Inspection on 03/01/06 for 39 Beresford Gardens

This inspection was carried out on 3rd January 2006.

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 23/08/05

39 Beresford Gardens 17/02/05

39 Beresford Gardens 20/09/04

39 Beresford Gardens 22/01/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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 39 Beresford Gardens Cliftonville Margate Kent CT9 3AG Lead Inspector Patrick Gough Unannounced Inspection 3rd January 2006 12:15 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 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 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 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. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 39 Beresford Gardens Address Cliftonville Margate Kent CT9 3AG 01843 221332 01843 221332 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) The Avenues Trust Limited Karen Jean Sedgwick Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2005 Brief Description of the Service: 39 Beresford Gardens is a spacious detached property, in a residential area, within walking distance of Palm Bay, Cliftonville and spectacular views of the English Channel. Local shops and other amenities are close by and Margate and other seaside towns are easily accessed by public transport. The Home, itself, has got four bedrooms, one of which is on the ground floor and accessible to wheelchair users. There is a small front garden and a rear garden, which is lawned, with garden seating and a swing. The Home provides residential care in a homely environment for adults with varying degrees of learning disability and has facilities, which can adequately accommodate one adult with physical disabilities. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which started at 12.15pm and lasted for three hours. When the inspection commenced there were three members of care staff on duty as well as the manager. There are currently two adults accommodated in the Home. One of the residents was on the premises having her lunch, assisted by the manager and one member of staff, whilst the other resident was shopping with two other staff. The inspection focussed on the majority of the core standards, with which the manager assisted the inspector. There was a brief conversation with two staff, a tour of the premises and inspection of practice documentation, including one resident’s file. The one recommendation made at the previous inspection has been partially met and the timescale for completion will be extended. What the service does well: What has improved since the last inspection? Some progress has been made with the maintenance in that the drains have been repaired. The home is now fully staffed as a result of recent staffing appointments. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 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. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 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 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 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): 2 The residents’ needs are assessed and reviewed so as to identify resources and methods of practice, which provide the appropriate level of support. EVIDENCE: One resident’s file indicated that relevant information had been collated including who and what is important to the resident, how she communicates and the best approaches to use in various circumstances. This information was used to identify targets in the care plan. The manager stated that she had cared for this resident in a different environment previous to her placement in this Home and the knowledge gained through that experience was particularly helpful in supporting the resident’s care. There was evidence that the Home had researched and obtained background information on the resident’s ethnicity, particularly relating to language and communication. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 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 The care plans are clearly written and identify realistic and achievable targets so that the residents can have positive experiences. Suitable communication methods and good staff support encourages and enables the residents to contribute to decision making on a daily basis. Risk assessments are conducted to ensure that the residents’ safety is given paramount importance and to provide them with the same opportunities as their able peers. EVIDENCE: The resident’s care plan clearly reflected the needs that had been identified and there was good detail describing the target and the best approach and most effective responses to make. There was a holistic profile, which provided a considerable insight into the resident’s background and focussed on current abilities and how best they could be enhanced. The Home uses ‘person centred plans’ which ensure that residents are fully involved in decision making and that all needs are assessed and met. The manager is currently engaged in professional training on the use of this method of planning. The care plan is reviewed on a six-monthly timescale. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 10 Internal reviews are held bi-annually and although there is no attendance by a representative from the placing authorities, the Home provides the authority with a copy of the review proceedings and encourages participation. Key workers encourage residents to make choices about the way they live and promote their life skills through daily participation. Evidence of this was found in the weekly activity list, the daily log and observation of practice on the day of the inspection. Residents’ activities are fully risk assessed and they use community facilities with staff supervision. The risk assessments are reviewed routinely or as circumstances change. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 11 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): 13,15,16 The home provides a range of stimulating activities and experiences so that the residents are purposefully occupied and have the appropriate contact with their peers. The residents are given the necessary support to interact with their family and the Home has the facilities to accommodate visits. Personal care and life skills opportunities are provided for the residents on a daily basis so that they are encouraged to maintain their skills. EVIDENCE: Each resident has an ‘activities and events’ profile, which identifies how the resident’s life could be enhanced through activity. The residents regularly participate in the Trust’s organised events, which enable them to interact with residents from other Homes and Centres. The manager stated that consideration is given, on a regular basis, to possible participation in local community clubs, however where there is inadequate support or a lack of recognition of the residents’ needs, within the clubs, the home considers that the experience may be counter productive. On the day of the inspection one 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 12 resident attended her weekly aromatherapy session and had dinner out afterwards. Family contact is encouraged and there is representation at each of the resident’s birthday and review meeting and one resident’s family visits the home each week. The daily activity list confirms that the residents are purposefully engaged in personal care, life skills, activities and leisure throughout the day. A sample of daily activities indicated that there is a broad range of choice and a good balance between active involvement and restful ‘activities’. The Home has a small sensory room, which is equipped with a range of resources and the manager stated that one resident uses it regularly. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 13 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): The residents receive good quality personal support so that they can maintain a level of independence and access social opportunities. The health needs of residents are well met with evidence of the home working closely with other professionals. There are systems in place for the safe handling of medicines, which are effectively monitored by the manager. EVIDENCE: There is considerable importance placed on the level of personal support required by each of the residents. This is determined by the good needs assessment and knowledge of the resident as illustrated in the care plan and the identified approaches and responses. The amount of one to one support given to the residents is recorded daily so that the Home can adequately account for appropriate use of personnel resources and can effectively track the usefulness of such support. Healthcare needs and their provision were well documented in the resident’s file. Each resident’s weight is recorded monthly and food intake is monitored and recorded daily. There is a record of dental appointments, therapy provision, where appropriate, as well as medical practitioner intervention. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 14 Medicines are appropriately and safely stored and examination of medication administration records confirmed that entries were dated and signed. The manager confirmed that only staff trained in administration procedures are involved in giving medication. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 15 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): 22,23 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 home has a complaints policy and process, which is simplified in a symbol format for the residents. There have been no complaints registered since the last inspection and the manager indicated that good relationships exist with the neighbours. The residents have access to their relatives on a regular basis. The manager stated that new staff are supervised closely during their probationary period and adult protection training features in the induction programme. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 16 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 Whilst the residents’ accommodation is clean and comfortable enabling them to live and relax in homely surroundings, 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: The premises were clean and there were comfortable, adequately furnished communal areas for the residents. Two rooms were vacant and the two rooms occupied by residents were spacious and furnished and organised to suit the preference of the resident. One resident preferred her room to be devoid of any personal mementoes on display. One bedroom window had no curtains due to the resident’s behaviour although the home had tried all means to ensure the curtains remained in place. The window was partially frosted, nevertheless, so that the resident’s privacy and dignity was assured. The external drains have now been repaired and the cracks in the internal walls are being monitored over the coming weeks. It is planned that the affected walls will be re-plastered and the wallpaper replaced within six months. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 17 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): There are sufficient staff on duty with the necessary experience to care for the residents. EVIDENCE: At the time of the inspection the home was adequately staffed and the staff were actively engaged with the residents. Three new staff have been appointed and when they commence employment following completion of the required checks, the manager will have a full complement of staff. A handover session occurs daily between the two shifts and the manager stated that there is good teamwork. The staff were evidenced to be relating appropriately with the residents. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 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): 39 There are good monitoring systems in place to ensure that the practice implemented within the home provides the residents with high quality care and support. EVIDENCE: The Company has generated ‘service visit forms’, which record in sufficient detail the findings of unannounced visits by the service manager. It incorporates all the matters relating to the expected outcomes indicated in the NMS. There were relevant and appropriate comments on practice and achievements. The manager was advised to sign and date records on a regular timescale in order to evidence internal monitoring. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 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 4 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 4 X 4 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 4 14 X 15 3 16 4 17 Standard No 31 32 33 34 35 36 Score X X 3 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 39 Beresford Gardens Score 4 4 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X X X DS0000023300.V269159.R01.S.doc Version 5.0 Page 20 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. 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 YA24 Good Practice Recommendations Plasterwork in the house should be completed and wallpaper in the hallway should be renewed in order to improve the appearance of the communal areas of the home. 39 Beresford Gardens DS0000023300.V269159.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Kent and Medway Area Office 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 DS0000023300.V269159.R01.S.doc Version 5.0 Page 22 - 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. 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