Inspection on 21/06/05 for 40 St Clement`s Drive

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

40 St Clement`s Drive 14/05/07

40 St Clement`s Drive 06/03/06

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 HOME ADULTS 18-65 St Clements Drive (40) 40 St Clements Drive Leigh on Sea Essex SS9 3BJ Lead Inspector Sarah Meddle Unannounced 21 June 2005 10:00am st 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. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Clements Drive (40) Address 40 St Clements Drive Leigh on Sea Essex SS9 3BJ 01702 479842 01702 419842 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) Royal Mencap Society Mrs Pamela Francis Boughton Smith CRH 6 Category(ies) of Learning Disability registration, with number of places St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Care home for adults with a learning disability 6 Date of last inspection 20th January 2005 Brief Description of the Service: St Clements Drive provides care for six adults who have a learning disability. The premises are owned by 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 on Sea. Each service user has single bedroom accommodation and shares the use of the lounge, separate dining room and a conservatory. The home does not have a shaft lift. Bedrooms and a bathroom are sited on both floors. There is a small garden and parking area at the front of the house. Service users have access to a pleasant back garden, which has both lawn and decked area. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 5 SUMMARY The inspection was a routine unannounced visit to the home. There was one service user at home and one staff (the manager). The visit took place throughout the morning and over the lunch time period. The house was toured and records were looked at. What the service does well: 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. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 6 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 St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 7 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 5 40 St.Clements Drive provides effective information for prospective service users to decide whether the home can meet their needs. Assessments are detailed and reflect the needs of the service users. EVIDENCE: A Statement of Purpose and Service User Guide is available to enable service users make a judgement about the home. Assessments are carried out and a care plan is developed with clear input by the service user themselves. There have been no service users admitted since the NMS for Care Homes was brought into force and the organisation has revised assessment forms reflecting these should there be any prospective service users. The home regularly reassesses service users needs. Service users have licence agreements but these are outdated and could be replaced with those reflecting NMS. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 8 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 10 The home effectively supports service users to control the decisions in their lives. Service users are encouraged to maintain their independence within an effective risk managed process. Paperwork is up to date and relevant. EVIDENCE: Service users are involved in developing their own plan of care through a person centred planning approach and with the use of an advocacy service. The care plans centre on information ‘about me’, ‘things I do’ and ‘my health’ and these documents are supported with ‘essential life plans’ which illustrate ‘likes/dislikes’, ‘social history’ and ‘activities’. Each service users personal notes are individualised to Service users own preference. These are carrying out a chosen activity. These also detail the services users dreams and aspirations. Service users are actively encouraged and supported to be involved in day to day activities in the home such as home making skills, shopping and any other activity they choose to do out of the home. One service user spoken with said about the home “ I like it here and staff are nice”. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 9 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) 11-17 The home effectively enables service users to maintain appropriate and fulfilling lifestyles. Nutritious and varied meals are available. Relevant paperwork is in place and well kept. EVIDENCE: All service users currently attend formal day services, which is due to close in October 2005. Service users are anxious about future day care provision and the home is actively addressing this and working with the service users to find alternative meaningful activity. Staff at the home support the service users where necessary to access activities of choice outside of the home such as leisure or adult education classes: for example English, drama, numeracy and so on. Family members are involved with service users lives and are invited to social events and more formal reviews. Meals available are of good quality and records show a variety of meals are provided. Individual requests are taken from each service user and meals St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 10 prepared accordingly. Service users are involved in the planning, purchasing and preparation of meals as they choose. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 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 standard(s) 18 - 21 40 St. Clements Drive provides good personal and health care support to individuals living at the home. Where possible service users are supported to maintain independence and autonomy regarding personal and health care support. Paperwork to evidence this is well maintained. EVIDENCE: Service users personal care and support needs and preferences are detailed in the person centred plans and these are being updated as a part of the ongoing review/ reassessment. MENCAP have effective policies on handling medication and the current system in place is well maintained. No service users self medicate at the moment. The home maintains full detailed of service users wishes regarding their ageing or terminal health care. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 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 standard(s) 22 23 The home responds well to service users and their representative’s comments and assures service users they will be safeguarded from harm, abuse and neglect. EVIDENCE: MENCAP has good policies and procedures regarding complaints and protection of vulnerable adults. The Manager said she was confident that staff were aware of their content and of the signs and symptoms of abuse. New staff have attended training in the protection of Adults, in December 2004 which looked at identifying abuse and the reporting procedure. A complaints log is available. No complaints have been made to the home or CSCI about the service. Service users comment included that they “felt ok” and “staff are nice”. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 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 standard(s) 24 - 30 The home provides sufficient space and facilities to meet service users needs. Some areas of the home require attention due to looking shabby and worn. EVIDENCE: The home is presented as clean and attractive internally. The décor in communal areas is a little out dated and in need and redecoration. Due to age and disrepair externally, the home is not in keeping with the rest of the road. Service users bedrooms are attractively individually decorated and furnished according to individual taste. There are sufficient toilet and bathroom facilities both up and downstairs. Each service user is provided with a single bedroom. The kitchen is large and accessible to any persons using a wheelchair. There have been major problems with damp in 2 bedrooms and the dining area, which the staff have has tried to manage. This problem could compromise the health of service users and needs to be sorted out urgently as this has gone on for a long time. Others matters that require attention are rotten windows in the service users bedrooms and the lounge, and the crazy paving surrounding the house; front, side and back which has become dangerous to access (particularly in the event of a fire evacuation). St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 14 The manager stated that the organisation was now more able to deal with this with a change to by a service contract they have. The home was clean and tidy considering the early start to the inspection and this was positive to note. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 15 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 - 36 The home provides and maintains an effective staff team, which demonstrates the ability to meet the stated purpose of the home and meets the needs of the service users who live at the home. EVIDENCE: Most of the staff have worked at the home for a number of years. Two new staff have joined in the last 8 months. Staff records were in good order. Job descriptions were readily available outlining staff roles and responsibilities. Recruitment processes had been followed for the 2 staff files inspected and CRB checks were available. Supervision of staff is carried out every 2 months for all staff at the home. The manager confirmed she receives regular supervision. Reviews/ appraisals of employment are carried out yearly. Training opportunities are good and recent training has included: food hygiene, POVA, fire safety, first aid, epilepsy and medication training. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 16 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 - 43 The manager and staff ensure that the home continues to fulfil its stated aims and objectives. The general running of the home is inclusive and based on the needs and wishes of service users. Policies and procedures are explicit of the organisations expectation of the management of the home and paperwork. The home has not completed gathering the views of all interested parties in the conduct of the home and service delivery. EVIDENCE: The management approach is inclusive and it was clear that service users views are taken in to account in the way the home is run. The manager has achieved NVQ level 4 in management and is undertaking the care component. Quality assurance monitoring is to be further developed to include the views of others such social workers, health care professions, day service providers and so on. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 17 Health and safety is wall managed and risk assessments were in place and reviewed. The manager must ensure she pursues the environmental health and safety issues identified previously in the report (Environment). A response to this matter is required form the Registered Provider as part of the action plan. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 18 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 3 3 x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Clements Drive (40) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 3 3 I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 19 YES 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 24 Regulation 13 (3) Requirement The registered person to ensure that: all parts of the home to be free from hazards. Consult with the environmental health authority as to maintaining satisfactory standards of hygiene in the home and this refers specifically to damp and wood rot. The premises to be of sound construction and kept in good state of repair. The registered person to implement and maintain an adequate system gathering the views of all interested parties and for a report to be made available with a copy to be sent to the CSCI. 30/08/05 Timescale for action 01/12/05 16 (j) 23 2. YA39 24 3. 4. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 20 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 S Good Practice Recommendations Existing service users to be provided with a contract reflecting the National Minimun Standards for Adults Care Homes. St Clements Drive (40) I56 I06 S15467 St Clements V223832 210605 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Kingswood House Baxter Avenue Southend-on-Sea SS2 6BG 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. 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