Inspection on 17/01/07 for 35 Beaconsfield Avenue

This inspection was carried out on 17th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

35 Beaconsfield Avenue 08/02/08

35 Beaconsfield Avenue 13/02/06

35 Beaconsfield Avenue 24/10/05

35 Beaconsfield Avenue 07/01/05

35 Beaconsfield Avenue 13/07/04

35 Beaconsfield Avenue 01/12/03

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33 St John`s Church Road

Dovedale Court

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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 35 Beaconsfield Avenue Dover Kent CT16 1LS Lead Inspector Kim Rogers Key Unannounced Inspection 17th January 2007 12:30 35 Beaconsfield Avenue DS0000023167.V312733.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 35 Beaconsfield Avenue DS0000023167.V312733.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. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 35 Beaconsfield Avenue Address Dover Kent CT16 1LS 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) 01304 206448 01304 206448 The Robinia Care Group Ltd Mrs Yvette Hanlon Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 People with a learning disability. 18 to 65 years. Date of last inspection 13th February 2006 Brief Description of the Service: 35 Beaconsfield Avenue is a large terraced property located in a residential road in Dover town centre. This home provides personal care and support to 3 service users between 18 and 65 years who have a learning disability. The house has been sympathetically maintained and is in keeping with surrounding domestic residential properties. It is within walking distance of local shops, and leisure facilities. The accommodation is laid out over three floors, and provides three single resident bedrooms, a staff sleep-in room, lounge, laundry/smoking room, kitchen diner and a small courtyard garden is located to the rear of the property. Limited street parking is available. The accommodation is domestic in character and this is reflected in the decoration and furnishings of the home, which are of good quality. The property is unsuitable for any service user with significant mobility problems. The home is run by Robinia Care and the fee for living at 35 Beaconsfield Avenue ranges between £87,239 and £89,012 per year (about £1,692 a week) For further information about fees and what the fee includes please contact the Provider. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key site visit was unannounced and carried out by one inspector over about 4 hours. The manager, Ms. Yvette Hanlon, service users and staff assisted in the process. Three people currently live at the home, and all gave some feedback. People were coming and going in and out of the house and were doing activities with the staff and independently during the visit. A service user showed the inspector around the home, and with permission, some bedrooms were seen. The inspector spent time with service users, spoke to and observed staff and interviewed and observed the manager. Service users said ‘I like it here because it is quiet’ ‘We all work together as a team’ ‘We all get on’ All service users have a key to their room and the front door and take part in the daily chores of the home. Some work was done before the visit including talking to and surveying care managers and service users. The manager supplied a pre inspection questionnaire, with details of domestic checks and various other data about the home. A selection of records about service users, and some other documents such as staff files were sampled. What the service does well: Relationships are well supported. Service users have opportunities to access a range of community facilities and a variety of activities. Hobbies and interests are well supported. The home is clean and very homelike. Service users have free access to all parts of the home. The manager and staff are long standing and experienced. A person centred pathway has been developed for one service user to support their personal goals. Service users, with staff support, are completing individual health action plans. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 6 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. 35 Beaconsfield Avenue DS0000023167.V312733.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 35 Beaconsfield Avenue DS0000023167.V312733.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area for service users is adequate. This judgement has been made using available evidence including a visit to the service. Service users cannot be sure of the conditions of their stay. Service users cannot be sure their needs and aspirations will be assessed. EVIDENCE: The home has a service user guide, which has recently been reviewed. The manager said that some of the information in the guide was incorrect and some was not included, for example the fee. The manager agreed to amend this before completing with and distributing to service users. One service user moved into the home less than a year ago. However, there was no pre admission assessment for this person or any other service user at the home. This meant some important information about service users was missing from their service user plans. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area for service users is adequate. This judgement has been made using available evidence including a visit to the service. Service users cannot be sure all their personal goals will be supported. Risk taking is generally supported. Service users are supported to make decisions about their lives. EVIDENCE: Each service user has a service user plan. After reading these you do not get a feel for who the person is, where they are from and what life they want. Service users spoke about their hopes and dreams for the future but these have not all been recorded or planned for. Service user plans talk of ‘area of difficulty’ and ‘treatment plan’. Service users would benefit from having support plans with a focus on self-development. The manager said that all plans are being reviewed to be more person centred. The manager and team leader have worked with a service user to develop a visual pathway to support a personal goal. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 10 Risk assessments are in place and showed regular review. In one service user plan sampled it was evident the service user had been involved in the review. Some areas of independence have been increased. Some service users want more independence in some areas, for example getting a job, and this should be assessed and supported. Service users said they attend their review meetings, which are usually held at the home or head office. Choice and decision making is well supported in some areas like daily programmes, food and cooking, holidays and socialisation. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area for service users is good. This judgement has been made using available evidence including a visit to the service. Service users have opportunities to access community facilities and appropriate activities. Relationships are well supported. Service users rights and responsibilities are respected. Service users take part in planning and preparing meals and are offered a healthy diet. EVIDENCE: Service users have opportunities to take part in a range of activities at home and in the community. Service users told the inspector about a variety of community-based facilities accessed like colleges, shops, pubs, clubs and cafes and about recent holidays. Staff have use of a company vehicle to enable 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 12 easier access to community facilities or service users use pubic transport. Each person has an individual activity planner, which includes evenings and weekends. One person said they would like more 1-1 ‘talking time’ The team leader and manager agreed to include this on the weekly planner. Service users said they visit their friends regularly and have friends over to dinner. Service users said they have support to keep in touch with their families. Service users are able to invite family and friends to their review meetings. Service users take part in planning and preparing meals. Service users said they make their own breakfast and lunch and take turns to have staff support to cook the evening meal. Service users said they take part in going to the local supermarket and local shops for groceries. Since the last inspection, service users have all been given a front door key, which has increased independence and ownership. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area for service users is good. This judgement has been made using available evidence including a visit to the service. Service users personal and health care needs are met. Medication practice is safe and service users are supported to have control over their medication. EVIDENCE: Service users require minimal support with personal care. In one service user plan sampled there was no mention of personal care needs. The recording of needs and strategies to develop more independence in personal care could be improved. Service users said they don’t mind sharing one bathroom and are looking forward to using the new shower. A start has been made on completing individual health action plans. Service users are being supported to complete these. Service users are supported to access range of health care advice and support. Following individual assessments service users now have their own medication and medication records in their bedrooms. Medication is safe and secure. At present staff have the keys to the medication cupboards. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 14 A service user said ‘it is better now I have my tablets in my room’ Records relating to medication were in good order. The manager has introduced a competency assessment to check staff who administer medication. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area for service users is good. This judgement has been made using available evidence including a visit to the service. Service users are confident their complaints will be listened to and acted on. Service users feel protected and safe. EVIDENCE: The home has an adult protection and whistle blowing policy. Staff attend training in safeguarding vulnerable adults and said that further training is planned. Service users said they feel safe. Staff currently have control over service users personal allowance which is kept in locked tins in a locked cupboard. This means service users have to ask staff when they want some money. The potential for giving service users more control over their personal allowance was discussed with the manager and team leader who agreed to review this. Individual records of income and expenditure are kept and regular checks were apparent. Service users said they are being supported to increase their money awareness skills. The home has a complaints policy and records any complaints. Service users said they would talk to staff if they were not happy about something and are confident that staff would act on their views. A service user said ‘staff would sort it out’ There have been no complaints since the last inspection. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 16 Problem behaviours have been supported positively. A service user told the inspector about past problem behaviours that staff have supported them to overcome by teaching coping skills. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area for service users is good. This judgement has been made using available evidence including a visit to the service. Service users live in a clean, well-maintained home. Service users are happy with their bedrooms. EVIDENCE: A service user showed the inspector around the home, which is well maintained and homelike. Service users said they are happy with their rooms but one person said they would like to be able to see out of their bedroom window. The manager agreed to remove the frosted film on this window. Furniture is comfortable and of good quality. A service user said ‘I’ve got a lovely room’ Service users said bathroom and toilet facilities are sufficient and the home is always clean. Service users take responsibility for cleaning their own rooms and have the support they need to do their laundry. A service user said ‘we work as a team’ Staff have access to maintenance man who carries out minor repairs when necessary. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 18 Service users have control over their home and have front door and bedroom door keys. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area for service users is good. This judgement has been made using available evidence including a visit to the service. Staff and some service users have mandatory training but would benefit from training in person centred planning. Recruitment checks are sufficient but service users are not fully involved in the recruitment of staff. Supervision of staff is carried out and could be improved by including observations. EVIDENCE: The organisation has a training manager. Courses can be accessed through the training manager. Courses currently have an emphasis on mandatory training rather than values. Most staff are not trained in person centred planning or person centred active support although most have an NVQ qualification. The manager said the organisation has recognised this and is seeking to address it. Staff induction is in line with the standard. Some service users have attended some mandatory training courses. A staff file was sampled. Recruitment checks are carried out before a person starts in post. Short listing and interviews are carried out at head office. The 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 20 manager said service users meet new staff when they attend a trial day after passing the interview process but are not fully involved in the selection process. Service users confirmed this. This could be improved. Staff files were in order and well organised. Good records of supervision and appraisal were included. The manager said that observation is not part of the supervision and appraisal process but will consider including this in the future. Staff were observed supporting people positively giving encouragement and praise appropriately. Staff spoke with knowledge and understanding of service users needs. Service users were observed being at ease with staff. Staff are deployed around service users needs and work alone or in pairs. Most of the staff are long standing and experienced. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 21 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): 37,39,42 Quality in this outcome area for service users is good. This judgement has been made using available evidence including a visit to the service. The home is well run but lacks effective monitoring and audit. A quality assurance system needs to be developed to ensure service users views underpin the review and improvement of the home. Service users health and safety is protected. EVIDENCE: The manager has worked for Robinia and has been a home manager for several years. The manager has a City and Guilds qualification in management and a Registered Managers Award, which is a combined National Vocational Qualification level 4 in care, and management. The manager said the organisation intends managers to complete a qualification relating to learning disabilities in the future. The inspector observed the manager to be approachable and positive in interactions with 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 22 staff and service users. The manager is also the registered manager of another Robinia home. The lack of effective monitoring and audit systems means that the home is not demonstrating improvement and development, as it should be. Service users said they have weekly meetings chaired by staff and put ideas and suggestions forward. This was evident in the minutes but no action plan was in place to implement and support these ideas and suggestions. The quality assurance system, based on service users and stakeholder’s views, needs to be improved and implemented. The pre inspection questionnaire supplied by the manager shows that health and safety checks are carried out, as they should be. The manager said the home’s fire risk assessment has been reviewed following recent changes to legislation. The record of accidents and incidents was seen. All had been recorded and reported appropriately. 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 23 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 2 2 1 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 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X 35 Beaconsfield Avenue DS0000023167.V312733.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation 14 Requirement Assessments must be carried out and include a person’s aspirations. These assessments must be kept at the home. Standards 6, 7, 9, 18. Consult with service users (through person centred plans) and improve service users opportunity for independence and fulfilment. Ensure all personal gaols are identified and supported. Improve quality assurance processes (in line with minimum standard) seeking and taking note of the service users views and opinions. Timescale for action 31/03/07 2 YA6 12,16 30/06/07 3 YA39 24 30/06/07 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 Review the type of special window covering in a service users bedroom so the person can see out. DS0000023167.V312733.R01.S.doc Version 5.2 Page 25 35 Beaconsfield Avenue 2 3 4 5 YA36 YA34 YA37 YA1 Include an element of observation in the supervision and appraisal system. Ensure that service users have the support they need to be fully involved in the recruitment of staff. Service users would benefit if staff had person centred planning and active support training. The service user guide should have the right information including the fee and what it includes. 35 Beaconsfield Avenue DS0000023167.V312733.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: 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 35 Beaconsfield Avenue DS0000023167.V312733.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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