Inspection on 24/11/05 for 3 Emily Jackson Close

This inspection was carried out on 24th November 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 no outstanding requirements from the previous inspection report, but made 1 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 16/08/05

3 Emily Jackson Close 08/03/05

3 Emily Jackson Close 19/05/04

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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 Wendy Jones Announced Inspection 24th November 2005 09:30 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 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 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 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. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 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 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) The Avenues Trust Limited Mrs Teirry Dorothy Etheridge Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. People with learning disabilities may also have a physical disability and/or sensory impairment. 16th August 2005 Date of last inspection Brief Description of the Service: 3 Emily Jackson Close is a purpose built bungalow for six service users with a learning disability. It is one of three situated in close proximity to each other that are maintained by Kelsey Housing and managed on a day-to-day basis by The Avenues Trust. It is in a quiet residential area of Sevenoaks within walking distance of the town centre and main line transport systems. There is limited parking on site. There are separate day staff and one waking night staff for each house, with an additional sleep-in member of staff who rotates between the three houses. The building is single storey with six single bedrooms with en suite shower and toilet. All bedrooms have a TV point. There is no emergency call system in the bungalow, except for in the assisted bathroom. There is a lounge and dining room and a small rear garden. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by Wendy Jones, Regulatory Inspector between 9:30am and 12:30pm. Judgements are based on discussions with management and staff, observation, inspection of records and a tour of the building. What the service does well: What has improved since the last inspection? The laundry area now has an alcohol based disinfectant dispenser fitted and procedures are in place to make sure satisfactory standards of hygiene are maintained. Paper towel dispensers have also been fitted in the en suite shower rooms. New staff have been recruited although two full time equivalent vacancies remain and recruitment is continuing. Inventories of service users’ personal possessions have been completed. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 6 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 DS0000023860.V254140.R01.S.doc Version 5.0 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 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 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): These standards were not assessed on this occasion. EVIDENCE: Although procedures are in place, it was not possible to inspect whether these are followed as all service users have lived in the home since it opened ten years ago. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 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, 8 and 9 Service users needs and goals are reflected in their support plans. They are given assistance and supported to take risks and to make decisions about their lives. All participate in life in the home as far as they are able. EVIDENCE: Care plans for three service users were seen. They were comprehensive and took a holistic approach. Details of all areas of service users lives including their likes and dislikes, activities they enjoyed, what they like to eat etc., are well documented from a person centred perspective. Risk assessments covered activities and the environment and were clear and concise. Evidence that outcomes of risk assessments had been put into place was seen. An example was the removal of some furniture and the padding on corners of remaining furniture in the room of a service user who is prone to falling. Daily diaries are kept for each service user where details of the activities they have taken part in, what they have eaten, GP and other appointments and other areas of their day are recorded. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 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 the following standard(s): 11, 12, 14 and 16 Service users have appropriate opportunities for personal development and leisure activities. EVIDENCE: There is a minibus, which is used to take service users out on trips. In addition activities are provided in the home. The manager and service manager explained that a local resource service users enjoyed had been removed. However, they were hopeful that the sensory room and kitchen in this facility would soon be available again. Two service users like music and particularly enjoy it when the ‘music man’ visits on Thursday afternoons. There is also a range of other activities that provide stimulation for service users. Staffing levels have been increased since the last inspection and the home is continuing its recruitment drive to fill all vacancies and ensure a full programme of activities continue to be available for service users to take part in. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 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 the following standard(s): 18, 19 and 20 Service users personal, physical and emotional health needs are met and they are protected by the way the home deals with their medicines. EVIDENCE: Details of each service users’ personal, physical and emotional health needs are recorded in their care plans. Details of referrals to appropriate professionals and other health appointments are also recorded. A special bath aid for one service user had been recommended after referral to an occupational therapist. This has been purchased and staff are waiting for instructions from the OT on how to use it. No service users are able to administer their own medication. A medication file was seen that contained medication risk assessments and details of PRN medication that service users have been prescribed. The local pharmacy delivers medication and the Nomad system is used. Medication records had been accurately recorded and medication was stored appropriately and safely in a locked metal cupboard. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 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 the following standard(s): 23 Service users are generally protected from abuse, neglect and self-harm. EVIDENCE: Staff are aware of what to do if a potential adult protection issue is identified. A recent incident where a service user had been admitted to hospital with a dislocated left shoulder had been reported to both the adult protection coordinator for social services and the CSCI. The actions recommended following the investigation have been complied with. The agency that had provided the member of staff involved in the incident is no longer being used and a sign has been put up showing that this service user must have two members of staff for manual handling. However, the inspector was very concerned that two members of staff are not always available. There is only one waking member of staff on duty at night and the second, sleep-in, covers all three homes on the site. The manager and service manager were both equally as concerned and are endeavouring to obtain funding to increase staffing levels at night. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 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 the following standard(s): 24, 25, 26, 27, 28, 29 and 30 Service users live in a safe, reasonably well-maintained and clean environment, which meets their needs and lifestyles and promotes their independence. EVIDENCE: The home was clean and free from offensive odours on the day of the inspection. The dining room and communal areas have been redecorated recently and were light and airy. The manager explained that the Community Learning Disability Team had been involved and advised them on colours that would best suit the needs of the service users. Service users’ bedrooms have been decorated to their tastes and contain their personal possessions etc. All bedrooms have en suite shower facilities, which have now been fitted with paper towel dispensers as recommended at the last inspection. However, it was noted that the paper on the walls was beginning to peel and there was mould around the edges of the flooring, which could potentially be a health and hygiene risk for the service users. It is recommended that the en suites are redecorated to remove this risk. The service manager explained that a request has been made to Kelsey Housing for 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 14 these bathrooms to be refurbished and they are hopeful that the work will be carried out soon. There is also one communal bathroom that has been fitted with an Arjo Rhapsody bath and other bath aids. There is a curtain around the bath for privacy when service users use it. Service users have the use of a lounge that is comfortably furnished and has a TV, video, DVD and music centre. The kitchen is due to be refurbished as part of the ongoing maintenance schedule for the home. It contains a cooker, microwave, dishwasher, fridge freezer and was clean and tidy. The laundry is small and does not have room for a hand basin. An alcohol based disinfectant dispenser has been installed and procedures have been put in place to prevent cross infection as required by the Environmental Health Officer. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users are supported by a competent and qualified team and are protected by the home’s recruitment procedures. However, two service users are at risk as two members of staff may not always be available to undertake their care. EVIDENCE: A senior support worker and three support workers were on duty at the time of the inspection, which was appropriate to meet the needs of the service users at this time. The manager and service manager were also in attendance. Staffing rosters were seen. These showed that there is only one waking member of staff on duty at night. A second, sleep-in member of staff rotates between the three houses on the site. This raises real concern as two service users have been identified as needing two members of staff to undertake their care, including manual handling. In addition, one of these service users was the subject of an adult protection investigation after they had been admitted to hospital with a dislocated shoulder. This investigation had identified that two members of staff must always carry out manual handling for this service user. Both the manager and service manager were also very concerned about this situation. The service manager explained that risk assessments carried out by themselves and other professionals had also identified that two service users require two members of staff to be available at all times to meet their needs. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 16 She added that an application had been made to the funding authority for an increase in staffing to two waking staff at night. However, to date this has not been agreed. As two members of staff are not available at night service users’ health and safety is being put at risk. Staffing levels must be increased to a minimum of one waking and one, dedicated, sleep-in member of staff each night. The manager explained that two new members of staff had been taken on recently, but vacancies for two full time equivalent members of staff remain and recruitment is continuing. Staff were clear about their roles and responsibilities and how to meet the needs of the service users. Staff records were seen for three members of staff. These contained evidence that a thorough recruitment process had been followed and appropriate checks made. Hard copies of documents are kept in the Head Office of The Avenues Trust and are available for inspection on request. There is a performance management system in place and objectives and training plans were seen along with assessments and reviews that had been carried out during the year. A training file was seen that contained details and certificates of attendance for training that staff had undertaken. This linked with training plans seen and the needs of the service users. The service manager explained that the company sets a training plan up each year based on the training needs identified from the performance management process. In addition, inductions are run every six weeks to ensure that new staff receive this training as soon as possible and within six weeks of starting work. Supervision records were seen that showed that staff are supervised once a month. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40, 41, 42 and 43 Service users live in a well run home that is managed by a competent and qualified manager. Their rights and best interests are safeguarded and their health, safety and welfare is promoted and protected. EVIDENCE: The manager is qualified to NVQ level 4 in Management and has achieved the Registered Managers’ Award. A health care professional who has contact with the home commented that they were satisfied with the overall care provided to service users and had not received any complaints about the home. Comments received from service users’ relatives and visitors were all positive and all stated they were satisfied with the care provided. Comments included “we are welcomed by all the staff” and their relative “is in such a happy home and so well cared for”. Discussions with management, records seen and staff observed working in the home showed that the home is run with the best interests of the service users in mind. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 18 Records now contain inventories of service users’ personal possessions as required at the last inspection. All records are kept securely in the manager’s office. The home’s registration certificate is displayed in the entrance hall and a current insurance certificate is on the wall in the manager’s office. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 19 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 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3 Emily Jackson Close Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 3 3 DS0000023860.V254140.R01.S.doc Version 5.0 Page 20 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 YA33 Regulation 18(1)(a) Requirement Two members of staff must be working at the care home at all times to ensure the health and welfare of service users. This requirement follows on from a requirement set previously with a timescale of 22 December 2005 Timescale for action 22/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations It is recommended that en suites are redecorated to remove the risk to service users’ health any hygiene. 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 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. Extracts may not be used or reproduced without the express permission of CSCI 3 Emily Jackson Close DS0000023860.V254140.R01.S.doc Version 5.0 Page 22 - 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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