Inspection on 04/01/07 for 51a Chapel Park Road

This inspection was carried out on 4th January 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 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

51a Chapel Park Road 31/01/06

51a Chapel Park Road 19/07/05

51a Chapel Park Road 22/02/05

51a Chapel Park Road 12/10/04

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Insight - Eastchurch

Southfields

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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 51a Chapel Park Road 51a Chapel Park Road St Leonards-on-sea East Sussex TN37 6JB Lead Inspector Jeanette Denereaz Key Unannounced Inspection 4th January 2007 15:30 51a Chapel Park Road DS0000021408.V325559.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 51a Chapel Park Road DS0000021408.V325559.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. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 51a Chapel Park Road Address 51a Chapel Park Road St Leonards-on-sea East Sussex TN37 6JB 01424 204033 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) East View Housing Management Ltd Vacant Care Home 1 Category(ies) of Learning disability (1) registration, with number of places 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of residents to be accommodated is one (1) The service users accommodated will be aged over eighteen (18) and under sixty-five (65) years on admission. 31st January 2006 Date of last inspection Brief Description of the Service: 51a Chapel Park Road is a registered service for one service user with learning disabilities. It is a self-contained one bedroom flat with a separate kitchen and bathroom. The flat is next door to 51 Chapel Park Road another registered service for people with learning disabilities, but has a separate entrance to the main building. East View Housing (EVH) manages both services. The flat is situated in a residential area of St Leonards on sea. It is a short distance from local amenities and shops and has easy access to public transport. The current fee is £1300 per week. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 51 Chapel Park Road are referred to the ‘resident’. This report reflects a key inspection based on the collation of information received since the last inspection and an unannounced site visit conducted by an Inspector on the 4th January 2007. The site visit included a tour of the premises and an examination of various records including medication, care and staffing records. The Inspector met with the new manager, two staff members on duty and the resident. What the service does well: What has improved since the last inspection? What they could do better: The arrangements for the resident’s finances has been discussed at previous inspections regarding the resident and the staff supporting him, with outcomes to secure control and choice over his monies and access to his personal financial records. The inspector was informed that there has been meetings, 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 6 and this issue was on the agenda, but the resident’s parents continue to refused the discuss the matter. The staff must ensure that all visitors sign in the visitors book at all times, the inspector observed once again that her signature was the last in the book from her visit at the previous inspection in January 2006. The flat is small and the staff sleep in the lounge on a sofa bed, but there were comments that the sofa bed is uncomfortable. There was also bedding in the lounge, which was unsightly. The sleeping apparatus and bedding for staff undertaking sleeping duties should be discussed and reviewed. The ceiling in the toilet needs attention, as there were gaps in the ceiling tiles. 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. 51a Chapel Park Road DS0000021408.V325559.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 51a Chapel Park Road DS0000021408.V325559.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): 1,2,3,4 &5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide clearly says what service will be offered. A prospective service user could be confident their needs will be assessed, and the home will meet their needs and aspirations. EVIDENCE: EVH has a robust organisational policy and procedures for the admittance of new residents to the service. The resident now living at 51a Chapel Park Road has been there for over 3 years and seems very settled. However, if a new resident was to move in, they would have access to suitable written information to inform them of the service and what it is like to live at 51a Chapel Park Road in the form of a statement of purpose and service user guide. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 9 The resident has a written contract and service users guide, which have been signed by him and a representative, and the contents of these documents have been fully explained to him. During this inspection visit, the resident was present and he briefly spoke to the inspector, and it was evident from his conversation and behaviour he enjoys living at 51a Chapel Park Road. 51a Chapel Park Road DS0000021408.V325559.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): 6,7,8and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff demonstrated their knowledge of the individual resident, and are aware of the complex needs of this resident and encourage him to have an independent lifestyle as far as possible. EVIDENCE: The resident’s care plan were inspected on this visit, and indicated that the standard and depth of recording is very good. The flat is designed around the resident, and is full of his interests. He has a notice board, which indicates which member of staff will be supporting him. It is evident that he is consulted on all aspects of his life and the inspector observed discussions between the resident and the staff regarding his attendance to church, his evening meal and his recent visit to his parents and the surprise trip to the America. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 16 & 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home’s links the local community are excellent and enrich the resident’s live socially and educationally. EVIDENCE: The service is excellent in promoting the development of the resident’s personal, social and educational skills. His days are full of activities out in the community and when at home his has many interests, which, mostly are related to programmes he has seen on the television and videos. He has an interest in African drumming, and he now has private lessons. Other recreational activities include trampoline, rock climbing, attending the cinema, library and going out to restaurants. The menus are varied and are compiled with the resident, he is also involved all the shopping. The staff member on duty stated the resident really enjoys 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 12 his food, and he will help with the preparation if he is not engaged in something else, he always washes up and put all crockery and cutlery away after each meal. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19. & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The resident’s health and care needs are very well managed and take into account his individual preferences and needs. EVIDENCE: The resident has a 1:1 service and lives in a flat alone, and all his personal support is tailored to his needs. The resident was present at this inspection, and he briefly spoke to the inspector, and told her all about the church he attends and what priest would be saying mass on Sunday. The resident’s family are very important to him, and contact is very regular, and there is frequent communication between the staff and the family, especially with the mother and father. This young man has many hobbies and interests and it was evident he is supported to have a full and interesting life. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 14 The resident does not administer his own medication; the staff are all fully trained in the storing and administration of medication. The medication held in the home was inspected and found to be in order. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident is protected as far as possible from the risk of harm or abuse, however the staff and resident are vulnerable when using the cash card belonging to a third person. The home are doing all they can to resolve this matter, but a third party are blocking any change. EVIDENCE: The resident lives in a home that belongs to the EVH organisation, and all the staff receive awareness training on abuse to vulnerable adults. The Inspector continues to have concerns with the arrangements that are in place for the resident to access his personal allowance with staff using a (cash card) belonging to a third person. It is required that arrangements are made to secure the individual’s finances and safeguard the support staff. The home should advocate on the behalf of the resident and ensure they are working within the care standard 23.6, ensuring the resident has access to his own personal finances. The inspector was informed that at the resident’s recent review meeting the arrangements for his personal financial was on the agenda, but his parents refused to discussed this matter. The new manager was not aware of this situation, and she will be contacting the resident’s care manager. The inspector observed once again that her signature was the last in the book from her visit at the previous inspection in January 2006. The staff must 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 16 ensure that all visitors sign in the visitors’ book at all times, thus ensuring the safety and protection of the resident. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 17 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): 24,25,27,28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall standard of the environment including the décor and furnishing are good and provide a homely and attractive place for residents to live. EVIDENCE: The Inspector toured communal parts of the flat including the kitchen, lounge, bathroom and toilet. The inspector was not invited to visit the resident’s bedroom on this occasion, but his room was inspected a the last inspection and was found to be comfortable and very individually decorated and furnished reflecting the resident’s hobbies and interest as is the rest of the flat, with a comprehensive library of videos and DVD displayed attractively on bookshelves in the hallway. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 18 The flat is small and the staff sleep in the lounge on a sofa bed, but there were comments that the sofa bed is uncomfortable from heavy use. There was also bedding in the lounge, which was unsightly. The sleeping apparatus and bedding for staff undertaking sleeping duties should be discussed and reviewed. However, the rest of the flat was very clean and tidy. The home is generally well maintained but it was noted by the inspector that the ceiling in the toilet needs attention, as there were gaps in the ceiling tiles. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. 31,32,34, & 35 This judgement has been made using available evidence including a visit to this service. The staff employed have the skills and experience to meet residents needs and support them. However, the manager must ensure that at recruitment references from the last two employers of the candidate are requested, as stated in the organisation’s recruitment policy and procedures. EVIDENCE: EVH has a robust recruitment policy and procedures but there had been a downfall in the procedures of obtaining references for the staff being reviewed. There was confusion if reference requests had been sent out, as the staff member was from overseas, and he was under 21 years old and had been lone working. The staff member had had PoVA and CRB checks carried out and had undertaken the organisation’s induction training. Since the inspection visit the inspector has been contacted by the organisation’s senior management team and was informed the staff member has been removed and was working in 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 20 another area of the organisation where his age would not an issue, and his references have been requested. They have reviewed the procedures of obtaining and reviewing references for staff, and have made a managerial decision that the manager of the individual homes will take responsibility of obtaining references and following up late or absent references before the staff member take up duty. The decision was made that with a third person i.e. the head office of EVH sending out and receiving or not receiving references for all the EVH homes was not consistent, and not always following up late or absent referees and therefore not safeguarding residents. The Senior management team will be informing all the managers of this new procedure, and give advice and training in the sending, reading and interpret references. There has not been regular supervision for staff, but the new manager is in the process of setting up dates for staff supervision, and she will send a copy of the dates of the CSCI. The two staff members working during this inspection visit were very committed, and had a good knowledge of the resident. He was relaxed in their company and was chatting about the day and his plans. He also discussed with the staff member working that evening about his evening meal and was evident to the inspector he was totally involved in decision making and supported by a competent staff team. There was a matrix of training displayed in 51 Chapel Park Road which included the staff of 51a Chapel Park Road, and it was evident all staff are involved in training, with one staff member undertaking Ldfa training (Learning disability framework award), and other undertaking NVQ training a various levels. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. 37,39,41 & 42 This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The home benefits from a well-motivated and experienced manager, who is supported by motivated senior management team and enthusiastic staff team. A safe environment is maintained for residents. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 22 EVIDENCE: Since the last inspection the home now has a new manager, she is very experienced and has had managerial positions in other care homes. She will be making application to the CSCI to become the registered manager of 51 Chapel Park Road and 51a Chapel Park Road. Records showed that all aspects of health and safety were being met this included looking at appliance safety certificates, staff training, and accident records. All staff receive regular mandatory training and training that has taken place since the last inspection as been in Moving and Handling training, fire safety, food hygiene and Medication administration. A nominated staff member of the home, and also by the EVH organisation’s Health and Safety Officer carries out health and safely checks. The inspector saw documentation of the checks and audits. The senior management team of the EVH organisation also undertake monthly visits to the home as part of the Care Home Regulation (26), which requires a responsible person of the organisation to inspect the home, and write a report on the conduct of the home. All accidents and significant incidents are promptly reported to the CSCI. 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 23 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 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 x 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 x 3 x 3 x 2 3 x 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA41 YA23 Regulation 17(2) Schedule 4 (17) 13(6) Requirement Timescale for action 01/02/07 2 YA28 23(3) 3 YA34 17(2) Schedule 4 (6) The Responsible Individual and the manager must ensure there is a record of all visitors to the home, including the names of visitors to ensure the safety of the resident. The Responsible 01/03/07 Individual and the manager must ensure staff are provided with adequate facilities when sleeping in, this is to include the storage of bedding. It is required that the 01/02/07 manager and the responsible individual ensure there are full staff records within the home and available for inspection at all times. It is required that the manager and the responsible individual ensure that before staff are employed in the home, two written 01/02/07 4 YA34 Schedule 2 (5) 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 25 references are obtained relating to the person. Also there should be no lone working for an employee under the age of 21 years. 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 YA23 Good Practice Recommendations It is recommended that arrangements are made to secure the individuals finances, and safe guard the resident and staff, as at the present time they are accessing a third person’s pin number and bank account. With outcomes to secure control and choice over his monies and access to his personal financial records. The home are doing all they can to resolve this matter. However, it is the third party that are blocking any change. It is recommended that the Responsible Individual should ensure there is a programme of routine maintenance and repair to ensure the home is always in good decorative order. This is in connection with the ceiling in the toilet. 2 YA24 51a Chapel Park Road DS0000021408.V325559.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 51a Chapel Park Road DS0000021408.V325559.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!