Inspection on 09/09/05 for 3 Hainault Avenue

This inspection was carried out on 9th September 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Hainault Avenue 30/05/07

3 Hainault Avenue 02/01/06

3 Hainault Avenue 06/03/05

3 Hainault Avenue 24/08/04

3 Hainault Avenue 23/03/04

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

CARE HOME ADULTS 18-65 Hainault Avenue (3) 3 Hainault Avenue Rochford Essex SS4 1UH Lead Inspector Mrs Bernadette Little Unannounced Inspection 9th September 2005 01:15 Hainault Avenue (3) DS0000018076.V249011.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 Hainault Avenue (3) DS0000018076.V249011.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. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hainault Avenue (3) Address 3 Hainault Avenue Rochford Essex SS4 1UH 01702 545753 01702 545753 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) Estuary Housing Association Limited Mr John Long Care Home 1 Category(ies) of Learning disability (1) registration, with number of places Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2005 Brief Description of the Service: 3 Hainault Ave is a two-bedroom bungalow situated in a quiet residential area. Hainault Avenue provides one-to-one care for a service user who has a learning disability. The second bedroom is used as an office/ sleeping in room. The property is owned and managed by Estuary Housing Association. Shops and local amenities are within walking distance of the premises. The home has its own vehicle available to provide transport for accessing day centres and other leisure activities. The bungalow was furnished and decorated in a homely style. There is a large lounge and dining area. The conservatory leads out into the enclosed garden and was being used as a run for the rabbit. Parking is available to the front of the property. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection that took place over a four hour period on a Friday afternoon. Three staff, including the registered manager were spoken with and assisted with the inspection, as did the resident. A tour of the premises was undertaken and time was spent looking at records and documents. What the service does well: What has improved since the last inspection? 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. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 6 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 Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 7 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): 1,2,3,4,5 Hainault Avenue offered a good level of information to people thinking of using the homes’ services. Estuary’s described assessment process protected residents. EVIDENCE: The current resident had lived at 3 Hainault Avenue for a number of years. A copy of the statement of purpose and a service user guide were readily available on the resident’s file. The home’s policy and procedure on admission, and the information in their statement of purpose and service user guide, confirmed a thorough preadmission assessment process to ensure that the home can meet the needs of the resident. The documents also stated that introductory visits would be offered to the prospective resident, and a minimum three-month settling in period would be followed by a formal review of the placement. A pictorial format contract was also on the file, this had been signed by the resident and had a recent date. Information needed to be available regarding the additional charges to be paid by residents. This could be maintained as a separate record or included in the contract and the service user guide. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 8 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, 9, 10 The care management documentation was well organised and provided staff with appropriate information to manage the persons care needs. EVIDENCE: The care plan was detailed and provided clear information on how to meet the resident’s needs. Care notes were written both day and night and supported the plan of care. The care plan was supported by a range of risk assessments that considered the resident’s rights and abilities. There was evidence of monthly reviews. A recent change to the resident’s night-time plan had not been recorded in the care plan but was in the report book. This needed to be included in the care plan. Consideration was also needed as to whether this was an infringement of rights that needed to be recorded. Staff spoken with demonstrated appropriate respect for residents’ confidences. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 9 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, 13, 14, 15, 17 The home provided the resident with good support to access to a range of activities both at home and in the community. The maintenance of relationships with both family and friends was well supported by the staff. EVIDENCE: Records showed that there is a detailed plan of activities for the resident on a daily basis. This included involvement in the community in leisure and social activities as well as opportunity to attend a day resource centre twice weekly. Discussion with the resident confirmed that they went horse riding, to church and also did things at home that they liked, for example sewing and writing. The staff assisted the resident to visit their family on a regular basis. Records also evidenced that the resident was encouraged and supported to build friendships. The resident confirmed that they liked the food and were involved in the shopping each week. The resident made coffee for everyone during the inspection. The record of food served showed choices, including the occasional take-away meal and consideration for nutritional intake. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 10 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, 21 Personal support was offered in a way that suited the resident’s needs. EVIDENCE: Staff at Hainault Avenue did not need to offer assistance with any intimate personal care, and the resident was independent in getting up, washing etc. They did however provide support with issues such as choosing appropriate clothing and this was documented in the care plan. Records confirmed appropriate support to access all primary health care services. The registered manager advised of a previous conversation regarding the wishes for end of life practices. The resident’s advised view was not noted in their care plan. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 11 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 The homes complaints procedure had been written in pictorial format to support resident understanding. Staff had been provided with training and had an understanding of adult protection issues that safeguarded residents. EVIDENCE: A copy of the complaints procedure was on the resident’s file and a copy was displayed in the office. This was in pictorial format to be easier to understand. The registered manager stated that no complaints had been received by the home since the last inspection. The three members of permanent staff spoken with confirmed that they had had training on the protection of vulnerable adults, the manager advising that his had been earlier that week. Staff were aware of Estuary’s policy and procedure on this matter and also on the whistleblowing policy. One staff stated that they did not find the whistleblowing policy an easy document to read. All staff spoken with were aware of the correct procedures to follow and expressed confidence in reporting any concerns. A policy and procedure on physical intervention was also available. Not all staff had had to training and management of behaviour that challenges and a risk assessment on this issue may need to be considered. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 12 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, 30 The premises provided the resident with a homely living environment that met their needs. EVIDENCE: The premises was seen to be well maintained and decorated. It was comfortably furnished, clean and odour free. There was ample living space in the lounge/diner and separate kitchen. There was a conservatory which did not have any furniture but which was used for the pet rabbit. The resident also had the use of the garden. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 13 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, 33, 35, 36 The staffing levels, training and stability of the staff team provided the consistency to meet the residents needs. EVIDENCE: 3 Hainault Ave headed three permanent staff who had worked with the resident for some time. They were supported by two bank/agency staff who were also stated to know the resident and his needs well. All three permanent staff spoken with confirmed that the staffing levels were appropriate. The registered manager was undertaking NVQ level 4, one staff advised that they had just completed NVQ three and the third member of staff is currently undertaking this. Training files were available for four staff, with no file being available for one of the bank staff. The registered manager was advised that next of kin details and contact numbers needed to be available for all staff. The files inspected indicated that staff had been provided with mandatory training as well as service uses specific training. Supervision records were seen to be available, including those for one of the bank/agency staff. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 14 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, 43 3 Hainault Ave presented as well organised and run in the best interests of the resident. Additional attention to some records could enhance this more effectively. EVIDENCE: The registered manager has worked at the home for several years. He has had appropriate training and is currently undertaking NVQ level 4 in Care and Management. Staff spoken with confirmed that the manager is easy to approach and his supportive. Policies and procedures requested were readily available and known to staff. There were corporate and regularly reviewed. In addition to those identified throughout the report the accident records, visitors record and display of the registration certificate met requirements. The registered person had not regularly sent copies of the monthly reports on the home to the commission has required. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 15 Appropriate records were kept of the resident’s finances. It was noted that the resident had recently been charged for a take-away meal which did not comply with Estuary’s policy. The records show that a camcorder had been purchased by/for the resident that was not recorded on his record of personal possessions. This was amended at the time of the inspection. A range of safety inspection certificates and health and safety checks were sampled and met requirements, with the exception of the water. A risk assessment regarding legionella was in place. Records demonstrated that the home’s practice in relation to regular checks did not meet it’s requirements. Current certificate of liability insurance was displayed. There was no evidence to suggest that the home is anything but a financially viable. Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 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 3 3 3 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hainault Avenue (3) Score 3 3 X 2 Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 2 2 3 DS0000018076.V249011.R01.S.doc Version 5.0 Page 17 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(2) Requirement The service users plan must be kept reviewed and updated as changes occur. A record must be kept of any limitations agreed with the service user as to their freedom of choice and power to make decisions. A record must be kept in the care home of all people employed and to include the detail required by the schedule. The person registered must undertake monthly monitoring visits to the home and the copies of the report to the commission for social care inspection as required by this regulation. The person registered must maintain a record of the care homes charges to the service user including any extra amounts payable. This refers additionally to the resident being charged for take-away meals. A record must be kept of the residents possessions and DS0000018076.V249011.R01.S.doc Timescale for action 01/10/05 2 YA9 Schedule 3 (3)q 01/10/05 3 YA35 Schedule 4(6) 01/10/05 4 YA41 26 01/10/05 5 YA41 Schedule 4(8) 01/10/05 6 YA41 Schedule 4 01/10/05 Hainault Avenue (3) Version 5.0 Page 18 7 YA42 13(4) valuables that the home assisted to look after. This refers to the camcorder and any other such item The person registered must 01/10/05 ensure the safety of service uses at all times and ensure that water temperatures are tested regularly in accordance with their risk assessment relating to legionella 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 2 3 Refer to Standard YA21 YA23 YA23 Good Practice Recommendations The registered manager should include information in the client care file if information is known regarding his wishes for the end of life It is recommended that the whistleblowing procedure be developed to include a more user-friendly format It is recommended that a risk assessment be undertaken to ascertain whether all staff need to have training in the management of behaviour that challenges Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Hainault Avenue (3) DS0000018076.V249011.R01.S.doc Version 5.0 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!