Inspection on 14/05/07 for 40 St Clement`s Drive

This inspection was carried out on 14th May 2007.

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

40 St Clement`s Drive 06/03/06

40 St Clement`s Drive 21/06/05

40 St Clement`s Drive 20/01/05

40 St Clement`s Drive 01/10/04

40 St Clement`s Drive 16/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOMES FOR OLDER PEOPLE 40 St Clement`s Drive 40 St Clement`s Drive Leigh On Sea Essex SS9 3BJ Lead Inspector Sarah Hannington Unannounced Inspection 14th May 2007 11:00 X10015.doc Version 1.40 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 40 St Clement`s Drive DS0000015467.V346426.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 Older People. 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. 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 40 St Clement`s Drive Address 40 St Clement`s Drive Leigh On Sea Essex SS9 3BJ 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) 01702 479842 F/P 01702 479842 www.mencap.org.uk Royal Mencap Society Mrs Pamela Francis Boughton-Smith Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2006 Brief Description of the Service: St Clements Drive provides care for six adults who have a learning disability. The premises are owned by Dimensions (UK) Ltd formerly New Era Housing Association and managed and registered by Royal MENCAP. The house is a two storey family style house in a residential area of Leigh-onSea. Each resident has single bedroom accommodation and shares the use of the lounge, separate dining room and the conservatory. The home does not have a shaft lift. Bedrooms and a bathroom are sited on both floors. There is a small back garden and parking area at the front of the house. Residents have access to a pleasant back garden, which has both lawn and decked area. 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over three hours to complete. During the Inspection two support workers supported the inspection process. A tour of the home took place. Staff and a resident were spoken with. The visit mainly focused on all Key standards. Random samples of records, policies and procedures were inspected What the service does well: What has improved since the last inspection? What they could do better: 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are given a service user guide which informs them of the services provided and they also are encourage to visit the home prior to any admission. This allows prospective residents and there families make an informed choice as to whether or not the home will met their needs. EVIDENCE: Men-Cap policies and procedures are in place regarding pre admission activity such as a prospective service user visiting the home and assessments to be carried out prior to them moving in. The most recent Service user moved into St Clements on 13th April 2007. On the 23rd March 2007 prior to admission date, a service user application form, Initial assessment and the homes assessment were in place. Assessments included service user views, likes, and dislikes, skills and abilities and how 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 9 they preferred daily routines to be. Once in placement the home monitored, observed and recorded needs, behaviour and aspirations of individual service user. Throughout all documentation it included service user, representative and managers signature. Overall the standard of pre-admission and post admission documentation is to a high standard. 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8,9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care Plans reflect and highlight all residents’ individuals’ needs. The care plans include all aspects of an individuals needs. The review of clients care plans is evident. EVIDENCE: The home has a support plan in place and this is based on person centred planning. Care Plans are tailored to the individual service user and includes staff’s observation, monitoring and regular meeting between key workers, service users, other professionals and families. Risk assessments are in place to minimise risk, these are due to have the format changed so as they give the service user the chance to add views, for professionals, advocates, friends and family involvement. Risk assessments do correspond with Care plans, guidance given to staff and are well written and thought out. 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 11 Recently there has been an introduction of a new health action book. Subjects includes topics from very simple information such as, what my name is and what I like to be called, how I like to relax, preferences, as one individuals states I like to have a Horlicks before I go to bed to more complex. Information such as “how I communicate,” medical information, appointments, investigations, specific skills and abilities, fears and phobias. All information is written as much as possible from the individual views and is written in a sensitive and professional manner. All paperwork looked at gave clear concise and practical guidance for staff to use and protected both the service user and staffs health and safety. The home has implemented an annual medical review and check up made by the local GP. There are also annual reviews that are attended by service users, families, advocates, social worker, other professionals and day centre staff. In supervisions, hand overs and staff meetings any issues relating to individuals are discussed and any possible solutions found. A monitored medication dosage system is in place for each resident. Medication is stored in a lockable cabinet and the administration records were being maintained in accordance with agreed procedures. Record sheets had been correctly recorded and signed for. One service user is supported in administering their own medication this is handled, monitored and to a high standard. Training records indicated that all staff had medication training. During inspection staff interaction with service users was observed to be caring, appropriate and supportive. All documentation inspected on the site visit evidenced that privacy and dignity is proactive amongst the staff team. 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activity plans for each individual are in place. Relatives and friends are encouraged to have regular contact with the home. A variety of regular nutritious meals are being provided. EVIDENCE: A service user who has been at the home for four weeks has already had an essential life plan implemented. This Plan records all preferences, what is important to that individual, memories, goals and aspirations. Other service users that have been in placement for some time have a book called My life book, this work is on going and is based on person centred approaches. It tracks what a person has achieved and experienced for that year and holds a persons essential history. Each individual has a daily diary in which routines, leisure and day service are recorded. There is a wide range of activities and recreational range of activities offered to the service users at St Clements.Each individual has a plan for the week. Additionally there is a folder entitled leisure activities, this contains information about the local area and what is availbale within the community. Residents have monthly meetings and have a link worker within the home 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 13 that can put forward any issues views to the staff meeting or within their supervisions. Relatives and friends are encouarged to have contact with the home and there are no restrictions on visiting times. Service users who may not have family or friends as a support are encouraged to have a befriender or have both advocate and family represent and support them. The health action book gives details of what individuals perceptions and understanding are on foods, what are good foods and what are considered bad foods and where they may need support. The health action book also implements equality and diversity by taking into account any special dietry needs including cultural, religious or for any health reasons. Weight is regularly recorded and foods eaten are recorded. Most of the time staff tend to encourage the group to cook meals that can be eaten by all service users regardless of a particular individuals health needs - this is good practice as it evidences that staff are working in an anti-discriminatory way, by not drawing attention to, or putting focus on one persons health circumstances. However within this system there is plenty of choice for alternative meals if requested. The home records foods given to individuals for lunch when they are accessing day services. Service users are consulted over menus, help with the weekly shop, pepare and cook meals. Every week each service user cooks a favorite of theirs for the rest of the group. Finances were looked at as part of this site inspection and was seen to be accounted for to a good standard. Men-cap also do a yearly financial audit 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and each service user and relative has a service users guide that highlights the complaints procedure. The homes policy and procedures and training of staff protect residents from abuse. EVIDENCE: There have been no complaints or POVA issues recorded at the home or made to CSCI since the last inspection. Staff spoken with had a good understanding and knowledge of Protection Of Vulnerable Adults reporting procedures. Records were also available of where staff had attended P.O.V.A. (Protection Of Vulnerable Adults) training. 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The outside environment is pleasant, attractive and provides appropriate and practical usage for the residents of home. The home environment provides a clean, comfortable and safe environment in which to live in. The home and layout needs to be developed for the specific client group at the home. EVIDENCE: On the day of inspection the home was observed to be clean, tidy and odour free. Overall the home environment presents no health and safety issues. The environment was homely comfortable and practical for the use of service users of St Clements Drive. The home has had new flooring for the halls and stairs and all communual rooms have recently been decorated. On the day of inspection a painter and decorator was in the process of completing service users bedrooms. Service users are encouraged to have a choice in decor. New furniture for the lounge have been ordered. 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 16 There are baths aids provided for those service users that need them. However, for one service user their needs may be changing due to age related issues. The home needs to organise a OT (Occupational Health Therapist) to re-assess this individuals needs specifically linked to the usage of bathrooms and the approriateness of them. The home has already identified this issue in their own annual quality assurance assessment - self assessment sent out prior to inspection by CSCI, by maybe needing to install a wet room( a walk in shower room). 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty, their experience and skill is able to meet the needs of residents. Recruitment records are in place and to a good standard. Staff have had mandatory and specific client related training. EVIDENCE: Staff spoken with felt that they are supported through the management structure and support from supervision and staff meetings. Training opportunities are good. Four weeks staff rosters were inspected and these continue to be appropriate to meet the needs and numbers of existing residents. Staff have regular meetings and monthly supervisions. Staff have recently attended specific client related courses such as dementia. The manager is NVQ 4 qualified and three staff presently hold NVQ qualification. There are future plans for staff to attend NVQ training within the next year. 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Management systems are good and the home is run in the best interests of residents. Evidence to show that teamwork have developed the service and improved the standards of care. The management does respond robustly & rectify matters of health & safety when identified. There is a quality Assurance monitoring process implemented. EVIDENCE: Records as required by regulation were available and seen to be satisfactory, evidencing that the health and safety of residents are promoted and protected Records relating to fire drills, fire equipment, emergency lighting/alarms, gas and electrical safety installation certificates, employers liability certificate and COSHH data records and health and safety policies and procedures were all 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 19 readily available and seen to be appropriate. All support workers are allocated specific work responsiblities such as COSHH and the manager monitors this. During the inspection the fire alarm was triggered due to work being carried out within the home and staff and service user responded to the home’s protocols around this and appropriately. Quality assurance surveys have already been sent out by the home on the 28th April 2007 and returned. All surveys looked at praised the staff, home and care received. One survey looked at comented: The care my relative receives at the home is excellent. They receive very good support and I feel the home achieves a high quality of life for them. 40 St Clement`s Drive DS0000015467.V346426.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 Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 4 40 St Clement`s Drive DS0000015467.V346426.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO 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 OP21 Regulation Reg 23 (1) (a) Requirement The home needs to ensure that the bathroom facilities are adequate and reassessed for the residents needs. This is specifically linked to one resident needs changing due to health and age related issues. Timescale for action 31/10/07 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 40 St Clement`s Drive DS0000015467.V346426.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 40 St Clement`s Drive DS0000015467.V346426.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. 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!