Inspection on 31/07/07 for 3 Emily Jackson Close

This inspection was carried out on 31st July 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

3 Emily Jackson Close 24/11/05

3 Emily Jackson Close 16/08/05

3 Emily Jackson Close 08/03/05

3 Emily Jackson Close 19/05/04

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 3 Emily Jackson Close Eardley Road Sevenoaks Kent TN13 1XH Lead Inspector Geoff Senior Key Unannounced Inspection 31st July 2007 10:00 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 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) glebe.house@theavenuestrust.co.uk The Avenues Trust Limited Mrs Terry Dorothy Etheridge Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. People with learning disabilities may also have a physical disability and/or sensory impairment. The home is restricted to care for one person with a learning disability who is over the age of 65 years whose date of birth is 16/06/1935. 26th July 2006 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, who may have physical or sensory impairments. One service user is over 65 years of age. It is one of three situated in close proximity to each other that are maintained by Kelsey Housing Association and managed on a day-to-day basis by The Avenues Trust Ltd. 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 two waking night staff for this house. 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. The home’s current scale of fees are £1253.27. Additional charges include: Hairdressing £10-£25, Toiletries Varies, Magazines-Varies, Holidays individual, Transport 15p per mile. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit undertaken on 31st July 2007 between 10 am and 4pm. Discussions were held with management and support workers and, to a more limited degree, with the service users. Judgements were based in conversations, direct observations and reference to documentation. Additional information was gained from telephone discussion with service user parents after the visit and from the Quality Assurance Assessment completed by the management. Not all the NMS were inspected at this visit. Key standards were looked at and one recommendation was made. This relates to staffing. The findings are contained in the text of the report. What the service does well: What has improved since the last inspection? The management and staff team look to innovate and further develop the service. Active support has increased involvement and levels of engagement. The home has responded positively to the findings of the last report, Issues identified have been fully addressed or are in the development planning. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. Service users can be confident that their individual needs and aspirations are assessed, monitored and addressed. Prospective service users can be confident that their admission to the home would be based on thorough assessment and informed choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All six service users have lived together in the home since its opening in 1995. As there have been no new admissions this area was not fully assessed. It was reported however that The Avenues Trust has clear procedures to follow when vacancies occur. These include formal assessments, trial visits and involvement of those already living at the home. The assessments and information gathered during visits form the basis of the care support plan and guidance for the staff. The home consults and has a good working relationship with the appropriate specialist services for their clients. There are indications that the changing 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 9 needs of individuals are catered for, including the acquisition of equipment and modifications to improve safety and access in and around the house. Staff have access to training to ensure they can adequately support the service user needs and communicate appropriately with them. Comments from relatives include positive statements in praise of the staff sensitivity to service user needs and persistence in supporting involvement and inclusion in all aspects of daily life. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. Person centred care plans, risk assessments and guidelines offer detailed information to ensure support staff consistently meet the individual health and social care needs of those living here and to track the care provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The content and detail provided within the service users’ files informs and enables new and existing staff to understand and effectively support the needs of service users, and help them work towards achieving identified goals. Daily diaries and separate activity records are kept for each person and note the completion or otherwise of support tasks identified in care plans. Photographic, pictorial and object referencing is used to aid communication and better understanding between service users and staff. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 11 In-house care reviews take place regularly. Service users over the age of 65 years have their care plans reviewed monthly. Service users were observed interacting comfortably with staff on matters relating to their general activity and health care. Staff were seen to be positive and supportive in response. Service users are helped to communicate their preferences, ideas and concerns individually to staff as group meetings would not to be effective. Risks are viewed positively by the home and assessments are undertaken in order that service users can participate in activities with the appropriate level of support and supervision or are helped to understand why limitations may be placed on their lifestyle. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,17. Quality in this outcome area is good. The quality of care for service users is enhanced because the home provides a range of therapeutic and leisure activities based on personal needs, wishes and interests. Service users can feel confident that their families and friends are welcome to visit the home and contact with the local community is well maintained. Service users benefit from being given meals that offer choice and variety and cater for special dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A structured but flexible routine has been established in the home whereby service users can participate in a range of in-house and community based 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 13 activities. It was reported that the recruitment of additional drivers for the minibus and the acquisition of four powered chairs has greatly increased accessibility to the town and other venues. ‘Person centred active support’ is being positively promoted in the home and various adaptations have been made to enable participation and involvement for all at some level. Discussion with family members confirmed that they are welcome to visit at anytime. Home visits are facilitated. Staff keep in touch with relatives by phone to up-date any significant developments. Relatives are also invited to attend and contribute to reviews. Very positive comments were received regarding the care and service offered to their sons/daughters. Mealtimes are at a pace that respects the dietary needs and level of assistance required by the individual service users. Staff are aware of individual likes, dislikes and preferences and cater accordingly. In the spirit of active participation meals are planned and prepared with the involvement of service users. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. Service users’ health, social and personal care needs are well supported with regular contact with specialists and external professionals. The Service users are treated with genuine respect and dignity by care staff and are protected by robust medication procedures This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are treated with dignity and respect and levels of privacy are maintained. All of the service users require assistance with aspects of personal hygiene and care. The organisation ensures that staff are instructed and supervised to provide this thoughtfully and sensitively. Each service user has a health action plan for recording, monitoring and communicating matters relating to the individual. It was reported that the 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 15 home has developed positive relationships with the local healthcare professionals who provide a good level of support. Additional equipment and facilities are assessed and provided where service users have had changing levels of need. Each has an en-suite shower or choice of bath or spa bath. All staff involved in the handling and administration of medication are trained and are subject to an annual assessment and top up training. The home uses a Monitored Dose System of medication. Storage is adequate for the needs of the home and records were clear and up to date. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. Systems are in place to enable those living and those visiting the home to raise concerns or complaints with staff and people they trust. Protection from abuse is promoted through staff training and understanding of the support and actions they may need to take This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints procedure both in written and audio formats. Due to the nature of the service and those living here, using this system is limited. It is evident that the majority would be heavily reliant on a relative/ advocate/staff to identify concerns and raise them on their behalf. Feedback from relatives indicated an awareness of the procedure and an assurance that they would be comfortable raising concerns with the management if need be. The home’s records indicate they have not had any formal complaints. The home does hold a compliment book with a number of positive entries. Staff spoken with indicated a good understanding of how to protect the vulnerable and prevent abuse, including reporting under local procedures. There are no current Adult Protection alerts regarding this home. Due to disabilities experienced by the service users, adaptations, bedsides and 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 17 brackets are used to support service users in bed. Full assessment of such restraint is undertaken within multi disciplinary process to ensure restraint is use in the best interest of the service user and their well being. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. Service users live in a clean, comfortable and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a purpose built bungalow, well presented, and bright, with adequate internal space and equipment for those requiring full physical care. The dining room and communal areas are light and airy. There are good standards of hygiene and cleanliness. Not all rooms were seen at this visit, as service users were resting or not present to give their approval. It was reported however that individual bedrooms have been decorated to the needs and tastes of the occupant. All 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 19 bedrooms have en suite shower facilities. It was noted at the last inspection visit that En-suites are in serious need of redecoration. Redecoration and repair is part of the ongoing development plan and, whilst some areas have been attended to, some still require attention. One of the shower rooms is to have floor covering replaced in the near future. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is adequate. Service users can be confident that the home maintains an adequate level of staff to safely support them. The care of service users is enhanced because there is a good staff induction and development programme for new and established permanent staff. Service users would benefit from a stable staff team established through continued positive recruitment to the vacant positions and NVQ training This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was confirmed that written references are sought and all staff are CRB and POVA checked prior to commencement of duties. Further to observations noted at the last inspection the management has endeavoured to recruit staff to 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 21 permanent positions and address the issue of drivers for the minibus. This has had some success but a number of vacancies remain. Bank and agency staff cover the shortfalls. They are inducted and supported and offered supervision in the same way as permanent staff as well as attending house meetings. The manager needs to ensure that, due to complex needs of the service users and H&S requirements when moving and lifting, the staffing levels at all times are such that the opportunities for choice are not compromised. (e.g. Day activities and choice of bedtime). Avenues offer staff a good development programme. There is a comprehensive induction process that all staff are supported to work through. Staff receive regular role specific and statutory training updates throughout their employment. It was reported that currently, one of the staff supporting service users has attained NVQ Level 4; one has a Level 3, one has Level 2. Three are working towards Level 2. This ratio does not meet the expectations of the National Minimum Standards but the Management is aware and encourages new staff to apply as soon as they have completed their probationary period. 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. The home is well managed resulting in a caring and supportive service that promotes the health, safety and welfare of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is currently on sick leave. The continuing management of the home is undertaken by the deputy Ms Fox and a staff team described by one of the relatives as ‘Alpha Plus’. An open and positive ethos has been fostered in the home enabling staff, relatives and service users to feel involved in and to feedback about the service. Relatives spoken with after the visit confirmed that the management 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 23 and staff ensure that they are kept up to date with progress and developments. Monthly monitoring visits are carried out by senior managers to the home. These ensure that the standard of care and relevant documentation is maintained and that the premises are in good order. The health, safety and welfare of the service users, staff and visitors to the home are well maintained in all areas. Staff receive the necessary induction and training into the service, supported by a range of policies and procedures which are reviewed and updated as required 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 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 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 25 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 Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA35 Good Practice Recommendations The ratio of NVQ qualified staff should at least meet the expectations of the NMS 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 3 Emily Jackson Close DS0000023860.V345739.R01.S.doc Version 5.2 Page 27 - 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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