Inspection on 03/11/05 for 230a Mountnessing Road

This inspection was carried out on 3rd November 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 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 9 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 17/10/06

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 - 3rd November 2005 10:00 Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 1 10:00 Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 2 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.V264038.R01.S.doc Version 5.0 Page 3 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.V264038.R01.S.doc Version 5.0 Page 4 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.V264038.R01.S.doc Version 5.0 Page 5 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. 2nd June 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. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection undertaken over a six and a half hour period, on a Thursday afternoon. This was the second routine inspection of 230 Mountnessing Road in this inspection year. The standards not covered at this inspection were considered during the last inspection. All parts of the premises were looked at as were records and documents. Time was spent with the seven residents and seven staff, talking to them about, and looking at, ordinary everyday life at 230 Mountnessing Rd. The help that staff and residents gave was much appreciated. What the service does well: What has improved since the last inspection? What they could do better: The person who owns the home needs to look at the list of things to do at the end of this report. Some of the things havent been done since previous reports and they must now make sure that all the right records are in the home all the time. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 7 They must also make sure that staff can show that they have had all the training that they should have to do their job at 230 Mountnessing Road. 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. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 8 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.V264038.R01.S.doc Version 5.0 Page 9 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): 1,3 The homes documents provided prospective residents with ample information to help to make a choice about living at the home. EVIDENCE: The Statement of Purpose and Service User Guide provided information on the admission criteria for 230 Mountnessing Road, as well as the services and facilities offered. They also identified the training and experience that staff had so that prospective residents and their supporters could identify if the home was the right place to meet their specific needs and wishes. It would be appropriate if all staff were to refresh themselves on the home’s statement of purpose and service user guide. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 10 Care plans were generally to a satisfactory standard. They still needed some development to ensure consistent care for residents. Staff had a clear view on maintaining information appropriately to protect residents’ right to privacy EVIDENCE: Care plans generally provided clear details for staff to follow and were supported by risk assessment. The areas identified for development at the last inspection, for example in relation to epilepsy, had not been included. A care plan had not been updated to identify recent family involvement, despite recent review of the care plan. Advice was provided to staff, who were open and interested in improving the quality of the care plans. Start also gave practical examples of how residents were supported to take every day decisions to the best of their ability. The home had a policy and procedure on client confidentiality and access to files and staff demonstrated awareness of appropriate actions. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 11 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, 16, 17 Residents were supported to take part in a range of activities that were individually appropriate. EVIDENCE: Records showed that residents did take part in age appropriate activities along with their peers. One resident explained that they had been dog racing the evening before and had a meal out. Staff advised that two other residents also enjoyed this event one resident is to be taken to a football match as this is a particular interest for that person. Three residents went out with staff during the inspection on a planned shopping trip and meal out. Observation of practice and discussion with staff indicated that residents rights were respected. The nutrition record identified where residents had specific dietary needs. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 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, 20, 21 Personal support was offered in a way that respected residents’ privacy and dignity. EVIDENCE: Residents were seen to be offered personal care in private and doors were closed to ensure dignity. Staff confirmed that they had received appropriate training to support residents with transfers and new hoisting equipment had recently been provided. All residents also had to personal slings appropriate to their individual needs and sizes. The home operated a clear key worker system to assist with continuity of support. Staff demonstrated an awareness of residents’ individual support needs The protocol for PRN {as required} medication had been updated, but only by the manager, with no input from the resident’s consultant. Files indicated that resident supporters had been involved in planning for and dealing with growing older and death of the resident. Where there were no supporters the manager had made choices along with the key worker but there was no evidence that the independent advocate had been involved as planned. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Staff knowledge and training protected residents as did clearer information for staff on how to use residents money. EVIDENCE: Permanent and agency staff confirmed appropriate training in relation to protection of vulnerable adults, and were able to describe appropriate actions. A member of staff had recently reported what they considered to be inappropriate practice. Estuary had responded promptly and appropriately and the issue is being investigated with the support of appropriate agencies. The sampled records of resident expenditure demonstrated that residents were no longer being charged for shared toiletries wipes etc. The records available covered a limited time period, but were supported by numbered receipts. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 230 Mountnessing Road provided adequate space and equipment for residents. The home was not well decorated to a standard that provided pleasant surroundings for residents. EVIDENCE: Residents’ bedrooms continued to be personalised and individually decorated and to meet their needs and lifestyles. Communal areas were in poorer decorative condition. Paint swatches were seen on the wall and staff confirmed that colours has now been chosen and that all communal areas were to be decorated. The portable heaters, labelled with residents’ names and seen at the last inspection to be in the wrong rooms, continued to be in the same position. Areas of the home continued to need better cleaning and this was particularly noted again in the laundry. It was noted positively that the label asking that the washing machine not be used as anything higher than 50° had been removed. The agency staff member in charge of the home did not know what the home’s practice was in relation to the washing temperatures of wet/soiled linen. Staff records again did not indicate that staff had had any recent training on infection control. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 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 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): 31, 32, 33, 34, 35, 36 The continued use of agency staff, even those used on a regular basis, did not offer the best opportunities for consistency for both staff and residents. The stability of the permanent staff team provided some balance for residents. The home’s recruitment practices did not best protect residents. EVIDENCE: All permanent staff files sampled contained a clear job description. Staff spoken with were clear on their roles and responsibilities. Staff spoken with felt that some agency staff were a real asset while others did not get involved with actual hands on work with the residents. Staff spoken with confirmed that no staff were undertaking NVQ training. The four staff training records sampled did not evidence recent fire/health and safety training, but did show that many other basic mandatory training courses had been completed and updated. The training profile did not evidence issues identified at the last inspection as service uses specific training needs, for example, epilepsy. Staff spoken with confirmed that the current staffing level of one qualified nurse and three care staff on each day shift and one qualified nurses and one care staff at night was adequate to meet the needs of the residents. The roster again did not contain the full name of all staff and hours worked. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 16 Staff recruitment files were inspected for two recent and one long serving member of staff. One of the newer applications indicated that written references had been taken up after the person started working at the home, the date of this hadnt been taken from the contract of employment. Despite previous written responses from Estuary, there were no staff records available for any agency staff member at the home and no evidence confirming that appropriate checks and references had been undertaken. The agency staff on duty did not have evidence of their training and there were no records available in the home in relation to agency staff training. These issues have been raised with Estuary on previous occasions and must be addressed. It is noted positively that there had been more frequent supervision on the staff files sampled. It was noted that there had been limited discussion on individual training needs in the more recent supervision notes. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 17 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, 38, 41, 42, 43 230 Mountnessing Rd presented as an organised home with a management style that was approachable to both staff and residents. Policies, procedures and the home’s record keeping systems mainly protected residents. Some aspects of the home’s fire safety practices did not best protect residents. EVIDENCE: The manager was on annual leave the time of this inspection. Staff reported an open and supportive management style. Corporate policies and procedures were provided by Estuary, and staff spoken with had an awareness of these. The majority of records sampled were of a satisfactory standard unless otherwise stated previously in this report. Additionally the rota needs to identify the full name of all staff. Fire doors continued to be wedged open to allow residents access around the home. They were not fitted with magnetic door closures to protect residents in the event of emergency. Current certificated of liability insurance was displayed. There was no evidence to suggest that the home was anything other than financially viable. Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X X 2 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mountnessing Road (230a) Score 3 X 2 2 Standard No 37 38 39 40 41 42 43 Score X 3 2 3 3 2 3 DS0000015548.V264038.R01.S.doc Version 5.0 Page 19 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 YA6 Regulation 15(1) Requirement Timescale for action 01/12/05 2. YA24 3. YA30 4. YA33 5 YA34 A care plan to be in place for each resident that shows how all areas of their health and welfare is to be met and be kept up-todate to reflect changes (Previous timescale of 15/07/05 not met) 23(2)d The person registered must keep all parts of the home clean and reasonably decorated. (Previous timescale of 15/07/05 not met). 13(3) 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 timescale of 15/08/05 not met). 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 not met). 17(2) The person registered must ensure records are available for inspection in line with regulatory requirements. This includes references being in place prior to employment commencing and complete records for all agency staff working in the care home, to be in place prior to their first DS0000015548.V264038.R01.S.doc 01/12/05 01/01/06 03/11/05 03/11/05 Mountnessing Road (230a) Version 5.0 Page 20 shift 6. YA35 18 The person registered must ensure that all staff are provided with training appropriate to the work they are to perform. (Previous timescale of 15/07/05 not met). The person registered must ensure evidence of a quality assurance and monitoring system, which includes all aspects of the service. ( this is a requirement from the last inspection not assessed on this occasion. It will be carried forward to a future inspection). The person registered must make arrangements for all staff to have fire training ( Previous timescale of 15/08/05 not met). Evidence to be available for inspection. The person registered must ensure that the requirements set out on the fire authority certificate are implemented. These include break glass units and magnetic door closures. (Previous timescales of 20.12.04 and 01/07/05 not met ). 01/12/05 7. YA39 24 03/11/05 8. YA42 23(4)d 03/11/05 12. YA42 23(4)a 03/11/05 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 YA20 YA21 Good Practice Recommendations Review of protocols for as required medications should be supported by the relevant health care professional. An independent advocate should be accessed where possible to assist in ascertaining the residents plan of care for end of life wishes and needs DS0000015548.V264038.R01.S.doc Version 5.0 Page 21 Mountnessing Road (230a) 3. YA23 4. YA32 The whistleblowing policy should be written in plainer language.(This is carried over from the last inspection) A copy of the multidisciplinary guidelines on the protection of vulnerable adults should be available in the home and known to all staff. 50 of care staff should undertake NVQ training Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mountnessing Road (230a) DS0000015548.V264038.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!