Inspection on 16/08/05 for 3 Emily Jackson Close

This inspection was carried out on 16th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Emily Jackson Close 31/07/07

3 Emily Jackson Close 24/11/05

3 Emily Jackson Close 08/03/05

3 Emily Jackson Close 19/05/04

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Southfields

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

CARE HOME ADULTS 18-65 3 Emily Jackson Close Eardley Road Sevenoaks Kent TN13 1XH Lead Inspector Paul Stibbons Unannounced 16 August 2005 09:30 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. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 3 Emily Jackson Close Address Eardley Road Sevenoaks Kent TN13 1XH 01732 465703 01732 465703 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) The Avenues Trust Limited Mrs Teirry Dorothy Etheridge CRH Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. People with learning disabilities may also have a physical disability and/or sensory impairment. Date of last inspection 08 March 2005 Brief Description of the Service: The home was purpose built for six service users with a learning disability. The home is one of three situated within close proximity to each other. The establishment is maintained by Hyde Housing and managed on a day to day basis by The Avenues Trust. Each house maintains independent day staff and at present employs one waking night staff per house, with an additional sleeping in member of staff who rotates between the three houses. The building is single storey and consists of single bedrooms with en-suite shower and wc facilities. All bedrooms have a TV point. Apart from the assisted bathroom the home does not have an emergency call system. Day space consists of a lounge and dining room. There is a small rear garden. The home is situated in a quiet residential area within walking distance of Sevenoaks town centre and main line transport systems. There is limited parking on site. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulatory inspector Paul Stibbons carried out this unannounced inspection. The home’s manager and service manager were present. The manager gave feedback on the requirements and recommendations from the previous inspection. A tour of the building was undertaken and a number of records were inspected. Due to the disabilities of some service users some judgements about quality of life is through direct observation and discussions with two members of staff who were on duty. What the service does well: What has improved since the last inspection? The WTE for the home has been raised to 14 and consideration is being given to making the rotating sleep night into a waking night. The home’s manager has developed an internal quality assurance system. All staff have completed training on adult protection. The home has acquired electric wheelchairs making access to the local community easier; the home is located in a hilly area. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 Stage 4.doc Version 1.40 Page 6 Seniors giving supervision to team members have the appropriate experience. 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. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 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 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 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) 3, 4 The home can meet the needs of the service users through the individual and collective skills of the staff team and the input of specialist services. EVIDENCE: Care plans viewed evidenced input from occupational and physiotherapists when developing individual care support plans. One service user was returning to the home from hospital after sustaining an injury. The manager stated that she had arranged for relevant specialists to re-assess the service user’s requirements the following morning. The manager has previously stated that the service user group had remained stable for a number of years, however in the event of a new service user applying for residency a phased admission process takes place with an initial introductory visit and a trial period of a minimum of three months. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 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) 7, 9, 10 Service users are provided with visual information to respect their rights to make decisions within their capability. The home’s policies and procedures uphold service users’ rights to confidentiality. EVIDENCE: Service users’ ability to make day-to-day decisions is restricted by their profound learning disabilities. Staff were observed to encourage service users to make some decisions by using visual objects of reference. One service user has recently purchased a garden swing chair with their own money. The manager stated that the service user’s family assisted them in making the decision to purchase. Where able, service users have the freedom to move around the house. One service user was observed to be wearing headgear whilst moving about the house. The manager explained that under a risk assessment the headgear was to protect the client who is prone to falls. Some unnecessary furniture had been removed from their room for the same reason. Staff members receive training on confidentiality during induction and information was seen to be securely stored in the manager’s office. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 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) 13, 14, 17 The home has an appropriately equipped minibus enabling access to the local community for service users. A timetable of in-house activities provides opportunities for stimulation and development for service users. Service users are provided with a varied and nutritional diet. EVIDENCE: Service users visit the town centre and this activity has been made easier by the acquisition of electric wheelchairs for service users. Activities within the home provide stimulation for service users and daily reports evidence service user involvement. An increase in staffing levels would increase opportunities for service users. The menus viewed showed variety and a healthy and balanced diet. The community dietician has provided guidance in particular for one service user with additional needs. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 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) 19, 21 Service users’ health care needs are monitored and fully met by referral to relevant specialists. Relatives and service users are consulted to ensure their wishes are met in the event of illness and death. EVIDENCE: Service user physical and emotional health needs are monitored through the individual care plans and referred to relevant professionals where appropriate. One service user recently admitted to Kent and Sussex Hospital and diagnosed with dislocation of left shoulder and chest infection. Service user returned home on day of inspection and a re-assessment of their needs is arranged. This injury has been reported to CSCI and is currently under investigation by the AP team. Action to be taken following the death of a service user is recorded in their individual care plans. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 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, 23 Service users can be confident their views are listened to and acted on. Service users are protected from abuse by the home’s policies and procedures. EVIDENCE: Complaint of pain by one service user was responded to by the staff team contacting the district nurse and then the GP on four separate occasions to resolve their health needs. All staff members have received training on adult protection policy and procedure. Recent action confirms procedure activated by reporting of incident to CSCI and Adult Protection team for investigation. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 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, 26, 27,28,29,30 Service users live in a safe, well-maintained and clean environment. All bedrooms are single with en-suite facilities that are equipped to meet all their needs and afford privacy. Service users benefit from adequate communal space with handrails throughout and specialist equipment is provided. EVIDENCE: All areas of the home are well maintained and bedrooms are personalised to reflect individual lifestyles. Service users’ bedrooms all have en-suite facilities with appropriate aids to meet their needs. There is not a hand drying facility for staff in the en-suites and it is a recommendation that a paper towel dispenser or other means is installed. In addition to en-suites there is an assisted bathroom; wheelchairs and commodes are provided to promote service users’ independence. The laundry room is restrictive in size and there is insufficient room to install a hand basin. Following consultation with the EHO it is a requirement to install a “Hibiscrub” dispenser with adequate procedures to prevent cross infection. On the day of inspection it was noted that the home was clean and free of offensive odours. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 Stage 4.doc Version 1.40 Page 14 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) 32, 33, 35 Appropriately trained staff that are competent and qualified meets Service users’ individual and joint needs. Unfilled staff vacancies restrict opportunities for service users. EVIDENCE: The Avenues Trust places emphasis on staff training through induction and other relevant courses to meet individual service user needs. Two members of staff spoken with felt the training met their needs to effectively fulfil their roles and responsibilities. Seven of nine team members hold NVQ level 2 or above and one other is on a waiting list. Further recruitment of staff is required to minimise impact on the existing team and service users. The manager states that recruitment is ongoing but difficult in the local area. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 Stage 4.doc Version 1.40 Page 15 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, 41, 42 Service users’ rights and best interests are protected by the home’s policies and procedures under the leadership of a competent and qualified manager. EVIDENCE: The home’s manager is qualified in NVQ level 4 management and Registered managers award. NVQ4 in Care starting September 2005. Team members stated that they found the manager to be approachable and 100 supportive. The service users’ health, safety and welfare is protected by the quality assurance system the home’s manager has developed. Inventories of service users’ personal possessions do not contain sufficient detail to provide a clear audit trail. It is a requirement that these records are reviewed and updated. Reg 26 inspections are undertaken on a monthly basis by the area service manager and details submitted to the Commission. Safe working practices are promoted through staff training within a risk assessed framework and specialist input where relevant. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 Stage 4.doc Version 1.40 Page 16 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 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 x x 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x 3 2 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3 Emily Jackson Close Score x 3 x 3 Standard No 37 38 39 40 41 42 43 Score 3 x x x 2 3 x H56-H06 S23860 3 Emily Jackson V242506 160805 Stage 4.doc Version 1.40 Page 17 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 YA30 Regulation 16(2)(j) Requirement Make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. In this context an antimicrobial solution dispenser in the laundry area as recommended by the EHO. Adequate numbers of staff employed to meet the needs of service users. Previous timescale was 30 April 2005 Service users inventories of personal possessions must be completed to provide a clear audit trail of acquisition/disposal dates. Timescale for action By 25 October 2005 2. YA33 18(1)(a) By 22 December 2005 By 25 November 2005 3. YA41 17(2) Schedule 4 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 YA30 Good Practice Recommendations It is strongly recommended that paper towel dispensers or other means of drying hands for staff are installed in all areas providing personal care. 3 Emily Jackson Close H56-H06 S23860 3 Emily Jackson V242506 160805 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent TN16 9NT 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. 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