Inspection on 24/10/05 for 35 Beaconsfield Avenue

This inspection was carried out on 24th October 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 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

35 Beaconsfield Avenue 08/02/08

35 Beaconsfield Avenue 17/01/07

35 Beaconsfield Avenue 13/02/06

35 Beaconsfield Avenue 07/01/05

35 Beaconsfield Avenue 13/07/04

35 Beaconsfield Avenue 01/12/03

Similar services:

Insight - Eastchurch

Southfields

Thorndene

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 35 Beaconsfield Avenue 35 Beaconsfield Avenue Dover Kent CT16 1LS Lead Inspector Julie Sumner Unannounced 24/10/05 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 35 Beaconsfield Avenue Address 35 Beaconsfield Avenue, Dover, Kent CT16 1LS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01304 206448 01304 206448 Robinia Care South East Ltd Mrs Yvette Hanlon Registered Care Home 3 Category(ies) of Learning Disability registration, with number of places 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 07/01/05 Brief Description of the Service: 35 Beaconsfield Road is a large terraced property located in a residential road in Dover town centre. 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 offers a service to learning disabled adults who have additional complex needs, and require long term support, staffing is provided on a 2:3 basis throughout the day with a sleep in staff member at all times, additional staffing is available if needed and will reflect the level of support and supervision required. This is a female household. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out during one afternoon in October. The home was clean, fresh and welcoming. All the service users were in the home carrying out their usual activities. They all participated in the inspection, very ably saying what they like about living at 35 Beaconsfield Avenue and how they like to spend their time. All comments received were positive. The home has won an award within the company for “most improved home” and one of the carers won “best carer”, staff and service users were very proud of this. The home has made good progress with the recommendations made from the previous inspection. The following methods of inspection and information gathering were used: One-to-one and group discussion with service users and staff, observing activity in the home, touring the home and reading and discussing policies, plans and records including individual service user plans, medication charts, complaints logs, quality assurance reports, some staff records including training records and duty rota. What the service does well: The ethos in 35 Beaconsfield Avenue is that this is the service users’ home and staff are there to support them with their lifestyle. There is a good supportive philosophy to maintain and develop independence skills. Service users explained how they were supported and about their hobbies, interests and college courses. Service users enjoying going out and meeting their friends and were getting ready to go to a Halloween party in the evening, arranged by one of the clubs they regularly attend. Service users said they have “wonderful Christmas’s”, “wonderful staff” and “wonderful birthdays”. Service users are very clear about what to do in case of fire as they have practiced in fire drills and had the procedures and consequences explained to them. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 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 H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Not inspected at this time. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 Service users know that their personal goals are reflected in their individual plans and that potential risks are managed. Service users know that their views are listened to and that their records will be kept securely maintaining confidentially. EVIDENCE: Each service user has a written individual plan identifying care and support needed with guidelines for staff. One of the service users talked to the inspector about her plan and her usual chosen activities. Weekly meetings are held for service users to discuss any issues and reflect on positive things. The service users instigate these and minutes are taken as a record. There is a range of risk assessments designed around each individual’s needs. Risk assessments are carried out prior to individuals going out. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 Residents benefit from a variety of leisure and occupational activities that are arranged to provide education and social experience and develop individual autonomy. EVIDENCE: Service users have individual activity timetables and a sample of these were viewed and discussed with service users who were happy to explain what they like to do. Service users attend college studying different skills including: speaking and listening, IT, artwork and life skills. Some of the courses offer awards and certificates and some of these achievements were displayed in the home. Service users talked about the clubs they belong to and said they enjoy meeting with their friends. Service users are developing independence skills and learning to manage their own behaviour difficulties. Local facilities are utilised including public transport as part of the independence training. Service users discussed their experiences and techniques they have learned to become calm when they are anxious. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The systems for medication administration are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: All staff have completed medication training and certificates were viewed. All medication administration records viewed were recorded accurately and all prescriptions were printed with clear instructions. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The home has a clear and accessible complaints system with evidence that service users feel that their views are listened to and acted on. EVIDENCE: All service users are aware of the complaints procedure and are able to use it if needed. Service users said there was plenty of opportunity to voice any concerns and that they are resolved quickly. All complaints have been logged and action to resolve was well documented. There are no outstanding complaints and none have needed to be passed to CSCI. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 30 The home is well maintained and decorated providing residents with an attractive and homely place to live. Not all service users are able to see out of their bedroom window. EVIDENCE: Service users took the inspector around the home. All areas were clear and clean. Bedrooms are individualised. One bedroom had a covering over the window pane that prevents her from looking out of the window. This needs to be reviewed as the individual’s needs have changed and there are other ways to support privacy and dignity. All bedrooms are single and are domestic in size and character. None of the bedrooms have hand washbasins and it was not considered to be beneficial to install them. Reasons as to why the installation of a washbasin has not been considered appropriate is documented in each individual service user plan. The recommendation from the previous inspection report has therefore been met. The bedrooms not having wash basins needs to be included in the statement of purpose and service user guide. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 14 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 35 Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. Staff are multi skilled ensuring good quality care and support. EVIDENCE: Two staff were on duty. One staff sleeping in who arrived for a 4pm shift start and one of the staff who had worked during the day finished her shift. The staff said that the staff on duty could increase if there was a need including at night time, which would be based on individual assessment. Staff are encouraged to study NVQ 3 when working in smaller homes as they are often left in charge of the home whilst the manager is based in a larger home in the local area. 4 NVQ 3 certificates were on display with a mixture of certificates of achievement from both service users and staff. Training records and some certificates were viewed. All mandatory training is up to date. Some specialised training to support individual service user needs has been included in the training plan and has been completed. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 16 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 42 The home is well maintained. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include the views of service users, staff and relatives. EVIDENCE: The company have produced a report from the annual quality assurance monitoring outcomes for the whole of Robinia. There is a file containing the report and feedback questionnaires from service users, staff, relatives and other professionals who have been involved. Feedback is sought from the service users living in 35 Beaconsfield Road and this does feed into the overall company report. There are anonymous questionnaires available in the home. Regulation 26 visits are carried out and reports given to CSCI monthly. Maintenance certificates were viewed. One of the maintenance men employed by the company was carrying out routine checks on thermostatic valves and carbon dioxide levels at the time of the inspection. A legionella check was 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 18 carried out earlier in this month. The Environmental Health Officer has completed and health and safety inspection and no problems were identified. An internal audit has been completed and all environmental risk assessments have been completed and signed. Fire procedures were clear and understood by all present at the inspection. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 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 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 35 Beaconsfield Avenue Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 20 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 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 26 Good Practice Recommendations Review the type of special window covering in service users bedroom and whether there is an alternative that will not prevent the service user from being able to see out of the window. 35 Beaconsfield Avenue H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent, TN23 1HU 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 H56-H05 S23167 35 Beaconsfield Avenue V244999 241005 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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