Inspection on 23/08/05 for 39 Beresford Gardens

This inspection was carried out on 23rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

39 Beresford Gardens 20/02/07

39 Beresford Gardens 03/01/06

39 Beresford Gardens 17/02/05

39 Beresford Gardens 20/09/04

39 Beresford Gardens 22/01/04

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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 39 Beresford Gardens Cliftonville Margate Kent CT9 3AG Lead Inspector Josie McCabe Announced 23/08/05 at 09:45hrs 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. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 39 Beresford Gardens Address Cliftonville, Margate, Kent. CT9 3AG 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) 01843 221332 01843 221332 The Avenues Trust Limited Karen Sedgwick Registered Care Home 4 Category(ies) of Learning Disabilities registration, with number of places 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/02/2005 Brief Description of the Service: 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and started at 09.45am. It took place over one day and the inspector spent seven and a half hours in the home, observing the care being given to the residents and talking to the staff and manager. A tour of the home was made and records were also examined. There were no outstanding requirements from the last inspection and all standards were being met, several to an exemplary standard, and showed a high level of care being given to the residents. A recommendation was given for the home to complete the redecoration of some areas of the house, namely re-plastering and new hallway wallpaper that needed attention. The manager confirmed that this was down for completing. The inspection outcomes were fed back to the manager, at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home needs re-plastering in parts and new wallpaper in the hallways, in order to continue to provide a home-like environment for the residents. The manager informed the inspector that this work would be completed once planned work to the outside drains has been carried out. Please contact the provider for advice of actions taken in response to this 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 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 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 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) 1, 2, 3, 4 and 5. The home has policies and procedures for prospective admissions Residents needs are fully assessed and they and their relatives and placing authorities are informed of terms and conditions. EVIDENCE: Residents and their relatives are given information about the home before moving in to include the residents guide. The manager described the assessment and admission process and residents records seen showed these processes being carried out in full which provided residents with equipment they needed and helped them to settle into the home. This included staying for a meal and getting used to the other resident they would be living with and the staff. The manager also visited the resident and completed a pre-admission assessment of needs, collecting information from staff and ensuring that appropriate facilities were available for them when they moved in to the home. This included the provision of a special headboard and the removal of the fireplace hearths in the house to ensure a safe environment. Residents are given a statement of terms and conditions and key workers help them to understand their rights, which are contained within the home’s statement of purpose and residents guide and is given out to residents, relatives and placing authorities. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 9 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 10 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, 8, 9 and 10. Residents placement plans and risk assessments contain assessed needs in all areas of daily living, and are to a high standard, which ensures individual choices are met and that their independence is promoted. Residents are encouraged to make decisions about their lives from good support from staff and they are consulted about any changes. Staff follow policies which ensures that information about residents is kept confidential. EVIDENCE: The residents placement plans, risk assessments and specialist assessments seen clearly described assessed needs and goals, which were being achieved. The home uses ‘person centered plans’ which ensure that resident’s are fully involved in decision making and that all needs are assessed and met. Evidence was seen of the plans being regularly reviewed to meet changes for the care of the residents. Key workers encourage residents to make choices about the way they live and an example was seen in the records where one resident who likes swimming activities had a summer holiday away, where a hot tub was provided which was thoroughly enjoyed. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 11 Residents are encouraged to be as independent as their disability allows and they go out with staff support every day. One resident likes to post letters and goes out to the local post box on her own with staff observing for support and safety. Residents activities are fully risk assessed and they use community facilities with staff supervision. An example was seen in the records of this and how one resident who likes roller-coaster rides, was going on local rides to get used to them in preparation for a holiday to Eurodisney in France. Consultation questionnaires are sent out by the organisation to families and placing authorities in order to gain feedback on the care being provided to the residents. Comments are then hared with the manager through the business planning development group for action if needed. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 12 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) 11, 12, 13, 14, 15, 16 and 17. Residents use community facilities which give them the opportunity for personal development and to take part in appropriate activities. They are supported by staff in having contact with relatives and friends. Residents rights are respected by staff in the care being provided in the home. Residents receive a healthy diet and meals are sociable occasions. EVIDENCE: The inspector saw staff interacting with the residents and taking them out to appointments and activities. Community facilities are fully used and one resident contributes to recycling by going with staff to the other homes to collect bottles and visits the bottle bank at a local supermarket. Records showed residents enjoying a wide range of activities which they have chosen, such as the pub, cafes, swimming pool and bowling. Both residents attend the organisation’s day opportunity centre to enjoy activities. Residents have contact with family and friends, and visit them. One resident maintains contact with two people she used to live with and they were invited to a birthday party at the home. One resident visits family and stays without staff supervision. The home has started a newsletter which is sent to families 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 13 and friends and shows what activities the residents have been enjoying and keeps them up to date with developments. Staff interviewed by the inspector showed an understanding of residents rights and were seen treating them with kindness and respect. Residents rights are also covered in the staff induction training and records have been seen of this. Choices for the weekly menu are discussed with the residents and picture cards are used for them to indicate what they would like to eat. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 14 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) 18, 19, 20 and 21. The health needs of residents are well met with evidence of the home working closely with other professionals. Personal support is offered to meet individual residents needs. There are systems in place for the safe handling of medicines which are monitored by the manager. Residents and relatives last wishes are known in the case of illness. EVIDENCE: Residents health needs were seen recorded in care plans and records showed key workers were providing personal care and support. This includes help with personal hygiene, accompanying residents on health appointments and supporting them in care reviews. One resident was attending a health care appointment at the local doctor’s surgery during the inspection. One new resident’s care plan showed how the staff were getting her used to a new routine at night to help her settle in. There are health care policies which staff follow to ensure residents health needs are met. Residents medication is regularly reviewed by the psychiatrist. The medication policies and procedures have been reviewed and senior staff monitor the medication records and storage for safe handling. Medication was being appropriately stored for safe practice. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 15 The inspector has been given evidence of past residents deaths and how the home dealt with this in a dignified manner and which included the resident’s and relatives wishes. Wishes for current residents have been sought following consultation with families. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 16 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 and 23. The home has a satisfactory complaints system which ensures that complaints from residents and relatives would be acted upon. Staff have knowledge of adult protection issues, they have received training and there are procedures in place which ensures they are competent in this area. EVIDENCE: The record of complaints shows no concerns recorded at the time of the inspection. Resident’s key workers act as advocates and they work very closely with them in order to ensure that they are happy living in the home. Staff said that they had gone through the adult protection procedure during their induction and received adult protection training which is repeated on a rolling basis. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 and 30. The home was clean and free from odours. Residents have chosen to keep their bedrooms they way they want them. Residents privacy was being respected and there is equipment to meet their personal and mobility needs. New plaster work in some areas of the house and the wallpaper on the landing needs attention to continue to provide a home-like environment for the residents. EVIDENCE: During the tour of the house all areas were clean and free from odours and comfortable for the residents use. Residents bedrooms are individual and have been decorated to their choice. Records seen showed appropriate fire safety and health and safety checks being completed and monitored by the manager. The manager informed the inspector that plasterwork and new wallpaper needed in the house would get completed once the work to the outside drains is completed. There is a lounge and sensory room for residents use and a well kept garden. There are privacy locks on the bathroom/wc doors and specialist equipment is used for residents who have mobility needs. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 18 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36. Policies and procedures are in place, which ensures residents are receiving care from staff who have been appropriately vetted, trained and supervised and to the number to meet the needs of the residents. EVIDENCE: Records of satisfactory employment checks on members of staff have been seen. Supervision records showed staff having regular supervision and staff meetings had been carried out. Staff have received appraisals to assess their needs. Staff interviewed said they have good support from the manager in order to do their job and like caring for the residents. Staff had received induction training and foundation training such as first aid, safe handling of medicines, fire safety, food hygiene and physical intervention training and records seen showed this. Staff have completed and are completing NVQ care training which has increased their competence in the care of the residents. The induction training used in the home is the training given for staff caring for people with learning disabilities which ensures residents needs are being well met. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 20 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) 37, 38, 39, 40, 41 and 42. The home is well managed to meet the needs of the residents. The manager has several years experience of caring for residents with learning disabilities and has completed the NVQ Level 4 training in care and management which has increased her competence. There is a quality assurance system in place to monitor the care of the residents and the way the home is being run. The staff policies and procedures have been reviewed and ensure that the welfare of residents and staff is being promoted and protected. EVIDENCE: Evidence was seen of the manager monitoring the care of the residents and holding regular staff meetings in order to check that the home is being conducted in a satisfactory manner. Records were being kept to a high standard, had lots of information, up to date and cross-referenced with each other. They showed a history of the residents care being provided. The service manager visits the home unannounced every month and carries out a monitoring visit, and produces a report which is sent to the inspector. The quality assurance system in place, includes action taken from staff, relatives 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 21 and visiting professionals comments. There is a development plan which ensures the manager and proprietor address issues and plan for the future. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 22 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 3 4 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 4 3 4 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 4 4 4 3 4 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 4 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 39 Beresford Gardens Score 4 4 3 3 Standard No 37 38 39 40 41 42 43 Score 4 4 3 4 4 3 3 H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 23 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 24 Good Practice Recommendations Plaster work in the house and wallpaper in the hallway to be renewed to provide a home-like environment. 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 24 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 39 Beresford Gardens H56-H05 S23300 39 Beresford Gardens V238569 230805 stage 4.doc Version 1.40 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!