Inspection on 17/10/06 for 35 West Thorpe

This inspection was carried out on 17th October 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

35 West Thorpe 10/10/08

35 West Thorpe 07/01/06

35 West Thorpe 26/07/05

35 West Thorpe 31/03/05

35 West Thorpe 28/06/04

35 West Thorpe 27/01/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 West Thorpe (35) 35 West Thorpe Basildon Essex SS14 1LX Lead Inspector Nicola Dowling Unannounced Inspection 17 October 2006 10:00 th West Thorpe (35) DS0000018083.V312332.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 West Thorpe (35) DS0000018083.V312332.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. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Thorpe (35) Address 35 West Thorpe Basildon Essex SS14 1LX 01268 285788 01268 285788 Telephone number Fax number Email address Provider Web address Name of registered provider. Name of registered manager Type of registration No. of places registered (if applicable) Estuary Housing Association Limited Mrs Maureen Lawrence Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Care and accommodation to be provided to no more than three service users. Care and accommodation to be provided to three service users with mental disorder excluding learning disability or dementia. 07/01/06 Date of last inspection Brief Description of the Service: West Thorpe is a care home for three residents with mental health problems. It is located within walking distance of Basildon town centre and forms part of a residential estate. Basildon council own the property. The house is domestic in size; there is a communal lounge, a kitchen with a dining area and a conservatory that is used as a smoking area. Each resident has a single room. There is a well maintained garden to the rear of the property with a patio area. The home is near to local shops, facilities and public transport. The home has a car for the use of the residents. The weekly cost of care at this home is £1248.82. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection site visit took place over a five hour period on one day. The site visit consisted of a tour of the home, talking with staff and residents, observing the care given and reading of documents. All the residents were seen and spoken to. The member of staff on duty assisted with the inspection as the manager was away from the home at a meeting. In addition the survey forms that were received back from the residents and their relatives were used and contributed to this report. The inspector would like to thank the staff and residents for their help and hospitality during the visit. What the service does well: What has improved since the last inspection? There have been improvements in the residents environment. For example the conservatory has new blinds and a new floor and the kitchen has been decorated. The residents’ also have a flat screen TV in the smoking area and the lounge. For the residents safety a new fire alarm system has been fitted that includes magnetic fire closures. West Thorpe (35) DS0000018083.V312332.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. West Thorpe (35) DS0000018083.V312332.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 West Thorpe (35) DS0000018083.V312332.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, 2,4, 5 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. There is good documentation to support and safeguard the residents who move to the home. EVIDENCE: Currently the home is full and the three residents have lived together at the home for some time. The home manager will undertake an assessment of any prospective residents. There was evidence the Care Programme Approach documentation had been followed and this reflected in the residents care plans. The home has a Statement of Purpose and Service User Guide that is informative and sets out what a new resident can expect when being introduced to the home. For example, having the opportunity to attend a meal at the home and staying over night. The Service User Guide and Statement of Purpose need amending to include the smoking area and the key contacts page needs updating. There was evidence that each resident has a contract. The contract details the room that they occupy, the fees and the terms and conditions of their stay amongst other things. The contracts are written and have been signed by the resident and manager. West Thorpe (35) DS0000018083.V312332.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 group is good. This judgement has been made using available evidence including a visit to this service. Residents are well looked after and involved in their care. EVIDENCE: All residents have an up to date care plan with a risk assessment that they have signed. There is evidence of Care Programme Approach care plans and these have been used to form the home’s care plan. Residents are able to make most of their own decisions. Some restrictions are in place as agreed with the multi-disciplinary team. Support is offered to residents with their finances. For example the home keep money in a secure place in the home and keep good records of money spent by the residents. Financial accountability was raised as an issue and this information was taken back to the home to be addressed by the home manager. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome group is excellent. This judgement has been made using available evidence including a visit to this service. Residents enjoy an active lifestyle and good food at this home. With purposeful occupation and trips out and holidays to look forward to. EVIDENCE: Two of the three residents have planned weekly schedules that involve going out to day centres where they undertake purposeful occupation. On the day of the site visit one resident returned with a typing certificate. One resident has started to attend weekly sessions at a local college for cookery and daily living skills. He reported that he enjoyed the cookery sessions. Residents enjoy the local facilities and some are able to go independently into the town. The home arranges a variety of activities for the residents, for example, bowling, going to the cinema and going out for meals. Quality day trips are also arranged along with short break holidays, the last in September was to the New Forest, in July this year they went to Lowestoft. Staff keep pictures of trips and holidays and write an account of where they went to keep as a memory. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 11 Residents are encouraged to undertake some chores in the home. For example setting the table and clearing away afterwards, along with keeping their rooms clean and tidy. Staff supervise activities and will assist were needed. Residents have their own key to the front door and to their rooms and can come and go from the home when they choose. Food is brought fresh and staff reported that there is little processed food used. Shepherds pie was being cooked today and residents commented on how nice it smelt. The dinner for tomorrow was a roast leg of lamb. Food in the fridge was properly stored. Residents can help themselves to drinks, however for healthy living tea and coffee is monitored. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 12 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, 21 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Residents’ physical and emotional needs are well looked after at this home. EVIDENCE: Staff supervise residents with their personal hygiene and provide support when needed. None of the residents require any special equipment. However for one resident an air conditioning unit has been purchased for their bedroom to assist them to have a more comfortable night sleep. Community psychiatric nurses call regularly to the home and staff report that the resident is seen in the privacy of their own room. Residents have good contact with the mental health services and regular reviews of care are arranged. There was evidence that the residents have their physical needs recorded at the home, and that they have health screening checks. Medication is stored correctly and the MAR sheets where correctly filled in. One resident self medicates and there are checks and risk assessments in place for this. It was noted that a medication error was dealt with by the manager regarding an agency worker. This incident was not reported to the Commission for Social Care Inspection. Of the three residents one has made a will. There is evidence that this subject was approached with the two other residents. However it was not taken West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 13 forward due to the distress that the topic caused. As this documented evidence was not dated the home should revisit this subject to establish if the residents have a view on their last wishes. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The complaints policy and adult protection policy are satisfactory EVIDENCE: There have not been any adult protection incidents at the home. The adult protection policy contains a clear procedure about what to do if abuse is suspected and there is evidence that staff have had training on this topic. There have been no recorded complaints with the CSCI since the last inspection. Information on how to complain is available in the residents’ kitchen. Feedback from the residents’ surveys suggested that they know how to complain. When asked residents said they felt safe in the home. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 15 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 group is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable homely environment that is kept clean. EVIDENCE: The premises are safe comfortable airy and clean. There are no offensive odours and residents have access to all areas of the home. There is ongoing maintenance and the home is still waiting for new windows to be fitted by Basildon Council. It is expected that they will be replaced in 2007. Residents have their own bedrooms with TV’s and other personal electrical equipment. They share the bathroom upstairs. The conservatory off the lounge is used as a smoking room. The residents have a new flat screen TV in there. This room has also been fitted with new blinds, flooring and chairs. The residents spend a lot of time in this room that looks out into the garden. The garden is big and the residents help to keep it. Residents spoken to were happy with the homes environment. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 16 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, 34, 35 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. There is a well supported and trained staff team that look after the residents. However staffing numbers may not be sufficient to meet the residents needs at all times. EVIDENCE: There is one member of staff per shift. If the need arises the staff contact the on-call person to arrange for another staff member to help at the home. As mentioned in the last report at times lone working may not always meet residents’ needs in terms of spontaneous activities. The home manager is in the home on a supernumerary basis for three days a week. However if incidents occur the staff have to rely on the on-call system for extra help. Agency workers are used in the home. The staff are flexible and work outside their shifts for example when taking residents out for the day or on holiday. The staff at the home were observed to be comfortable with the residents and treated them with respect. Feedback from questionnaires indicated that there were usually enough staff and that staff were dedicated and positive in their attitude. Recruitment records were checked and these contained the proper documentation, such as criminal record bureau checks and checks against the protection of vulnerable adults register. There is ongoing training at the home. Of the core team of five care staff two have an NVQ and one staff member is undertaking the NVQ3. Staff have West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 17 received training in protection of vulnerable adults, food hygiene, infection control fire and various other courses. Training specific to the residents at the home include obsessional compulsive disorder (OCD) and dealing with residents that are partially sighted. Staff confirmed that they receive supervision from the manager. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. This is a well managed home that is run with the interest and safety of the residents in mind. EVIDENCE: The home manager holds the NVQ 4 managers award and has the experience to run the home well. There is evidence that the manager has regular training. Estuary Housing Association seek the views of the residents in all of their homes and this is called their Quality Network Review. The organisation produce an annual report reflecting the findings of the review and an action plan to improve their service which is informed by the residents. This home also does questionnaires independently from the quality network project to seek the views of the residents in their own home. A random selection of safety certificates were checked and these were up to date. Reporting of incidents at the home needs improving. For example incidents at the home that were not reported under regulation 37 are; a West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 19 medication error and a disagreement between residents resulting in the on-call person being contacted. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 20 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 3 3 x 4 3 5 3 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 2 34 3 35 3 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 4 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 2 3 x 3 x x 2 x West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 21 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 YA42 Regulation 37 Requirement The Registered Person must ensure that all incidents are reported under regulation 37 Timescale for action 13/12/06 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 YA1 YA21 YA33 Good Practice Recommendations Minor amendments to the Statement of Purpose and Service User Guide are needed The home manager should update the residents last wishes documentation. The home should constantly review how staffing numbers meet residents needs. West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 22 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 West Thorpe (35) DS0000018083.V312332.R01.S.doc Version 5.2 Page 23 - 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. 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