CARE HOME ADULTS 18-65
36A Birling Avenue Rainham Gillingham Kent ME8 7EY Lead Inspector
Andrea Leverett Unannounced Inspection 10th February 2006 10:00 36A Birling Avenue DS0000038517.V283260.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 36A Birling Avenue DS0000038517.V283260.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. 36A Birling Avenue DS0000038517.V283260.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service 36A Birling Avenue Address Rainham Gillingham Kent ME8 7EY 01634 234423 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) Medway Council Mrs Paula Anne Robbins Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 36A Birling Avenue DS0000038517.V283260.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Mrs Robbins completes the Registered Persons Award by 2005. (Do not put on certificate) 21st September 2005 Date of last inspection Brief Description of the Service: Birling Avenue is a local authority (Medway Council) respite unit, providing planned, short stay respite for Adults with Learning Disabilities. The Home is used by 70 service users annually, with up to 7 service users staying at any one time. The Home is situated in a residential area, within walking distance of shops and local amenities. Public transport (rail and bus) is nearby. The Home also has its own vehicle. The property is large and spacious, providing accommodation on two floors. 36A Birling Avenue DS0000038517.V283260.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first in the year running from April 1st 2005 to March 31st 2006. The visit was spent talking to service users, support staff and the manager. Some judgements about quality of life and choices were taken from direct discussion with service users, observation and discussion with support staff and evidencing records held at the home. A partial tour of the premises was undertaken. What the service does well:
36a Birling Avenue provides a welcoming and homely environment, and is clean, bright and airy. Service users benefit from staying in an environment that is decorated and furnished to a good standard Service users’ needs are being met and the support staff respects their right to make informed choices about the service and personal lifestyle. Service users benefit from the opportunity to take part in a range of community activities. Including maintaining activities that they would have undertaken if not using the respite service. The service benefits from a well-trained stable support staff team and a motivated manager. The service has its own transport for the benefit of service users, which is unmarked and domestic in character. 36A Birling Avenue DS0000038517.V283260.R01.S.doc Version 5.1 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. 36A Birling Avenue DS0000038517.V283260.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 36A Birling Avenue DS0000038517.V283260.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): None of the above was inspected on this occasion. EVIDENCE: 36A Birling Avenue DS0000038517.V283260.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): 8 Service users cannot be confident that there views are sought regarding the day-to-day running of the service. EVIDENCE: It was noted at the last inspection that the home did not facilitate service user meetings to ascertain their views regarding the general running of the home. A requirement was made that the Home should seek the views of service users and keep records to evidence that this has been done. This has not yet been met although the manager informed the inspector that the first of these meetings is due to take place next week. 36A Birling Avenue DS0000038517.V283260.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. Service users cannot be confident that they are able to take part in appropriate personal and sexual relationships. EVIDENCE: Discussion with the manager and examples given at the last inspection demonstrated that staff have not received training regarding service users sexuality and relationships and local policies and procedures are not in place. In order that service users rights and needs are not undermined in this area, 2 requirements were made. The manager informed the inspector that training has now been agreed and dates will be made for this to be undertaken. The manager also informed the inspector that a sexuality policy is not yet in place. These two requirements therefore remain outstanding and the Home is required to produce an action plan giving dates as to when this work will be completed. 36A Birling Avenue DS0000038517.V283260.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): 20 Service users benefit from having their medication appropriately stored and recorded but more could be done to improve the safety of the administration of medication. EVIDENCE: It was noted at the last inspection that one service user self administers insulin via the PEN method and although there is an expectation that staff supervise and monitor this, they have not received any formal training in this area. Discussion took place with the manager regarding the need to ensure that all staff that support this service user has received appropriate training to do so and a requirement was made. The manager informed the inspector that it has been agreed that this training can go ahead although a date has not yet been set. The service is now required to provide the commission with an action plan with dates to confirm when the above training will be undertaken. 36A Birling Avenue DS0000038517.V283260.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): 22 Service users are not made aware of their right to complain. EVIDENCE: The service has a complaints and compliments file, which the inspector viewed and there has been no complaints in the last 12 months. The Home also has a complaints procedure, which although it has been produced in an accessible format it is not displayed very visibly within the service. A recommendation has been made that the Home look at ways of making the complaints procedure more visible and making service users aware of how to use it. 36A Birling Avenue DS0000038517.V283260.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): None of the above were inspected on this occasion. EVIDENCE: 36A Birling Avenue DS0000038517.V283260.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): 35 The care of service users is compromised because staff do not receive regular training or have the knowledge to work with service users in some key areas. EVIDENCE: It was noted at the last inspection that one service user self administers insulin via the PEN method and although there is an expectation that staff supervise and monitor this, they have not received any formal training in this area. Discussion took place with the manager regarding the need to ensure that all staff that support this service user has received appropriate training to do so and a requirement was made. The manager informed the inspector that it has been agreed that this training can go ahead although a date has not yet been set. A requirement was also made at the last inspection that staff have the training and knowledge to support service users in the area of sexuality and relationships. Again the manager informed the inspector that this has now been agreed but a date for the training has not yet been set. The service is now required to provide the commission with an action plan with dates to confirm when the above training will be undertaken. 36A Birling Avenue DS0000038517.V283260.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): 42,43 The health, safety and welfare of service users are promoted and protected. Service users could benefit from better financial planning if the Home had its own budget to work to. EVIDENCE: A partial tour of the premises and maintenance records seen evidenced that the Home and its equipment and facilities are maintained appropriately. Regular fire drills are undertaken and records are kept to evidence service users responses. Records also evidenced that fire equipment is tested weekly. It was noted at the last inspection that the service does not manage its own budgets making effective forward planning difficult to achieve. Although the manager is required to provide a “wish list” of the home’s needs, the prioritising and planning of improvements are controlled at senior management
36A Birling Avenue DS0000038517.V283260.R01.S.doc Version 5.1 Page 16 level. A requirement was made regarding this and the manager informed the inspector that she is confident that the service will have its own budgets to work to in the next financial year. 36A Birling Avenue DS0000038517.V283260.R01.S.doc Version 5.1 Page 17 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 2 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 2 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X X 3 2 36A Birling Avenue DS0000038517.V283260.R01.S.doc Version 5.1 Page 18 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 YA15 Regulation 13.6 Requirement The registered person must ensure that staff has the training and knowledge to support service users in the area of sexuality and relationships. Outstanding from the last inspection. New action plan required. The registered person must ensure that the Home has a sexuality policy in place. Outstanding from the last inspection. New action plan required. The registered person must ensure that service users views are sort regarding the service provided and that records are kept to evidence that this has been done. Outstanding from the last inspection. New action plan required. The registered person must provide evidence to the commission that appropriate budgets are in place for the service. Outstanding from the last inspection. New action plan
DS0000038517.V283260.R01.S.doc Timescale for action 10/04/06 2. YA15 13.6 10/04/06 3. YA8 12.3& schedule 1.10 10/04/06 4. YA43 25.3 10/04/06 36A Birling Avenue Version 5.1 Page 19 required. 5 YA20 13.2 The registered person must ensure that staff receives Diabetic PEN training from a suitably qualified person. Outstanding from the last inspection. New action plan required. 10/04/06 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 Refer to Standard YA22 Good Practice Recommendations It is recommended that the service makes its complaints procedure more accessible and visible to service users. 36A Birling Avenue DS0000038517.V283260.R01.S.doc Version 5.1 Page 20 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
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