Inspection on 03/09/07 for 230a Mountnessing Road

This inspection was carried out on 3rd September 2007.

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 17/10/06

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 230a Mountnessing Road 230a Mountnessing Road Billericay Essex CM12 0EH Lead Inspector Mrs Bernadette Little Unannounced Inspection 3rd September 2007 11:15 230a Mountnessing Road DS0000015548.V347315.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 230a Mountnessing Road DS0000015548.V347315.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. 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 230a Mountnessing Road Address 230a Mountnessing Road Billericay Essex CM12 0EH 01277 632914 F/P 01277 632914 yolanda.inciong@estuary.co.uk 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 230a Mountnessing Road DS0000015548.V347315.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. 17th October 2006 Date of last inspection Brief Description of the Service: 230 Mountnessing Road provides 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 four single bedrooms with washbasin. 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 £1,686.10 as advised by the manager at the site visit and confirmed in a resident’s contract. Various additional charges are made for hairdressing and activities in the community, and chiropody, sensory sessions and aromatherapy at home. 230a Mountnessing Road DS0000015548.V347315.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 Rd, and eight hours were spent at the home. Time was spent with the eight residents, observing a mealtime and general routines of the day. Four staff and the manager were spoken with, and the manager was present and assisted for the greater part of the site visit. A tour of the premises was undertaken and records, policies and procedures were sampled. Care records were tracked for one resident and sampled for others for specific issues. Completed surveys were received from five staff prior to the site visit, as were surveys for eight residents that were completed for them by the staff as residents have no verbal communication. Surveys were sent to an independent advocate and relatives of two service users. No responses were received at the time of completing this report. An Annual Quality Assurance Assessment (AQAA) was sent to the home prior to the site visit. While it had not been received by the commission, the manager was able to demonstrate that she had e-mailed it within the requested timescale. It was then sent by Estuary and received on the day after the site visit. Information from the AQAA, all surveys, observations and the discussions with staff at the site visit are reflected in the text of the report. The assistance of all of those at 230 Mountnessing Rd is much appreciated. What the service does well: What has improved since the last inspection? Meetings for residents have begun and this offers a way of thinking about things that are important to residents and having a special time for staff to work with residents to look at these. 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 6 One extra person works at the home most days and this person is often a driver. This means that residents get more chances to go out into the community and to do other interesting things. Some things had been made safer, such as dangerous things like cleaning materials being locked away safely in a cupboard, and this protected residents. Permanent staff had had fire training and there was more are training on safeguarding people given to staff. Checks of the fire system and equipment and water were being done more regularly. These help to keep residents safe. 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. 230a Mountnessing Road DS0000015548.V347315.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 230a Mountnessing Road DS0000015548.V347315.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. People thinking about living at 230 Mountnessing Rd will be provided with information about the home to help them make a decision and will have a full assessment to make sure that the home is the right place for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a statement of purpose and service the user guide in a folder in their room. The service user guide is being prepared in an easy read format supported by coloured photographs. Residents also have an easy read format statement of terms and conditions on their file and for the file sampled, this had been agreed as appropriate by an independent advocate. The contract explains that information on the fees, and what they include, is contained in the service user guide. There have been no new admissions to 230 Mountnessing Rd for some time. Estuary have a detailed policy and procedure on admissions, supported by clear assessments processes that include information from other people. 230a Mountnessing Road DS0000015548.V347315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. People living at 230 Mountnessing Rd can expect to receive good care and support. Their care plans have good detail to help staff to meet their needs in a consistent way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA advises that there is a file record for each resident consisting of risk assessment and care plans, daily and monthly evaluations, six monthly review and health monitoring records, as well as a Person Centred Program and talking book. The care file was made available for inspection for the one resident’s file requested. This contained good information supported by risk assessments in the main. There was good detail to show how the care and support was to be given, which helped with consistency. Care notes were written three times daily which is good practice. There was a monthly overview report and a six monthly review. At the time of the last inspection, staff were required to sign the care plan to confirm they had read it. This was particularly helpful with so many agency staff as a support to consistency of care. This was noted to have stopped some months back and not all staff on duty on the day of the site visit 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 10 had signed to say they read the care plan. The manager advised that she would add this to the list of information for new staff. A personal planning book was later seen for another resident. This was pictorial in format and had good information about the resident’s life and preferences, but was not always realistic or personal to the resident. For example, it stated in one section that the person viewed that they wanted to live in their own home and make more friends and possibly have a girlfriend. The manager confirmed that it was very unlikely that the resident in question would be able to express this verbally or make such a plan. The care plan sampled clearly advised that bed rails were used for the resident. There was no risk assessment in place to support their use. No risk assessment was in place relating to tissue viability, although the person was unable to immobilise independently and spent their time either in their wheelchair or their bed. Staff spoken with confirmed that seven of the eight residents do not have verbal communication on the eighth resident has very little verbal communication. They advised that they try to offer choices to residents and enable them to make decisions where this is possible and interpret their communications. Staff gave an example with food and drinks, for example one resident will move away where another can push your hand away. Residents would then be offered an alternative or be offered again a little later. One resident clearly indicated that they did not want the evening meal. They were asked if they would like, and were offered an alternative of fruit, which the staff knew that they liked. They were later offered a sandwich and drink, which was put on the table for them and which they then chose to go and have. 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. Residents have improved access to fulfilling and interesting opportunities and were provided with appropriate support and a nutritional diet. Residents could be shown more consideration in the planning that affects their daily lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The section on hobbies and interests in the care plan tracked was left blank, and planned activities were to have breakfast in bed, watch TV, listen to music and have time to play in the bath. The care notes for this resident fort the previous week showed a fortnightly sensory session, attendance at an evening social club, and an aromatherapy session. The two previous weeks showed the only activities as aromatherapy and sensory sessions. The whiteboard in the office shows a plan of activities for residents for the coming week, and staff advised that amendments needed to be made to this for this resident. It was recommended that the activities be better planned and spaced as there were to be a large number of activities for the resident in this week. 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 12 Staff spoken with advised that some residents, who were more able, do have access to more activities. It is noted positively that additional staff hours have been provided to support residents to access the community and to have more opportunities for stimulating and interesting activities outside the home, which also provides its own transport for residents. Activities on the whiteboard and discussion with the staff on duty as well as cross-referencing with residents care and financial records and photographs available showed that residents attended activities on a rotational basis such as a mainstream music club on Saturday, a Wednesday social club, day outings, went to the hairdresser, the pub or for meals out. Few residents have regular visitors, but there was evidence that these are welcomed and encouraged. Better respect was shown for residents on this occasion as the practice of each person always being charged a routine amount for toiletries each month, which indicated a practice of shared toiletries or unfair charging, had stopped. Both the lunchtime and evening meal were home cooked foods and looked to be enjoyed by the residents. Liquidised foods were prepared separately so that they looked appetising and retained their flavour to allow residents to make choices. Staff were seen to wear appropriate aprons when preparing food. A four week rotated menu is followed. In addition, nutrition records show that residents are offered regular snacks and drinks as well as main meals and do have variety, for example they are offered tea or coffee or cold drinks. Ample food stocks were seen to be available. Residents were given the opportunity to feed themselves where appropriate. Where a resident needed to be fed, the staff member sat with the person and provided appropriate support. Lunch was being served to the residents at the 11:20am. Staff confirmed that this was to accommodate staff training and it was discussed with the manager that this does not respect residents, and that routine should accommodate them and not the other way round. 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 13 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, 21 Quality in this outcome area is adequate. Resident’s health care needs are met and consistency of their care is supported by the use of the keyworker system. Residents’ privacy and dignity was not always best protected. Residents are not best protected by the homes management of medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents at 230 Mountnessing Rd need support from staff for all their personal care. Rotas and observation indicated that there is always at least one female member of staff on duty. Residents have an allocated key worker that helps with consistency of care. Staff spoken with were aware of residents’ needs, routines and ways of communicating. Staff confirmed that there is enough equipment to help them to support residents well, including hoists and individual slings, assisted baths and showers and also beds that can be varied in height. Information on helping residents with transfers and the equipment they needed was in each persons room, with pictures to help to make the instructions clearer. Bedroom doors were seen to be closed when personal care was being offered which protected peoples’ dignity. A resident was observed to have partly removed their underwear and to be picking at their continence pad. This was 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 14 pointed out to two staff sitting in the lounge but no action was taken, until a specific request was made that staff support the resident to protect their dignity. The care plan looked at had a section for health care. Recent records of professional appointments show contact with the GP and several contacts with an occupational therapist. Medication reviews were also recorded. Records of checks of the person’s weight showed that this was monitored and bowel and epilepsy seizure monitoring forms are also available. Medication is administered only by qualified nursing staff. A sample of the signature and initials of staff deemed competent to administer medication was available. The manager advised that staff are due to have updated medication training/competence assessment but no plans are in place for this currently. Medication was securely stored, and the manager confirmed that no controlled drugs were currently prescribed. Medication Administration Records (MAR) had photographs of residents that helped with identification. The MAR for one resident showed one omission. Taking this and one refusal into account, the medication did not tally with the records and four tablets were unaccounted for. For another of this resident’s medication, two tablets were unaccounted for. Medication audited for another resident showed one tablet could not be accounted for. Guidance was available and had been reviewed for a resident who had medication on an ‘as required’ basis. Information on what will happen to residents at the end of their life was recorded on each persons file sampled. While one resident’s detailed history demonstrates that they are from a Jewish family, their end of life plan shows that they will have a cremation and no rites according to their recorded faith and this was agreed by an independent advocate. The manager advised that the previously appointed social worker had planned to seek information regarding this, but was no longer in post. It was recommended that she discussed this with Estuary to record the reasons behind this decision, as it does not seem to respect the persons diversity. 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 15 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. People who use the service have access to an understandable complaints procedure that ensures that they are listened to. Residents are generally safeguarded by staff knowledge and training but not by the way the home uses their money. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information on making a complaint was displayed in an easy read format in the home and is also in the service user guide. The manager was recommended to clarify the information so that people understood that the commission do not investigate individual complaints but that these could be taken to the local/funding authority if felt appropriate. No complaints have been received by the home or the commission regarding 230 Mountnessing Rd. Guidance was given to the manager on ensuring staff would know how to log a complaint in a confidential manner and the appropriate action to take, especially as agency staff often act as the qualified person in charge of the shift. There has been one safeguarding (previously known as pova) referral made by an outside agency and alleging inappropriate behaviour by staff from 230 Mountnessing Rd. This is currently being investigated. Staff spoken with at the home were aware of what abuse was and what to do to report it. This was confirmed in the staff surveys. All staff, both permanent and agency had records of training on this issue. However, it was identified in the record of resident finances that residents had been charged for a take-away meal, for food while they had been an outings and for activities. This does not comply with Estuary’s own policy, or the information in the residents’ contract and the service user guide. 230a Mountnessing Road DS0000015548.V347315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 30 Quality in this outcome area is good. Residents at 230 Mountnessing Road live in a safe, pleasant, clean and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The communal areas of the home were decorated last year and new carpets curtains and furniture were provided making it a nicer place for residents to be. Some damage has already been sustained to the walls in the dining room and lounge at one end of the building. The sensory room was tidy. Residents rooms had keylocks fitted to the bedroom doors so that they could be locked. They were individually decorated and personalised and had things that related to residents individual interests for example music. Assisted bathrooms were available at both ends of the building. Bins for hazardous wastes were fitted with yellow bags and lids so they reduce the risk of cross infection or odours. The outward opening toilet doors had signs on them now warning people to open them carefully, has previously there was a concern that they could be opened out onto a resident who uses the floor to mobilise. All areas were seen to be clean and safe. 230a Mountnessing Road DS0000015548.V347315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. Residents have enough trained staff to support and meet their needs and the home try to have regular agency staff so they are familiar faces for residents. Residents are not best safeguarded by some of the staff recruitment procedures. Staff are not always given the support they need to help them to do their work. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 230 Mountnessing Rd has had staff vacancies for a long time. This has been more difficult for them recently as two of their permanent staff are currently on suspension. They use agency staff and try to use the same people whenever possible so that they are familiar to and with the residents to support consistency of care. Staffing levels remain at one qualified nurse and three carers all day and one qualified nurse with one carer at night and levels are advised as adequate by the manager and staff. Additionally it was noted positively that, following the requirement from the last inspection, Estuary have reviewed the staffing levels and there is now an additional person on duty for about seven hours a day, five days a week. These hours are normally filled by a person who is also a driver, and so can take residents out more. One rota had the names of permanent staff on and another record had the name of the staff who were on duty each day, but this sometimes only had the agency 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 18 staff’s first name. This is not good practice and there should be a record of the full name of people and the hours they worked at the home. The manager advised that two staff are currently undertaking NVQ level 3, one staff is undertaking NVQ level 4, one is thinking of restarting the training and the others are not interested. Access was readily available to the staff recruitment files on this occasion, however no new permanent staff had been employed since the last inspection. Profiles were requested for the three regular agency staff and individual files were available. One did not contain evidence that references and checks etc had been undertaken and that was no evidence of fire training or a nursing qualification. One file did have information confirming checks, references, training and employment history along with an induction list and a copy of guidelines for new staff. The third member of staff had a profile including information on current training but no photograph to evidence identity and no induction record. A training matrix was not available and some of the information available to the manager was out of date. She confirmed that the training planned at the last inspection had occurred with three staff attending training on Asbergers syndrome, three on communication and four on risk assessment. Inspection of three staff files confirmed that staff have regular annual updates in basic training such as moving and handling, basic first aid, food safety, risk assessment and infection control, which is good practice. There was evidence that staff also attend resident specific training such as epilepsy awareness, managing challenging behaviour, practical communication skills for daily activities and enhancing community experiences and dementia. All staff, both agency and permanent had a record of attending training on protecting vulnerable adults although this had not been updated for all staff within their own timescales. Staff do not have annual appraisals. The files for the three permanent and three agency staff showed that supervision has been provided with on an erratic basis with most files having had only two sessions this year, which does not show that staff are offered regular support. Staff meetings have been held regularly. To assist with communication, a book is completed daily along with the daily handover log with identified sections for recording any occurrences or information that need to be handed over each shift. Sections of Part 2 of the AQAA were not completed and there was no information completed regarding the number of shifts covered by agency staff, nursing staff or staff other than care staff, the ethnicity of staff, the completion of recruitment checks, information on training regarding infection control or information on the most recent update of policies and procedures. 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 19 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, 39, 42 Quality in this outcome area is adequate. People living in 230 Mountnessing Road benefit from living in a home that is reasonably organised, but would be better supported by better awareness and monitoring. The health and safety of individuals living and working in the home is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of 230 Mountnessing Rd is a qualified nurse who has worked at the home for some years. She had evidence of recent training on subjects such as managing challenging behaviour, infection control, safeguarding adults, clinical supervision, health and safety and fire safety. The manager has three supernumerary shifts each week, and also undertakes shifts as part of the care team. Since the last inspection a deputy manager has been appointed which the manager confirmed provides additional support, for example with issues such as supervision. However it was noted that all staff have not had regular supervision. It is disappointing that the management was unaware of Estuarys policy and procedure regarding the use of residents’ money, or the change to residents’ mealtime with lunch at 11.20 until informed by the inspector. 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 20 Improvements are also noted positively to have taken place and several of the requirements from the last inspection have been met. There are however some outstanding requirements that needs to be actioned without delay. The AQAA identifies that there is an “effective quality assurance and monitoring system in place” and that evidence can be seen in the records of regular house meetings, service users meetings, supervisions, the completion of the person centred program for each service user which is shown and discussed with them, and through monitoring of care plans and regular reviews. There is no system in place to gather information from other stakeholders who may be able to offer objective views on the care service provided and this should be considered. Estuary have not regularly undertaken the required monthly monitoring visits to the home that help them to look at whether the home is being run properly. Records of two more recent visits were available, one for March and one for July 2007. The latter of these stated that the records regarding service users money had been checked and considered satisfactory. It has been identified earlier in this report that residents’ money was being used inappropriately in some cases. Records examined relating to Health and Safety were examined and found to be in order. There is an updated Fire Risk Assessment in place and the fire alarm, fire doors, emergency lighting are checked regularly. Regular fire drills are recorded but should include the name of the staff who attended. Current safety inspection certificates were available relating to the gas, electrical fixed wiring, the fire alarm and the emergency lighting. The available certificate regarding the fire equipment was out of date. 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 21 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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 x 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 2 2 X 2 X X 3 X 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 22 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 YA9 Regulation 13(4) Requirement Service users must be protected from unnecessary risks to their health or safety and risk assessments put in place for example relating to tissue viability or the use of bed rails. Service users’ must be treated with respect in the planning of the days routines and the timing of their meals should not be planned around staff training schedules, and residents should be supported to maintain their dignity at all times. Service users must be protected from financial abuse and they must not be charged for items clearly identified in their contract/service user guide as being already included in the cost of their placement at the home. Timescale for action 03/09/07 2. YA16 YA17 YA18 16(2)(i) 12(3) 12(4) a 03/09/07 3. YA23 13(6) 20 03/09/07 4. YA33 17(2)Sch4 So that there is clear evidence of enough and appropriate staff to care for residents, the roster to show the full name of all staff and the hours to be worked. DS0000015548.V347315.R01.S.doc 03/09/07 230a Mountnessing Road Version 5.2 Page 23 (Previous timescale of 01/07/05, 03/11/05, 01/06/06 and 17/10/06 not met). 5. YA34 17 (2) To safeguard residents, records must be maintained in the care home, as required by regulation and schedule to show that all appropriate references and checks on staff are in place prior to employment commencing. This includes having evidence from the agency before the person starts working in the home that they have ensured all references and checks are in place and are appropriate. Previous timescales of 03/11/05 01/06/06 and 17/10/06 not met. 6. YA37 YA39 10(1) 26 To ensure best care outcomes for residents, the manager must ensure they are up to date with current policies and practices in the home. The care outcomes/ conduct of the home generally must be checked monthly and more effectively by Estuary and the record of the visit must be available for inspection. 03/09/07 03/09/07 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 YA12 YA21 Good Practice Recommendations Service users’ opportunities to participate in leisure and other meaningful activities should be better planned and to be spaced out over the monthly planner. Decisions made about service users’ end of life practices DS0000015548.V347315.R01.S.doc Version 5.2 Page 24 230a Mountnessing Road should be explained to show they have been thought about carefully and respect the person’s own situation. 3. YA22 Staff should be provided with more awareness of the home’s policy and procedure in relation to complaints and their logging/recording. (This is outstanding from the last inspection ) The whistleblowing policy should be written in plainer language. (This is outstanding from previous inspections ) Staff should receive formal supervision at least six times annually. (This is outstanding from previous inspections ) 4. 5. YA23 YA36 230a Mountnessing Road DS0000015548.V347315.R01.S.doc Version 5.2 Page 25 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. 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