CARE HOME ADULTS 18-65
West Thorpe (35) 35 West Thorpe Basildon Essex SS14 1LX Lead Inspector
Nicola Dowling Unannounced Inspection 7th January 2006 09:00 West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 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.V276638.R01.S.doc Version 5.1 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.V276638.R01.S.doc Version 5.1 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(s)/company (if applicable) Name of registered manager (if applicable) 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.V276638.R01.S.doc Version 5.1 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. 26th July 2005 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. West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over a four hour period on a Saturday. The inspection consisted of a tour of the home, talking with staff and residents, observing the care given and reading of documents. All of the residents were seen and spoken to along with the staff member on duty. There were no visitors to the home however questionnaires were seen that gave the relatives view of the service. What the service does well: What has improved since the last inspection? What they could do better:
The management of emergencies and individual activity choices is limited due to there being one member of staff per shift. Therefore this makes any spontaneous visits or activities difficult to organise if different residents choose to do different things. West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 Page 6 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.V276638.R01.S.doc Version 5.1 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.V276638.R01.S.doc Version 5.1 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): 5 Each resident has a contract that they have access to. EVIDENCE: Residents have their terms and conditions of stay in the home explained to them and these contracts are signed by the resident. Residents’ contracts are kept in their care file and the resident has access to if they want to see it. West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 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 and 7 The care plans are good in the home, however spontaneous individual activities can be hard to manage. EVIDENCE: Three care plans were inspected and all were good and evidenced that the residents have taken part in them. They are regularly reviewed and amended according to need. Residents are encouraged to manage their own money. In the home residents can give their cash to be looked after in the home’s safe. They can recall their money at any time to spend on items that they want. For those residents that need help with managing their money staff are aware of the systems in place to do this correctly. The home operates a system of one staff member per shift and this includes weekends. This can limit the spontaneous individual choices of activities at the weekend for the residents. For example if one resident wants to stay at home, a member of staff must stay with them, leaving the other two residents unable to do an activity for example going out to the cinema. Planned trips and activities are managed by using an extra member of staff. However for unplanned activities all residents have to agree to do the same thing together.
West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 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): 15 The home maintain good family links . EVIDENCE: All the residents receive family visits. These visits range from going home and staying over night with a family member, to the home driving the resident to see a family member in another county. Staff are aware of the vulnerability of the residents and that some friendships are not in the resident’s best interest. However where appropriate staff will support friendships. West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 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 the following standard(s): 18 and 19 The residents have good personal and healthcare support at this home. EVIDENCE: The residents can go to bed and get up when they choose. Personal care is carried out in private and the staff provide good guidance and support to those that need prompting with their personal care. The care for this area is documented and monitored daily by staff. The residents maintain contact with their Community Psychiatric Nurses and good checks are kept on their physical health. These range from continence prevention to keeping appointments with doctors for the care of a cataract. West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: Standards 22 and 23 were inspected at the last inspection and were not inspected at this inspection. West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 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 the following standard(s): 24 The home provides a safe, warm and comfortable living environment. EVIDENCE: The premises are safe, comfortable, bright, clean and cheerful and free from offensive odours. The home offers a warm and comfortable environment for the residents. The kitchen has been redecorated and the home has a new tumble drier. One resident has a new bed that he was pleased with. The residents and staff worked together to make improvements to the garden creating a water feature and flowerbeds. The windows in the property are poorly maintained by Basildon Council who own the building. The manager has received a letter from the council stating that the windows will be refitted in the financial year of 2007. West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 Page 14 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 and 33 Staff have the competencies and skills to work with the residents, however staff numbers do not allow for management of spontaneous activities. EVIDENCE: The member of staff on duty had worked at the home for many years and was comfortable supporting the residents in the home. The residents were comfortable in her presence and approached without hesitation when they required her help. There is a regular staff team that receive good training opportunities within the organisation. Agency workers are used at this home however these workers are regular and familiar with the residents. The manager works the weekdays and three days a week is supernumerary to the staff rota. Otherwise there is one staff member per shift. From Monday to Friday two of the residents are out at various work places leaving one resident to be supervised by staff. The residents cannot be left on their own in the home and at the weekend all residents are at home with one staff member. Staff numbers at this time may not meet the individual needs. For example if one resident needed to go to the doctor urgently all the residents would have to go to the surgery. Or if one resident wanted to go to the cinema and another wanted to stay at home a compromise would be made and one resident would not get their preferred choice of activity. Extra staff are engaged for all planned trips, however the unplanned activities that are managed without individual choice because of the staff numbers.
West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 Page 15 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 and 42 The home is managed and run with the residents’ safety in mind. EVIDENCE: The registered manager is competent and has the experienced to run this home. A random selection of safety certificates was inspected and these were all up to date. Staff on duty were familiar with the fire drill and what to do if a fire occurred. There was evidence that staff had training on maintaining health and safety in the home, food hygiene and first aid. West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 x 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 x ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 3 33 2 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x 3 x x x x 3 x West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 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 YA34 Regulation sch2(1) Requirement The registered person must ensure a robust recruitment policy that includes proof of a persons identity and a recent photograph. Timescale of 31.07.05 not met. 12/09/05 NOT INSPECTED The Registered Person must insure that there are sufficient numbers of staff to meet the residents’ needs. Timescale for action 13/03/06 2 YA7YA33 18(1)(a) 13/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations West Thorpe (35) DS0000018083.V276638.R01.S.doc Version 5.1 Page 18 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
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