Inspection on 13/02/07 for 48 Holland Road

This inspection was carried out on 13th February 2007.

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 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

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 48 Holland Road Clacton on Sea Essex CO15 6EL Lead Inspector Neal Cranmer Key Unannounced Inspection 13th February 2007 9:30 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 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 48 Holland Road DS0000067256.V329423.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 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. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 48 Holland Road Address Clacton on Sea Essex CO15 6EL 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) 01255 474934 Creative Support and Consultancy Limited Melanie Purcell Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 4 persons) First Inspection since being registered. Date of last inspection Brief Description of the Service: 48 Holland Road is a large detached house situated in a residential area of Holland-On-Sea, a short distance from Clacton town centre, and the many amenities that the town has to offer. The house has two good-sized lounges, as well as two separate dinning areas, the house also benefits from a small conservatory area. The house has four bedrooms, two of which have en-suite facilities, with the remaining two having washing facilities, in addition there is a separate Jacuzzi bathroom with an adjoining shower room. The outside consists of an established, enclosed garden, which is unoverlooked, and includes an outdoor storage area and patio area; there is a small driveway, which can allow parking for a small number of cars. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection since being registered in July 2006, during the course of the inspection the inspector was supported by the home’s registered manager. One person living in the home was spoken with, as was one member of staff. Tour of the premises included viewing of one person’s room and communal areas. During the course of the inspection a range of documentary evidence was sampled. Twenty- six of the forty-three standards were inspected, of these twenty-two were met, of the remaining four, one was a requirement, with the remaining three constituting recommendations for best practice. What the service does well: What has improved since the last inspection? This was the first inspection of the service since it’s registration in July 2006; therefore it is not possible to comment on this section of the report at this point in time. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 6 What they could do better: • • It is recommended that care plans could be further developed to ensure that guidance to staff is clear and unambiguous. It is recommended that records pertaining to people’s healthcare needs would benefit from being kept in a manner that makes them more easily accessible. It is recommended that the home develop a complaints log for the recording of any complaints received by the home. Provision needs to be made for the registered manager to undertake the Registered Managers Award. • • 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. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 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 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 4 and 5. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People living in the home can expect to be provided with the necessary information to enable them to make an informed choice about the home’s ability to meet their needs. People living in the home can expect to be provided with opportunities to trial visit the home before making a choice to move there. People living in the home can expect to be provided with an individual contract of terms and conditions relating to their residency. EVIDENCE: The home’s Statement of Purpose was sampled and found to be in order, and included details of a summary of the home, the number of places provided, the admission process and the process for monitoring the quality of the home’s service provision. Evidence was seen in people’s plans of care of them having had opportunities to visit the home prior to admission, the initial first three months admission to the home is on a trial basis, following which a contract between the commissioning agency and the provider was set up, alongside a basic 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 9 agreement between the home and the person, both of the samples seen had been signed by representatives of the person living in the home and the home. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that their assessed and changing needs will be reflected in their individual plans of care. People living in the home can be assured that they will be supported to the best of their individual abilities to make decisions about their lives. People living in the home can expect to be supported to take risks as a part of developing an independent lifestyle. EVIDENCE: People living in the home have individual care plans that are either generated from a Care Management assessment or the home’s own assessment of need, and covered all aspects of the person’s personal and social support needs, designated key workers assist people living in the home with all aspects of 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 11 their daily lives. Although the care plans were generally good, they would benefit from some further development to ensure that the guidance to care staff is clear. Evidence seen on the day indicated that people living in the home are supported to make decisions about their everyday lives with assistance as required, one person spoken with spoke of being free to choose when to get up and when to go to bed, and the routine of the home on the day of the visit was witnessed to be flexible to the wishes of the people living in the home. Risks to people’s health were seen to be assessed at the point of admission and there was evidence of there being management strategies in place to minimise the identified risk, whilst at the same time enabling people with the necessary level of support to develop as independent live styles as possible. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People living in the home can expect to be supported to take part in community activities that are age and peer appropriate. People living in the home can expect to be supported to maintain links with their families and friends. People living in the home can expect that their rights will be respected in all aspects of their daily lives. People living in the home can expect to be provided with a diet that is healthy and wholesome. EVIDENCE: 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 13 Due to the level of need of the people residing at the home none are currently able to undertake any paid or voluntary employment, although discussion with the manager indicated that some form of gainful employment was being sought on behalf of one person. Each person living in the home has a daily diary, sampling of two of these indicated them taking part in the following community based activities: • Attending college • Visits to local public houses • Walks out • Attendance at local clubs • Meals out. Discussion with a person indicated that the home has an open door policy on the receiving of visitors, and that they are free to receive their visitors in the privacy of their own rooms, or in one of the two quiet lounges On the day of the visit the daily routines of the home appeared to promote peoples independence, individual choice and freedom of movement, people were seen to have unrestricted access to all communal areas of the home. People living in the home were witnessed getting up at variable times throughout the morning, and breakfast was provided flexibly to meet these people’s needs. Staff were seen and heard interacting with people living in the home and not exclusively with each other, people were seen choosing when to interact with staff and when as they wished to take themselves of on their own and spend time alone. The home provides three weekly rotational menus, which were provided in a pictorial format, the menus seen were varied and nutritious, and provided for at least one hot meal a day, and included two choices, as mentioned previously meals were provided flexibly to meet people’s needs and wishes. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People living in the home can expect that their personal support needs will be provided for in a way that they wish and that is appropriate to their needs. People living in the home can expect that their physical and emotional needs will be met. People living in the home can expect that the home’s Policies and Procedures relating to medicines will protect them. EVIDENCE: Discussion with one of the three people living in the home was spoken with, and spoke of staff supporting them in a sensitive and supportive manner, as mentioned previously the routines of the home are flexible, and people are free to choose when to get up and when to go to bed. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 15 All of the people living in the home are registered with a General Practitioner; healthcare appointments are recorded in people’s daily diaries, along with any outcome (it was recommended that the maintenance of healthcare records be further developed, to make them more easily accessible). Evidence was seen of staff supporting people to attend and keep appointments, and there was evidence seen of the following healthcare professionals providing input into the home; Behaviour Support Staff, Community Nurses, Consultant Psychiatrist, Neurologists. Medication at the home is dispensed from a Measured Dosage System or individually named containers; the home does not maintain any medications that are of a controlled nature. All staff administering medicines do so only following having been assessed as competent to do so. Records sampled on the day of the visit were found to be in order. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People living in the home can expect that their views will be listened to and acted upon accordingly. People living in the home can expect that the home’s practice, policies and procedures will protect them from the risk of harm and/or abuse. EVIDENCE: The home’s complaints policy/procedure is basic but concise, and included timescales for responding to complaints, the policy/procedure was also available in pictorial format for ease of use by the people living in the home, since registration of the home there have been no complaints received. The home does not have a complaints log for the recording of any complaints received, and the registered manager was informed of the need for one to be maintained. The home has an Adult protection Procedure that included the following information: • Definition • Categories of abuse • A flowchart for referring suspected incidents of abuse • Staff guidance 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 17 • Copy of the appropriate referral form. All staff have received training in Adult Protection. Since registration the home has been required to make one Adult Protection Referral, sampling of records and discussion with the registered manager indicated that this had been managed appropriately. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People living in the home can expect to live in an environment that is comfortable, homely and safe, and that is kept clean. EVIDENCE: The home is fit for its stated purpose, being safe, comfortable, bright and cheery, and on the day of the visit free of any unpleasant odours. The home is situated close to a good variety of local amenities, and was in keeping with other properties nearby. The home was readily accessible to all of the people living there, and furnishings and fittings were domestic in nature, and were of a good quality. The premises met with the requirements of the local Fire Service and Environmental Health Department. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 19 The laundry facility at the home was situated well away from areas where food preparation takes place, and was equipped with a small domestic style washing machine and dryer, hand- washing facility was also available. People living in the home are supported to take part in managing their own washing. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People living in the home can expect to be supported by a team of staff who are competent and well trained, and who are regularly supervised by senior staff. People living in the home can expect to be protected by the home’s robust recruitment practice. EVIDENCE: All staff employed at the home are over the age of eighteen, three of the care staff are qualified to N.V.Q level three, and plans are in place for the remaining staff to undertake level two or three of the same award. Each member of staff upon commencement of their employment undertake Skills for Care Common Induction Standards. Three of the home’s staff files were sampled in respect of the home’s recruitment practice, each of the files sampled were seen to contain all of the relevant documentary evidence required by regulation e.g. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 21 • Copy of application form • Two written references • Criminal Records Bureau Disclosure • Evidence of induction • Evidence of training and development. Training records sampled showed that staff had received training in the following areas: • Adult Protection First Aid • Epilepsy Awareness • Health and Safety Awareness • Food Hygiene • Moving and Handling • Medication Administration. Discussion with the registered manager indicated that the following training was scheduled for staff: • Food Hygiene • Fire Safety • Health and Safety. Discussion with one member of staff working at the home indicated that access to staff training was good. Sampling of records, alongside discussion with the registered manager and staff indicated that staff receive formal supervision on a monthly basis. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People living in the home can expect to be supported in a home that is well run and managed. People living in the home can expect that their views and opinions regarding all aspects of the running of the home will be regularly sought. People living in the home can expect that the home’s practice will ensure their health and safety. EVIDENCE: The registered manager of the home has significant previous experience of supporting people with a learning disability, and is currently looking into 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 23 undertaking the N.V.Q level four registered managers award, the manager is only registered for the one establishment, and continues to undertake relevant training to enable them to remain up to date. The home was first registered with the Commission for Social Care Inspection in the summer of 2006, and has recently undertaken its first internal quality monitoring review, which consisted of the use of a range of stakeholder questionnaires including: • People who live in the home • Staff • Relatives. In addition to the use of the above questionnaires the following audits were carried out: petty cash, medication, care plans and the organisation. A copy of the report was provided to the CSCI, sampling of the questionnaires indicated that most of the responses were generally positive. The home’s safe working practices were sampled through the viewing of the following safety record: • Control of Substances Hazardous to Health (COSHH Assessmnets) Assessments. • Record of monthly health and safety checks • Records of checks on temperatures of fridges and freezers. • Fire risk assessment • Records of visits by fire officers • Fire alarm test record • Record of checks on fire fighting equipment • Records of checks of emergency lighting • Records of fire instruction given to staff • Records of fire drills. • Alarm commissioning certificate. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 2 X 3 X X 3 x 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 25 N/A 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. 2. 3. 4. Refer to Standard YA6 YA19 YA22 YA37 Good Practice Recommendations It is recommended that care plans be further developed to ensure that guidance provided to staff is clear and easily understood. It is recommended that people’s health care records be maintained in a way that makes them more readily accessible and easy to track. It is recommended that a complaints log be developed for the recording of any complaints received. It is recommended the manager make provision for undertaking the registered managers award. 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 48 Holland Road DS0000067256.V329423.R01.S.doc Version 5.2 Page 27 - 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!