Inspection on 11/10/05 for 6 Coleman`s Stairs Road

This inspection was carried out on 11th October 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 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

6 Coleman`s Stairs Road 11/11/08

6 Coleman`s Stairs Road 13/12/06

6 Coleman`s Stairs Road 24/03/06

6 Coleman`s Stairs Road 16/03/05

6 Coleman`s Stairs Road 22/09/04

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Insight - Eastchurch

Southfields

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Dovedale Court

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

CARE HOME ADULTS 18-65 6 Coleman Stairs Road Birchington Kent CT7 9HJ Lead Inspector Brenda Pears Announced 11/10/2005 at 09:30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 6 Coleman Stairs Road Address Birchington, Kent. CT7 9HJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01843 841967 The Avenues Trust Limited Mrs Daria Hudspeth Registered Care Home 4 Category(ies) of Physical Disablility (2) Learning Disability (2) registration, with number of places 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The home at 6 Coleman Stairs Road is a large detached bungalow situated in a residential area. It provides accommodation and support for 4 adults with learning and physical disabilities.The level of care and support is given on the basis of fully assessed need. Support is given to enable service users to participate in leisure activities provided both inside and outside the Home. There is access to relevant health care professionals and specialist support as required. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and the inspection consisted of speaking with staff members and service users. The methods of inspecting the home included checking records, tracking service user care plans, observations and a tour of the building. The focus of this inspection was on the core standards and on the quality of life for ser vice users. The Home was found to be clean, bright and free from odours at this inspection. Both the Registered Manager and the Service Manager were present at this inspection. As part of the pre-inspection process, residents and relatives were consulted for their views of the home. Families returned their comment cards, providing valuable feedback about the home, which helped in the planning of this inspection. Service users who were at home at this time were fully included in this inspection. The Home operates in a relaxed, friendly and comfortable way. The service users are at the centre of any activities and their opinions and preferences are sought on all matters. What the service does well: 6 Coleman Stairs continues to support service users to achieve their potential. Realistic goals are set and monitored with service users and appropriate advocates. Choices are given at all times with each day being spent as each individual wishes. Planned outings/activities are only undertaken if the service user wishes, if refused, then alternatives are offered until a suitable activity is decided upon. As an art session had been cancelled at an outside venue, the home offered space for the class to go ahead at 6 Coleman Stairs as service users enjoy this activity. One piece of work produced at this time is to be framed and hung in the home. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 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 standard(s) 2 & 3 Due consideration if given to the support needed by all service user and reviews are regularly undertaken. EVIDENCE: Assessments are undertaken by senior staff and also with relevant health care professionals such as speech therapists, physiotherapists and psychiatrists prior to any admission into the home. Files contain clear goals that are agreed prior to being set and person centred plans contain clear information of aspirations, life history and the level of support required. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 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 standard(s) 6 & 7 All activities are undertaken following discussion with each service user, supporting choice and autonomy. Detailed service user plans have been developed and are reviewed regularly to support any changing needs. EVIDENCE: Staff members ensure the wishes of service users are sought and that inclusion is undertaken at all times. This was evidenced at this time by staff constantly asking the preference of the service users present and full inclusion was observed during this inspection. Realistic goals are set and monitored with service users and appropriate advocates. Choices are given at all times with each day being spent as each individual wishes. Planned outings/activities are only undertaken if the service user wishes, if refused, alternatives are offered until a suitable activity is decided upon. The reason for not participating in certain activities is recorded to support the change and review of activities on care plans. Other information on care plans includes a personal history, information on preferred lifestyle, risk assessments and step-by-step intervention guidelines. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 10 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16 & 17 Service users enjoy their chosen activities, many of which are undertaken in the community, providing both choice and control. Friends and family relationships are encouraged and supported by the home. Meals are chosen on a daily basis by the service user, food eaten is recorded and the lunch time meal was seen to be relaxed and not rushed. EVIDENCE: All activities are decided through consultation with the individual and clearly set out in their person centred plan and supported by appropriate staffing levels. As an art session had been cancelled at an outside venue, the home offered space for the class to go ahead at 6 Coleman Stairs as service users enjoy this activity. One piece of work produced at this time is to be framed and hung in the home. Service users were enjoying this session and were happy to show their completed projects. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 12 Trips out, walks to local shops or the beach are part of daily activities and are recorded on each person’s care plan. The home is close to the centre of town and has a library and a variety of shops, cafes and pubs, which the service users are supported to visit. Other activities undertaken include trips to the cinema, pub and aromatherapy sessions. All relationships that are important to service users is encouraged and constant contact supported. Events in the home are undertaken with involvement and support from friends and family and pictures show outings with girlfriends that have been enjoyed. Lunch was being prepared at this inspection and food choices were offered to all service users. This meal was unhurried and a very relaxed experience. There is a wide variety of foods, fresh vegetables and fruit available. Meal preparation is undertaken with assistance and each person had whatever those wished for their lunch. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 & 20 All needs and preferences are clearly recorded on person centred plans, ensuring choices made by each individual are supported. Medication is appropriately stored and administered by staff to ensure the full health and safety of service users. A small medication fridge will be required to store any prescribed medication that needs cold storage. EVIDENCE: 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 14 The Inspector was informed that all personal care is supported and undertaken in the privacy of the service user’s bedroom or bathroom and this was the case during this inspection. Health professionals provide support that enables staff to provide full care needs for each service user. Healthcare visits are recorded and were evidenced in a sampling of records undertaken at this time. All service users have access to appropriate healthcare professionals and this is evidenced in care plans and notes of all healthcare visits. Due to a change in behaviours, one service user has been monitored and regular reviews have been undertaking regarding medication and diet. These checks have brought about some adjustments that are currently having positive results for this service user. Medication is administered via a monitored dosage system (MDS) and all relevant policies and procedures are in place. Medication training and individual competencies are assessed within the Home and regularly reviewed. Competencies are assessed through observations, discussions and questions regarding medication and its affects. While MDS medication is appropriately stored in good order, the home will need a medication fridge for any liquid medication requiring cold storage. No service user is currently selfadministering medicating. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Service users are protected and supported by policies, procedures and training in the home. EVIDENCE: There is a complaints procedure in place that is also available to service users in CD and video format. The manager explained that there is a good relationship with family and friends that encourages open discussions at all times. This was confirmed through the questionnaires received by the Inspector at this time. A complaints procedure was seen to be on display in the main entrance hall. Staff receive training in abuse awareness as part of their induction. Where service users require support regarding agitated behaviour, clear guidance is contained in the service user plan. Incidents are recorded, monitored and appropriately reported to the Commission for Social Care Inspection. The Home has a comprehensive system for the recording of service user finances that includes a daily check by staff on personal allowances and the retention of all receipts to cover any expenditure. If the seal is opened at any time, this is shown by a new seal number being allocated and staff double check all balances and two signatures are recorded at change over of shifts. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The Home was found to be clean, bright and free from odours at this inspection. The home provides spacious, safe and homely accommodation. Service user rooms are personalised and respected as an individual’s own space. The additional storage freezer in the outside storage/laundry area requires a service check as the seal is old and worn in some places. EVIDENCE: The accommodation at 6 Coleman Stairs is all on ground level to enable wheelchair access to the front and rear of the building. Rooms are spacious, light, airy and personalised with pictures of activities and holidays that have been enjoyed. There are substantial gardens to the rear, side and to the front of the property and adequate off street parking. A covered seating area at the side of the building has potted plants and sensory objects for service users to enjoy. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 17 Pictures and ornaments decorate bedrooms including some models and paintings that have been produced by service users. While the kitchen and inside storage was clean and orderly at this time, the freezer in the outside storage/laundry area is in need of servicing. The seal on this freezer needs cleaning and checking as some parts of the seal show signs of wear. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34,35 & 36 Service users are supported and protected by the staff training, recruitment and supervision process. Staff are given opportunities to develop their skills through the supervision process and also by opportunities identified in the organisation itself. EVIDENCE: All new staff undertake a full induction programme within the first six weeks of employment and statutory training is completed within the first six months. Staff needs with regard to training are identified by the Registered Manager during the appraisal process. This process forms the basis of training provided through the organisation. A full list of staff training undertaken and dates for refresher courses has been supplied. The home currently has more than 50 of staff with an NVQ level 2 qualification. Any staff identifying a desire to progress their role is supported by appropriate training and discussions through the supervision process. The registered manager also has regular supervision with the service manager. At the time of this inspection there were three care staff on duty plus the registered manager, there are three care staff on the afternoon shift and one 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 19 waking member of night staff. There is an on call system to support staff and this includes contact with the director or chief executive as appropriate. All activities and outings are assessed to ensure the correct staffing numbers are on the duty rota to support service users appropriately. This is evidenced through the review of rotas supplied prior to this inspection The company has a robust recruitment procedure that includes gaining full CRB checks prior to any staff commencing work. New employees are required to visit the Home prior to their start date to meet service users and staff. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 Quality assurance monitoring is regularly undertaken to assess the level of care being given and also the quality of the environment in the home. The home protects and promotes the safety and well being of service users. EVIDENCE: 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 21 The safety, health and well being of service users is considered at all times and the home was found to be clean and fresh in all areas. All staff are trained in safe handling of medication, moving and handling, fire safety, first aid, food hygiene and infection control as part of their induction. Regulation 26 visits are regularly undertaken and copies forwarded to the Commission for Social Care Inspection. All areas are systematically checked and any required plan of action is clearly identified and subsequently monitored. A formal quality audit is carried out annually by one of the directors, a service mnager and the registered mnager, an action plan is set from this process. Service user opinions and wishes are considered in future plans and questionnaires are sent out to next of kin, funding authorities and care managers. 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 22 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 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 6 Coleman Stairs Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 3 x x x H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 23 NO 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. 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. Refer to Standard 20 30 Good Practice Recommendations To consider the purchase of a small medicine fridge to ensure this is available at all times for prescribed medications requiring cold storage. To put fridge and freezers on regular check lists to support early detection of any areas needing attention 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 24 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent. TN23 1HU 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 6 Coleman Stairs Road H56-H05 S23299 6 Coleman Stairs V247841 111005 stage 2.doc Version 1.40 Page 25 - 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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