue around sharing toiletries. Staff should ensure that they actively support residents to make choices in relation to food. A photograph should be maintained on each resident’s medication administration recording record, particularly in light of the number of agency staff that are used in the home. Information on the plan for end of life care should be recorded on each resident file, and advice sought from relatives or advocates as appropriate. Staff should be provided with more awareness of the home’s policy and procedure in relation to complaints and their logging/recording. The whistleblowing policy should be written in plainer language. (This is outstanding from previous inspections ) All staff should be aware of the Estuary’s own, and the local multidisciplinary, guidelines on the protection of vulnerable adults. This includes the whistleblowing policy/procedure. The sensory room should not be used as a storage area. 50 of care staff should undertake NVQ training Staff should receive formal supervision at least six times annually. Outstanding from the last inspection, not considered on Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 30 YA16 3. 4. YA17 YA20 5. YA21 6. YA22 7 8. YA23 YA23 9. 10. 11. YA24 YA32 YA36 this occasion, carried forward to a future inspection. 12. YA42 Clarity should be obtained in relation to the letter from the Fire Authority identified in the report with evidence of appropriate action and compliance. Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Mountnessing Road (230a) DS0000015548.V316506.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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