CARE HOME ADULTS 18-65
25 Beacon Close Gillingham Kent ME8 9AP Lead Inspector
Andrea Leverett Announced 12 September 2005 9.30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 25 Beacon Close Address Gillingham Kent ME8 9AP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 3082900 The Avenues Trust Limited Jane Shoults Care Home 4 Category(ies) of LD Learning Disability - 4 registration, with number of places 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection Brief Description of the Service: 25 Beacon Close is one of a number of homes now managed by Avenues Trust. The home offers 24-hour care for 3 adults with learning disability. It is located in the end of a cul-de-sac within a residential area. There is a local bus route nearby to Rainham town centre is approximately a 15 minute walk away. The home also has its own transport for the of service users. The is a detached premises with accommodation on two floors. There are three single bedrooms,none of which have en-suite facilities. The first floor is accessed via a stairway. The home employes one manager an assistant and care staff. There is one member of staff at night on sleep-in and the organisation has an emergency on-call system. 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection took place on the 12thth Sept 2005. One inspector was in the home and the main focus of the inspection was the general environment and the well being of service users. During the inspection documentation and records were read, including care plans. A tour of the building was undertaken; the residents were spoken to and involved where possible. Time was also spent talking to staff and the management team. Due to the nature and needs of the service users, it was difficult to reliably incorporate accurate reflections of the service from them. Some judgements about quality of life and choices were taken from direct observation on the day, followed by discussion with support staff and evidencing records held at the home. What the service does well: What has improved since the last inspection?
25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 6 The decision- making processes have changed to allow more decisions to be made locally by the manager and staff team. This has enabled the Home to respond to service users needs in a timely manner and has improved quality of life and safety of service users. Service users now benefit from having their own transport, which is unmarked and domestic in character. 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. 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not inspected on this occasion EVIDENCE: 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 Service users benefit from having a care planning system that takes into account their changing needs and wishes with the use of appropriate risk management strategies. EVIDENCE: Records seen and observation and discussion with staff and the manager evidenced that the Home had an effective care planning system in place that was reviewed regularly and involved appropriate specialist health teams. It was also clear that activities and daily routines of the Home were service user led. The staff adopted a range of strategies to establish service users wishes and ensure their opportunity for choice making was maximised. 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 Service users benefit from having access to a range of appropriate activities within their local community. EVIDENCE: Records seen and observation on the day showed that that the Home was very proactive in ensuring access to appropriate educational and leisure activities. The inspector was impressed with the range and frequency of activities which included such things as horse riding, re-bound therapy, adult education classes, lunch out and evening clubs. Although service users have not had a holiday for many years, one has now been booked and the manager informed the inspector that she is confident that these will now be offered on a regular basis. 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 The Home is especially effective in seeking support and working in partnership with specialist health service professionals for the benefit of service users and ensuring that Service users changing needs are met. EVIDENCE: Records showed that service users have access to appropriate routine and specialist health services. Staff and the manager spoke enthusiastically about working in partnership with health services for the benefit of service users and feedback from health care professionals commended the Home in this regard. Care plans included specialist planned interventions, which had been developed with the support of health teams to enable service users to access the community. 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Service users benefit from having an accessible complaints procedure and know that their concerns and complaints will be acted upon. EVIDENCE: The Home has a complaints policy and procedure in place, which includes whistle Blowing. There is a complaints flowchart and a complaints and compliments book. Records showed that the Home has had no complaints in the last 12 months and has had 1 compliment from the health team. It was evident from discussion with the manager that she encouraged and respected the views of other stakeholders and families regarding service users needs and used a range of communication strategies in order to establish service users views. 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,27,29,30 Service users benefit from living in a Home that is clean, and safe, though the quality of the decoration and furnishings could be improved. Service users have appropriate aids and adaptations to maximise their independence. EVIDENCE: A tour of the premises was undertaken including service users bedrooms and the bathroom. The Home was clean and free from offensive odours throughout and on the whole appropriate infection control measures were in place. The freezer is currently sited in the laundry area, which is not appropriate in terms of infection control and a requirement has been made to move it. The home’s health and safety procedure includes monthly inspections of the premises with records kept of outcomes. Maintenance records seen included Gas carbohydrate emissions test and PAT tests. The Home also has an accidents book in place.
25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 14 Service users benefit from having an accessible complaints procedure and know that their concerns and complaints will be acted upon. An Occupational therapy assessment had also been undertaken for 1 service user regarding aids and adaptations in the Home and appropriate mobility aids were in place in order to maximise his independence. All service users benefit from their own room, which have sufficient space to meet their needs. Some bedrooms were in need of decoration and some furniture was old and uncoordinated and a requirement has been made that the Home should be reasonably decorated and furnished throughout. The homes bathroom was also in need of refurbishment. The Home has a through lounge/diner but does not have additional communal space for service users to meet visitors in private or undertake separate activities. This was discussed with the manager and staff and it was agreed that service users would benefit from an additional communal area. Some redecoration has been undertaken and the manager informed the inspector that they are in the process of replacing old stained carpets. It was also noted that 1 service user did not have a carpet in his bedroom and discussion took place regarding the need to assess service users needs in this regard and take action to provide a carpet if appropriate. The fire place in the homes lounge/diner has been partially boarded up using hardboard. It the fire place is not in use the inspector has recommended that this be removed or boarded over professionally. The homes radiators are covered and do not allow heating to be controlled in individual rooms. The need to ensure that this is addressed was discussed and a requirement has been made. 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35,36 Service users benefit from being supported by staff that are appropriately supervised and have the training and skills to meet their needs. EVIDENCE: Discussion with staff and evidence from previous inspections have demonstrated that a range of mandatory and service specific training is provided by the Home. Staff informed the inspector that induction training had been provided by Avenues and a rolling programme of training and refresher training is in place including NVQ’s. It was evident from discussion with and observation off staff and care records seen that they had the knowledge and expertise to meet service users needs. Service users seemed happy and relaxed around staff and indicated to the inspector that they were happy with the care they received. Staff also confirmed that they had regular 6 weekly supervision and were paid to attend staff meetings held monthly. 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,42 Service users benefit from a competent and experienced manager, who ensures that the home is managed in their best interests. The management of the Home could be enhanced by ensuring that the manager is able to complete her management training. EVIDENCE: Records showed that the Home had appropriate risk assessments in place to ensure the safety of service users and the inspector was satisfied that systems were in place to promote and protect their general health and welfare. The manager informed the inspector that she has been unable to complete her management qualification because the training company responsible has gone bankrupt. A requirement has been made that the registered person consider how she will now gain this qualification. She has several years experience of working with this client group in a management capacity. Observation on the
25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 17 day, records viewed and discussion with staff evidenced that the manager delivered an effective client led service. She presented as a motivated and enthusiastic manager and staff felt that she was approachable and inclusive in her management style. 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 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 x x x x x Standard No 22 23
ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 2 x 2 x 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x x Standard No 31 32 33 34 35 36 Score x x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
25 Beacon Close Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 3 x x x 3 x H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 19 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 24 Regulation 23.2(d)& 16.2 (c ) 23.2(p) Timescale for action The registered person must Action plan ensure that all areas of the home by 28th are resonably decorated and October furnished. 2005 The registered person must Action plan ensure that the tempreture of by 28th the radiators can be controlled October individually. 2005 The registered person must ensure that the freezer currently situated in the homes laundry area is re-sited. The registered person must ensure that the stained carpets are replaced or made good. Action plan by 28th October 2005 Requirement 2. 26 3. 30 13.3 4. 24 16.2 5. 26 16.2(c ) 6. 28 23.2(i) 7. 37 9.2(b)(i) Action plan by 28th October 2005 The registered person must Action plan ensure that the home reconsider by 28th the appropriatness of not having October a carpet in the service users 2005 room identified. The registered person is required Action plan to assess service users needs in by 28th terms of aditional communal October space. 2005 The registered person must take Action plan action to ensure that the by 28th manager is able to finish her October Registered Managers Award. 2005
Version 1.40 Page 20 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc 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. Refer to Standard Good Practice Recommendations 25 Beacon Close H56-H06 S64376 25 Beacon Close V240474 120905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent. ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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