Inspection on 14/12/05 for 57 Pembury Road

This inspection was carried out on 14th December 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

57 Pembury Road 17/10/06

57 Pembury Road 02/09/05

57 Pembury Road 19/10/04

57 Pembury Road 26/07/04

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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 57 Pembury Road Tonbridge Kent TN9 2JB Lead Inspector Paul Stibbons Announced Inspection 14th December 2005 10:15 57 Pembury Road DS0000023887.V261765.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 57 Pembury Road DS0000023887.V261765.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. 57 Pembury Road DS0000023887.V261765.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 57 Pembury Road Address Tonbridge Kent TN9 2JB 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) 01732 354949 The Avenues Trust Limited Doreen Phyllis Forward Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 57 Pembury Road DS0000023887.V261765.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Age range 40 - 65 Care of one service user is restricted to one older person whose date of birth is 05/02/1940 2nd September 2005 Date of last inspection Brief Description of the Service: 57 Pembury Road is a detached house within walking distance of Tonbridge town centre. The Avenues Trust Ltd are the registered providers. The home provides accommodation and care for 4 men who have learning disabilities, one of whom also has mental health difficulties. The accommodation is arranged on 2 floors with one ground floor bedroom. There is a small bathroom and separate toilet on the first floor and a shower room on the ground floor. There is a lounge and kitchen diner with access to the laundry and shower room via the kitchen. The home has steep stairs to the first floor and is therefore unsuitable for severely disabled people and wheelchair users. There is a patio area and small garden to the rear and parking for up to five cars to the front. 57 Pembury Road DS0000023887.V261765.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulatory inspector Paul Stibbons conducted this announced inspection from 10.15 hrs until 13.15 hrs. The pre-inspection questionnaire, self assessment, 2 comment cards from relatives and 1 from a service user, were received by the CSCI prior to the inspection. The home’s manager and one service user were present for the duration of the inspection. A tour of the building was carried out and a variety of documentation examined. Communication with the service user present was difficult and therefore some judgements made are through observation, discussions with the manager and where possible supporting records. What the service does well: What has improved since the last inspection? Since the last inspection the home has made progress in completing goal action plans with individual service users, these show short, medium and long term goals and how they may be achieved. A review of the storage and recording of medication has taken place and the medication room now has a thermometer and hand washing facility, also, PRN protocols are more specific in detail, thereby promoting the safety of service users. 57 Pembury Road DS0000023887.V261765.R01.S.doc Version 5.0 Page 6 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. 57 Pembury Road DS0000023887.V261765.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 57 Pembury Road DS0000023887.V261765.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): 1, 2, 5 Service users are provided with sufficient information to enable them to make an informed decision as to whether the home is able to meet their needs. EVIDENCE: Comprehensive assessments are carried out for all potential service users to ensure the home is able to meet individual needs. The home has recently assessed a potential new service user and declined the placement as the home felt unable to fully meet the needs of the individual. Care plans viewed demonstrated that a person centred planning approach is used to identify physical, social and emotional requirements. Service user guides give information on the home and contain individual contracts and terms and conditions of the placement. 57 Pembury Road DS0000023887.V261765.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, 10 Individual plans reflect the changing needs and personal goals of service users and their right to confidentiality is upheld. EVIDENCE: Care plans that were viewed evidenced progress in person centred planning and reflected the short, medium and long-term plans of service users. The changing needs of one service user indicated the need for equipment and adaptations in order to use the bath. The home’s manager has referred specialist assessments to Head office for funding. Service user files and confidential information was seen to be securely stored in the manager’s office. 57 Pembury Road DS0000023887.V261765.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): 14, 16, 17 Service users are encouraged and supported in making decisions affecting their daily lives and enjoy a healthy and balanced diet. EVIDENCE: Service users are supported in accessing a variety of leisure activities within the community and the home. Recent outings have included a visit to Chichester harbour and Christmas shopping trips with their keyworkers. Service user meetings are held where they are encouraged to make choices and they benefit from the use of pictorial aids when choosing meal preferences. They accompany staff on shopping trips to buy food and menus viewed indicated a healthy and balanced diet. Service users’ rights were seen to be respected during the inspection. 57 Pembury Road DS0000023887.V261765.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): 18, 20, 21 Service users receive personal support according to their wishes and requirements and medication is only administered by competent named staff who have undergone competence based assessment. EVIDENCE: Care plans viewed set out individual preferred routines and likes and dislikes. Daily records show that service users choose when to retire to bed and when they choose to get up. Medication was seen to conform to The Royal Pharmaceutical Society of Great Britain guidelines and is only administered by named appropriately trained staff who have been assessed as competent. It is recommended that service users’ consent to medication is obtained and recorded in the individual plan. The manager stated that service users’ wishes in respect of illness and death have been ascertained and recorded. 57 Pembury Road DS0000023887.V261765.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): 23 The home has policies and procedures in place to protect service users from neglect and abuse. EVIDENCE: Staff training files viewed evidenced staff training around adult protection and frequent refresher courses to re-inforce knowledge. 57 Pembury Road DS0000023887.V261765.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, 26, 27, 30 Service users live in a homely, safe and clean environment although some areas require refurbishment. EVIDENCE: The home was clean and tidy on the day of the inspection with adequate furniture for service users’ comfort. The kitchen units are showing signs of wear and tear and need replacing, the manager stated that a new kitchen is within the planned maintenance program. All of the bedrooms are single, spacious and reflect the interests and lifestyles of individuals, however, an ongoing requirement to provide hand wash basins in bedrooms remains unmet. There is also one bedroom with a badly soiled carpet, this must be cleaned or replaced The manager stated that quotes for this work have been submitted for approval. The location of the ground floor shower room is not ideally situated to provide privacy for service users’ and it is recommended that consideration be given to erecting a partition wall between the kitchen and this area for privacy and hygiene purposes. 57 Pembury Road DS0000023887.V261765.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 Service users benefit from well supported and supervised staff and are protected by the home’s recruitment policy and practices. EVIDENCE: Service users are protected by robust recruitment practices carried out by the Human Resources department. Before a position is offered a CRB check and verification of two references is obtained. All new employees undergo induction training and job descriptions clarify their roles and responsibilities within the service. One member of staff has an NVQ qualification and four have applied for a course of study. Training records show that other training courses relevant to the service have taken place. The manager stated that staff receive supervision in excess of six times annually. 57 Pembury Road DS0000023887.V261765.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, 42,43 Service users benefit from living in a home where their views on the service provided are actively sought. They are protected by the home’s policies and procedures and record keeping and there are competent and accountable management systems in place. EVIDENCE: The Avenues Trust has an annual quality assurance system in place that seeks feedback from service users and other stakeholders in the community. The service manager conducts monthly internal reviews and provides the CSCI with a copy of the findings. There was a notice displayed in the home informing service users of this inspection and comment cards were received back prior to the inspection. Service users were given the opportunity to speak with the inspector but none wished to on this occasion. Feedback received was generally positive. Policies and procedures were in place that complied with relevant legislation and safeguarded the rights and best interests of service users and confidential information was securely stored. An insurance certificate was displayed that adequately covered the services assets and 57 Pembury Road DS0000023887.V261765.R01.S.doc Version 5.0 Page 16 liabilities. There is a business and financial plan for the service that can be viewed by the CSCI on request. 57 Pembury Road DS0000023887.V261765.R01.S.doc Version 5.0 Page 17 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 x x 3 Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x x 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 3 x x 2 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 3 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score 3 x x 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 57 Pembury Road Score 3 x 2 3 Standard No 37 38 39 40 41 42 43 Score x x 3 3 3 3 3 DS0000023887.V261765.R01.S.doc Version 5.0 Page 18 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 2 3 Standard YA24 YA24 YA26 Regulation 23(2) (b) 23(2) (d) 16(2) (c) Requirement The kitchen units are worn and in need of replacement Service user’s bedroom carpet badly soiled and needs cleaning or replacing. Service users’ bedrooms should be provided with hand wash basins. Previous timescales 30/12/04 and 22/12/05 Timescale for action 30/04/06 30/03/06 30/04/06 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 Refer to Standard YA20 YA30 Good Practice Recommendations Service users’ consent to medication should be obtained and recorded in the individual plan. It is recommended that a partition wall be placed between the kitchen and laundry/shower room. 57 Pembury Road DS0000023887.V261765.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. Extracts may not be used or reproduced without the express permission of CSCI 57 Pembury Road DS0000023887.V261765.R01.S.doc Version 5.0 Page 20 - 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. 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