Inspection on 07/03/06 for 26a Sussex Avenue

This inspection was carried out on 7th March 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

26a Sussex Avenue 04/01/10

26a Sussex Avenue 20/09/07

26a Sussex Avenue 08/11/06

26a Sussex Avenue 14/01/05

26a Sussex Avenue 20/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 26a Sussex Avenue 26a Sussex Avenue Canterbury Kent CT1 1RT Lead Inspector Alex Turner Announced Inspection 7th March 2006 09:30 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 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 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 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. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 26a Sussex Avenue Address 26a Sussex Avenue Canterbury Kent CT1 1RT 01227 768845 01227 478896 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) MCCH Society Limited Mrs Janet Rita Castle Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: The Home is purpose built and has some minor adaptations and alterations to meet the requirements of a residential care home catering for people with physical difficulties. The Home is currently registered to accommodate ten residents. The Home is effectively two similarly constructed units that are joined together providing residents with a wide range of facilities. There are ten bedrooms for the residents’ use arranged on one floor. All of the facilities are accessible to persons using wheelchairs. The Home is well equipped with apparatus to assist with all the residents needs. There are good communal facilities and the Home benefits from a reasonable front garden and a secluded patio area that provides residents an opportunity to pursue leisure and social activities or horticultural hobbies. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced. All of the key inspection standards applicable to the operation of the home at the time of this inspection have been rated. The report relating to the previous inspection, conducted in October was not available hence it was impossible to reliably determine and follow up any issues that may have been raised following that visit to the home. The findings included in this report have been informed by the following sources of information; pre inspection comment cards completed by two relatives and eight people who were living in the home, informal time with staff and people living in the home at lunch time, general observations made throughout the visit, private discussion with one member of care staff, time spent speaking with the registered manager, and from the inspection of a selection of records and documents relating to care provision. What the service does well: What has improved since the last inspection? What they could do better: The service could do better to ensure that where the registered manager acts as an appointee the records of financial transactions are independently audited. The service should do more to arrange for alternative physiotherapy input in the absence of provision from the local Primary Care Trust. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 6 Storage of substances hazardous to health must improve. Storage solutions in general should be reviewed. The registered provider could do better to ensure that the manager and care staff working in the home attain the qualifications specified in these standards. 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. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 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 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standard was not assessed as all of the people living in the home have done so for a number of years. EVIDENCE: . 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People living in the home benefit from practice that recognises need; from a service that formulates plans and acts to meet these needs and one which takes into account and manages risk. EVIDENCE: The home has developed with each person living in the home care plans that addressed individual assessed needs. Care plans covered a very wide range of activities touching upon most if not all areas of day-to-day living. Many of the care plans inspected had been reviewed in the month preceding the inspection and four months before that. A key working system is in operation. Where it was identified there was a risk of behaviour that may cause harm care plans detailed individualised procedures. These plans focussed on minimising risk and preventing such incidences occurring by means of clear communication and understanding of behaviours. Practice observed during this inspection indicated that staff took time and effort to create and respect choices made by the people living in the home. Areas where it was apparent that choices were being made included for example times to get up, go to bed, what to eat, what to wear and what activities were undertaken. Arrangements have been made for people living in 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 10 the home to access local advocacy services and to maintain contact with and benefit from the input from their friends and relatives. Records documenting care reviews evidenced that people living in the home and their advocates / relatives where involved in the process. It was ascertained that the manager acts as an appointee for one of the people living in the home. Records were being kept of financial transactions and receipts kept there was no arrangements in place for these records to be independently monitored and audited. The requirement to make such arrangements has been made. It was evident from what was taking place at the time of this visit and in the records inspected that people living in the home were being supported to partake in activities that they were interested in. Procedures to consider and manage any risk inherent in activities undertaken were in place. Risks were being assessed and management strategies formulated; both were subject to review on a routine and on an as and when required basis. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 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): 12, 13, 15, 16 & 17. People living in the home benefit from a service that values their potential and works to create possibilities for involvement in the community be that be through education, employment or leisure services and facilities, each according to individuals wishes and preferences. The service values and promotes links with families and friends of people living in the home in line with individuals’ wishes. People living in the home benefit from good quality dietary provision. EVIDENCE: It was evident by the activities planned and those that were being supported during this visit that people living in the home were able to pursue and develop interests and pastimes. Five clear examples were found where arrangements had been made people living in the home to attending clubs and resource centres in the local community. Arrangements had been made and these were evident during this inspection of input from community volunteers to support people living in the home to have trips out and benefit from local services and facilities. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 12 The service has a positive attitude to and values the contribution that friends and families can make to their lives of people living in the home. Arrangements are routinely made and put into action to support people living in the home to maintain contact with their families. A number of examples of this were found for example visitors to the home being encouraged and welcomed and by supporting people living in the home to stay with their families at the weekends. It was clear from speaking with staff, looking through records and observing practice that efforts were being made to preserve and promote the rights of people living in the home to maintain and develop what levels of independence they had. This for example was seen to be through the creation of choices with regards to activities of daily living and respecting the choices that were subsequently made. Another example was the apparent routine practice of respecting the privacy of people living in the home for example by delivering personal care in private and by ensuring sensitive information about them was kept private. On many occasions throughout this visit staff were seen to be engaging directly with the people living in the home. Staff were seen to involve the people living in the home in discussion and routine activities that were taking place. Catering in the home is well managed. A cook / housekeeper is employed during the week with staff cooking at weekends. Menus are prepared with the people living in the home on a weekly basis. Likes, dislikes and dietary needs had been identified and were being catered for. Menus illustrated that there is plenty of variety and that a balanced diet is being promoted. Opportunities to help out in the kitchen and with the shopping were reported by staff to be often given to those who had an interest in this area of domestic living. Looking through records it was apparent that though nutritional needs were being assessed, reviewed and where the need was identified professional advice was sought regarding diet there was little to evidence that weight was being regularly monitored. The registered manager agreed that this was the case and spoke of the reasons why and of what action had been taken to address the issue. People living in the home who need help to eat were being assisted appropriately during this visit. It was noted that choices expressed regarding when, where and what they eat were provided for. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The service provides personal support, health care and manages medication in a manner that promotes and protects service users health and welfare. EVIDENCE: Given the needs of many of the people living in the home the lack of regular input from a suitably qualified physiotherapist was considered to be a shortfall in service provision. It was recognised that the service relies on the provision external to the home however given that the need for ongoing physiotherapy has been identified by the home itself more should be done to make alternative arrangements. The provision of personal care in the home aimed to protect and maintain the privacy, dignity and involvement of those to whom it was provided. Links with community health care services have been established and people living in the home have been supported to access and use these services in line with their needs. This was illustrated in records inspected and confirmed in discussion with the manager of the home. Medication was being managed in a manner that was in line with protecting and promoting the health and welfare of people living in the home. Staff were clear about the procedures and were seen to be following these in practice. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 14 Medication administration records were inspected; no anomalies or omissions were identified. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People living in the home are protected by safe care practice and clear written procedures in relation to complaints and adult protection. EVIDENCE: Written policies and procedures are in place that covering complaints and protecting adults from harm. The manager has reported that there have been no complaints or allegations of abuse made in the last twelve months. Two relatives of people living in the home completed pre inspection questionnaires and both indicated that they knew how to make a complaint if they needed to. One of the relatives indicated that they had once made a complaint and that it was resolved promptly and satisfactorily. Eight comment cards were received back from people living in the home. In all instances comments were made that indicated the people completing them had someone in and away from the home who they could talk to if they felt unhappy, sad or fed up. All of the comment cards completed confirmed that the person completing each one felt safe and were looked after and well cared for by staff in the home. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The physical size, design and layout of the home are commensurate with the statement of purpose and meeting the needs of the people who live there. More care was needed in relation to maintaining a safe and homely environment. The home was clean. EVIDENCE: Time was taken to look around the home with the registered manager. The size and design of the home was commensurate with the statement of purpose. One of the lounges had recently been decorated. The manager stated that wall hangings and such were soon to be reinstated. Bedrooms were personalised, equipped and furnished to suit the occupants needs and preferences. The carpets in some of the communal areas and bedrooms were marked, stained and appeared to be wearing very thin. The manager stated that replacements were being budgeted for. There were a significant number of incontinence pads stored openly in a number of areas around the home. This detracted somewhat from the notion of a homely environment. Stored in one of the laundry room cupboards were oil, engine cleaner, flammable liquids and other substances hazardous to health. The risk was highlighted and the manager took immediate action to remove these substances to a more suitable storage facility. The manager stated that there was an intention to build an external store and this may offer a solution to both of these problems. It was 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 17 noted that on a number of items of equipment there was a record to indicate that the equipment was regularly serviced and checked by specialist contractors. The home was clean and free from offensive odours. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 The service has organised induction and ongoing training for all staff. A team of staff whose suitability is ensured by the homes recruitment process supports people living in the home. EVIDENCE: Records inspected included those that indicated staff training is planned and delivered with reference to the statement of purpose and the needs of the people living in the home. The manager has provided information to the Commission confirming that close to 34 of staff have attained the National Vocational Qualification specified in the standard. Recruitment records were not available for inspection. The manager described the recruitment process as involving the checks required by the standards and regulations. The manager asserted that people living in the home are supported to contribute to the interview process. When asked how gaps in employment were checked the manager stated that the registered providers personnel department undertook this. The rating of standard met is given based on the manager’s integrity in relation to the procedures they described. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 43 The home is well run by competent and accountable management. EVIDENCE: The registered manager has been in post for approximately four years. It was confirmed that training to attain suitable care and management qualifications had been arranged though the qualifications had yet to be achieved. The overall findings in this report indicate that the home is being well run though the lack of both care and management qualifications is considered a major shortfall given the time that they have been in post. It should be noted that this rating is not indicative of any proven shortcomings in relation to the manager’s practice, competence or experience rather it is related to the lack of adequate arrangements to support them to attain the qualifications specified in this standard. The manager was clear about their remit and scope of responsibilities and accountability. With regard to day-to-day service provision the manager is supported by and operates within the context of the registered providers wider organisational structure. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 N/A 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 1 X X X X X 3 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA7 Regulation 13 Requirement Where the registered manager is an appointed agent of a person living in the home arrangements shall be made for the records of all incoming and outgoing payments to be independently audited. The registered manager shall ensure that people living in the home receive additional, specialist support and advice as needed from physiotherapists. The registered manager shall ensure that substances hazardous to health are stored in compliance with the Control of Substances Hazardous to Health Regulations (COSHH) 1999. The registered provider shall inform the Commission of the measures that will be taken to ensure that 50 of care staff attains the qualifications specified in standard 32. The registered provider shall give written notice to the Commission of the measures that will be taken to ensure that the Registered Manager attains the qualifications specified in DS0000023717.V274305.R01.S.doc Timescale for action 28/05/06 2. YA19 12 28/06/06 3. YA24 13 06/03/06 4. YA32 18 28/04/06 5. YA37 10 28/04/06 26a Sussex Avenue Version 5.1 Page 22 standard 37 and the anticipated completion date of training to do so. 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 YA24 Good Practice Recommendations The registered manager should consider alternative means of storing incontinence pads in areas other than where they may be openly seen. 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 26a Sussex Avenue DS0000023717.V274305.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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