Inspection on 04/10/05 for 5 High Beech Close

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 High Beech Close 28/07/08

5 High Beech Close 19/09/06

5 High Beech Close 05/05/05

5 High Beech Close 13/10/04

5 High Beech Close 20/04/04

Similar services:

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 5 High Beech Close St Leonards-on-sea East Sussex TN37 7TT Lead Inspector Jeanette Denereaz Unannounced Inspection 4th October 2005 16.00 5 High Beech Close DS0000021335.V248998.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 5 High Beech Close DS0000021335.V248998.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. 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 5 High Beech Close Address St Leonards-on-sea East Sussex TN37 7TT 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) 01424 850785 01424 721862 East View Housing Management Ltd Sharon Kathleen Fisher Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated will be four (4). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection 5th May 2005 Brief Description of the Service: 5 High Beech close is owned and managed by East View Housing Management Limited (EVH) and is home to 4 younger adults with learning disabilities. The house is a modern executive style and has four bedrooms. It provides spacious accommodation for the residents, with a kitchen, utility room off the kitchen, dining and lounge areas. It has a reasonable sized back garden and driveway to the front of the house, the office sited in the converted garage. The home is situated off the main road, which has bus routes to Hastings and Battle. The residents attend various day services during the week and are supported to pursue leisure opportunities in the evenings and weekends. 5 High Beech Close DS0000021335.V248998.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, the second in the year running from April 1st 2005 to March 31st 2006. The inspection took place between 16.00 and 18.00. The manager was not present during this inspection. The overall focus of the inspection was on meeting with the residents and staff on duty, reviewing the progress of the requirements from the previous inspection and a full tour of the home. Time was spent meeting the staff inspecting a number of records, policies, procedures and other documentation. All resident were spoken to and showed the inspector around the home including their bedrooms. As this report was made following the second unannounced visit, and does not cover all the standards, therefore for the reader to make a judgment about the home, it is recommended that a copy of the last inspection report of the 5th May 2005 also be obtained to have a clearer picture of the home. What the service does well: What has improved since the last inspection? What they could do better: The staff need to be familiar with all the home’s policies and procedures. During this inspection they staff when questioned were unsure where certain documentation was located, and with the home’s procedures for recording complaints and concerns. An immediate requirement was made with regards to the protocol for the giving out of medication, and for the re-ordering and stocking of medication within the home. It was noted in the daily log that medication was given to one resident which belonged to another resident, both residents receive the same medication, but one resident had run out, however the medication had 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 Page 6 been delivered but not booked in. This exchange of medication was not recorded on the individuals’ medication records. There is a need for the staff to receive further training on giving and recording of medication, and for all staff to understand and follow the home’s policy and procedures at all times. There have been discussions between the manager and the senior management regarding the slope and terrain of the garden, but at the time of this inspection no work had taken place. 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. 5 High Beech Close DS0000021335.V248998.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 5 High Beech Close DS0000021335.V248998.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): 2,3,4 & 5 Residents are given all the information they need to be able to make an informed decision to live at 5 High Beech Close. EVIDENCE: There have not been any new residents to the home since the last inspection. However, the home has a comprehensive policy and procedures in place for prospective residents. The home is part of the East View Housing Organisation and has detailed policies and procedures in place for prospective residents. All residents living the home have copies of their contracts statement of purpose and Service Users’ guides. 5 High Beech Close DS0000021335.V248998.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 The residents’ care and support are well managed enhancing their independence and overall quality of life. EVIDENCE: Residents told the inspector that the staff knew their needs well as was seen during this inspection and at previous inspections. Care plans were inspected on this visit, and the staff indicated that they had an understanding and input into the care planning. The standard and depth of recording is very good and conducted in a confidential matter. 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 Page 10 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): These standards were inspected at the last inspection on the 5th May 2005 and were fully met. EVIDENCE: 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 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 the following standard(s): 20 In general the health and care needs are very well managed, however, residents could be at risk if the staff are not fully aware of the home’s policy and procedures for the receipt, recording, storage and handling of medicines. EVIDENCE: During this inspection the inspector found an entry in the daily log referring to an incident when medication was given to one resident which belonged to another resident, both residents receive the same medication, but one resident had run out, however the medication had been delivered but not booked in. This exchange of medication was not recorded on the individuals’ medication records or the staff member reprimanded. There is a need for the staff to receive further training in the home’s policy and procedures for the receipt, recording, storage and handling administration of medicines. However, following the inspection the manager has taken action the staff involved has had a disciplinary meeting and further medication training and continues to be supervised. 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 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 the following standard(s): 22 & 23 These standards were found to be fully met at the last inspection However, the inspector questioned the staff on duty about the home’s policy and procedures on the prevention of abuse to the residents, they were unsure of the policy and procedures, and this could be unsafe for residents. EVIDENCE: The staff needed to be prompted by the inspector when questioned about the policies and procedures on the prevention of abuse, concerns and complaints. They were unsure where the home’s complaints book was kept and it was not found during the inspection. 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 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 the following standard(s): 24,27 & 28 The residents continue to enjoy living at 5 High Beech Close; it is safe, nicely decorated and homely. EVIDENCE: Since the last inspection the lounge furniture has been purchased, and the lounge and dining room is much improved. The residents told the inspector they really like the new sofas. There have been discussions with the manager and the senior management of EVH regarding the slope and terrain of the garden, and there are plans to landscape this area. This was a requirement from the last inspection. During the tour of the home, the inspector was invited to visit all the bedrooms and bathrooms. The en-suite shower room to the back bedroom was found to need the tiles to be cleaned and re-grouted, as there was mould and mildew present. The home in general was found very homely, clean and hygienic. 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 Page 14 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): 31,34 & 36 The staffs is very well trained and undertake robust induction training. But they need to have more confidence in running the home in the absent of manager to safeguard residents. EVIDENCE: The staff on duty during this inspection informed the inspector of the training they intend and have undertaken; they spoke very highly about the training opportunities offered by EVH. It was evident that supervision and staff meetings had taken place. The inspector did ask to see certain documentation, has part of the inspection procedure, but the staff were unable to locate certain files. They were not confident on what action they would take if a resident wanted to make a complaint or if there had been an allegation of abuse. However, they were very respectful toward the residents and fully aware of their individual needs. 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 Page 15 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): 39,40,41 & 43 Residents consider that the way the home is managed and run makes it an enjoyable place for them to live. Residents are safe in the home, being very well managed and maintained. EVIDENCE: As the home is part of the EVH organisation the information regarding the financial accountability of the service would be held at the EVH Head Office. However, the manager has responsibility for the household budget and records buying and spending appropriately, and EVH audits these accounts regularly. The Inspector had a meeting with the Senior Management Team on the 13th June 2005 and reviewed the past year and discussed future planning. 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 Page 16 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 3 3 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 2 x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 2 x x 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 5 High Beech Close Score x x 1 x Standard No 37 38 39 40 41 42 43 Score x x 3 3 3 x x DS0000021335.V248998.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 YA20 Regulation 13(2) Requirement The registered manager must ensure staff comply with the home’s policy and procedures for the receipt, recording, storage and handling of medicines. The registered manger must ensure all the staff understand the procedures for the reporting of all allegations and incidents of abuse, and action taken. With reference to the older ensuite shower room, the registered manager must ensure that the tiling is clean and hygienic. The registered manager must ensure that the external environment that includes the back garden area is landscaped to enable residents to access this area safely. The registered manager must ensure that all the staff understand their roles and responsibilities, and have the confidence to run the home in the absence of the manager. Timescale for action 04/10/05 2 YA23 13(5)(6) 30/11/05 3 YA27 23(2)(j) 30/11/05 4 YA28 23(2)(o) 01/01/06 5 YA31 18, 19 30/11/05 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 Page 18 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 5 High Beech Close DS0000021335.V248998.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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