Inspection on 13/12/06 for 6 Coleman`s Stairs Road

This inspection was carried out on 13th December 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

6 Coleman`s Stairs Road 11/11/08

6 Coleman`s Stairs Road 24/03/06

6 Coleman`s Stairs Road 11/10/05

6 Coleman`s Stairs Road 16/03/05

6 Coleman`s Stairs Road 22/09/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

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`s Stairs Road 6 Colemans Stairs Road Birchington Kent CT7 9HJ Lead Inspector Brenda Pears Key Unannounced Inspection 13th December 2006 09:30 6 Coleman`s Stairs Road DS0000023299.V306863.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 6 Coleman`s Stairs Road DS0000023299.V306863.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. 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 6 Coleman`s Stairs Road Address 6 Colemans Stairs Road Birchington Kent CT7 9HJ 01843 841967 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) The Avenues Trust Limited Mrs Daria Hudspeth Care Home 4 Category(ies) of Learning disability (2), Physical disability (2) registration, with number of places 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To admit one (1) Service User whose date of birth is 25/12/31. To admit one (1) Service User whose date of birth is 23.08.1940. Date of last inspection 12th June 2002 Brief Description of the Service: 6 Coleman Stairs Road is a large detached bungalow situated in a quiet 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. The fees for support from the home are set during the assessment period and are very individual to the needs of the service user, depending on the level of support required and the staffing numbers provided. The average fee levels start at various levels and currently go up to £1614.00 per week. 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken with a focus on the well being, safety and quality of life for service users living in the home. The methods of inspecting the home included a visit to the home and discussions with the manager, service users and staff. A tour of the building and observations of both staff and service users at this time are reflected in this report and evidence outcomes. What the service does well: What has improved since the last inspection? What they could do better: 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 6 One area of flooring in the kitchen and one area on the surface top in the kitchen are damaged. These areas will collect dirt and grime and therefore present a health and safety risk. The manager is aware of these areas and has brought this to the attention of the housing authority, but action must be taken to ensure the control of infection. While most areas were found to be clean and odour free, the carpet in the main hallway was very stained. This is washed regularly, but the manager explained that a new carpet cleaner with special products have been ordered to ensure this area is continually stain free. The carpet is quite light and as this serves as the only access to all areas of the home, does get used constantly. Some areas would benefit from ongoing maintenance, such as the skirting in the main hallway, which is very scratched and marked. This only requires painting, but a continuous maintenance programme would highlight these areas and ensure these are regularly upgraded. 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. 6 Coleman`s Stairs Road DS0000023299.V306863.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 6 Coleman`s Stairs Road DS0000023299.V306863.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with the information they need about the service. They have a full assessment of their needs and know that these needs will be met by the home. EVIDENCE: All initial assessments are undertaken with multi agency participation, including care managers, service users, families/advocates if chosen by the service user. Assessments include risk assessments, full assessment of needs, what the service user wants to achieve and a detailed support plan. Any wishes expressed by a service user are noted and subsequently worked towards, both short or long-term goals are developed and supported. Current service users are also fully involved in any placement into the home, only after ensuring everyone is comfortable and happy, does a placement become permanent. 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are reviewed and service users make decisions about their daily life, supporting independence and appropriate care. Service users are supported to make decisions and be involved in the running of the home. EVIDENCE: 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`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 10 Relevant policies and procedures are presented in symbol and audio format and service users are consulted on the running of the home through regular meetings with their keyworker. Service users are supported to take reasonable risks to allow them to undertake the activities they wish to. All risk assessments are kept under review. Service users personal information is kept secure. Staff are briefed on their responsibilities to maintain confidentiality as part of their induction into the home. 6 Coleman`s Stairs Road DS0000023299.V306863.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: Service users were fully included in this inspection process and individual support was appropriately given with due consideration for dignity and independence. All activities are decided through consultation with the individual and clearly set out in their person centred plan and supported by appropriate staffing levels. 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 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. A variety of food choices are available and food storage areas showed a wide selection of healthy food, snacks and fruit. 6 Coleman`s Stairs Road DS0000023299.V306863.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff do ensure healthcare needs are met, consider the dignity of service users and treat individuals with respect. Medication is administered and stored appropriately. EVIDENCE: Health professionals provide support that enables staff to give full care to 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. 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 14 Due to a change in behaviours, one service user was previously monitored and regular reviews have been carried out on medication and diet. This has resulted in some positive changes in behaviour and a change in some routines for this person continues to help with positive behaviours. 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. One service user was being assessed for a new chair as posture angles had changed and the chair being used was not giving appropriate support. 6 Coleman`s Stairs Road DS0000023299.V306863.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are listened to and routines and practices in the home support and protect service users. EVIDENCE: There is a complaints procedure in place that is also available to service users in CD and video format. The manager has previously explained that there is a good relationship with family and friends that encourages open discussions at all times. This has been confirmed through previous questionnaires received and also through direct discussions with family members. 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. An advocate has been obtained for one service user who does not have family contact. The member of staff on duty at the time of this inspection clearly described how behaviours would trigger awareness of any problems or difficulties being experienced by a service user. 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 16 6 Coleman`s Stairs Road DS0000023299.V306863.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home was found to be, in the main, 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. 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`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 18 While most areas were found to be clean and odour free, the carpet in the main hallway was very stained. This is washed regularly, but the manager explained that a new carpet cleaner with special products have been ordered to ensure this area is continually stain free. The carpet is quite light and as this serves as the only access to all areas of the home, does get used constantly. One area of flooring in the kitchen and one area on the surface top in the kitchen are damaged. These areas will collect dirt and grime and therefore present a health and safety risk. The manager is aware of these areas and has brought this to the attention of the housing authority, but action must be taken to ensure the control of infection. Some areas would benefit from ongoing maintenance, such as the skirting in the main hallway, which is very scratched and marked. This only requires painting, but a continuous maintenance programme would highlight these areas and ensure these are regularly upgraded. Rooms are very individual, pictures and ornaments decorate bedrooms including some models and paintings that have been produced by service users. The laundry area has now had the flooring coated to ensure the appropriate protection and control on infection. 6 Coleman`s Stairs Road DS0000023299.V306863.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 good. This judgement has been made using available evidence including a visit to this service. Staff undertake appropriate training, are competent and qualified to work in the home. The home’s recruitment policy and practices protect service users. 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 training is 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 to the commission 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`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 20 Staff have regular supervision and staff spoken to at this time confirmed that they feel supported by the manager and the staff team. A board in the hallway clearly identifies staff on shift and this information is supported by large photographs of each member of staff. Ensuring all service users are aware of who will be in the home and providing support. 6 Coleman`s Stairs Road DS0000023299.V306863.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. This judgement has been made using available evidence including a visit to this service. The staff and routines in the home protect service users and promote their safety and well being at all times. EVIDENCE: The Manager holds the NVQ 4 qualification in both care and management and the Registered Managers Award. It was evident through discussion with staff that they are well supported and involved in the running of the home. Quality assurance monitoring is regularly undertaken to assess the level of care being given and also the quality of the environment in the home. 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 22 Service user opinions and wishes are considered in current and future plans. The safety, health and well being of service users is considered at all times and the home works in a relaxed and inclusive way. Staff are trained in core skills that support service users needs and well being. Life skills and goals are supported by staff and the routines in the home are dictated by service users needs and wishes. 6 Coleman`s Stairs Road DS0000023299.V306863.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 x 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 YA30 Regulation 23 Requirement The registered person shall having regard to the number and needs of the service users ensure that all parts of the care home are kept clean and reasonably decorated. In that, the kitchen must comply fully with the control of infection in all areas. Timescale for action 28/02/07 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 YA30 Good Practice Recommendations It is recommended that an environmental audit of maintenance be developed. This will identify areas needing attention and ensure the home meets requirements in all areas. 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 6 Coleman`s Stairs Road DS0000023299.V306863.R01.S.doc Version 5.2 Page 26 - 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!