Inspection on 24/03/06 for 6 Coleman`s Stairs Road

This inspection was carried out on 24th March 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 13/12/06

6 Coleman`s Stairs Road 11/10/05

6 Coleman`s Stairs Road 16/03/05

6 Coleman`s Stairs Road 22/09/04

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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 6 Coleman`s Stairs Road 6 Colemans Stairs Road Birchington Kent CT7 9HJ Lead Inspector Jo Griffiths Unannounced Inspection 24 March 2006 10:00 th 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 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.V277779.R01.S.doc Version 5.1 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.V277779.R01.S.doc Version 5.1 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.V277779.R01.S.doc Version 5.1 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 11th October 2005 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. 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out between 10.00 and 14.00 on 24th March 2006. Staff on duty were spoken with, a tour of the premises undertaken and some records inspected. Service users were spoken with and observed in their daily activities as part of this inspection. What the service does well: 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`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 Page 6 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.V277779.R01.S.doc Version 5.1 Page 7 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, 3, 5 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. Each service user has a contract for their care. EVIDENCE: Each service user has a copy of the Service User Guide in their bedroom. This has been explained to each person in a way that is appropriate for them. The 4 people living at the home have been in residence for a number of years. A holistic profile provides a full assessment of each persons needs and identifies the support they require in everyday living. Service users needs are kept under review at the 6 monthly review meetings and through meeting with their keyworker 6-8 weekly. Service users needs are generally well met at this home and it was evident that the service users were very settled and happy. Service users have a contract with the home for their care. This states the terms and conditions of their care. Where possible these have been signed, usually by the relative. 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 Page 8 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, 7, 8, 9, 10 Service users have a person centred plan ensuring their needs are met. They are supported to make decisions and be involved in the running of the home. Service users are supported to take reasonable risks allowing them to enjoy independent lives. They know that their personal information will be handled in confidence. EVIDENCE: Each service user is involved in developing a person centred plan that identifies their needs and helps them to plan aspects of their lives. Most service users have close contact with relatives who are able to support the service user to promote their individual rights. Some service users may benefit from an advocate who is independent from the home. 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.V277779.R01.S.doc Version 5.1 Page 9 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): 11, 12, 13, 14, 17 Most service users enjoy sufficient numbers of meaningful activities and educational opportunities each week. All service users engage in appropriate leisure activities. Service users enjoy a balanced and healthy diet, but would benefit from a review of the serving times of meals. EVIDENCE: Service users access day services provided by The Avenues Trust. Activities include communication group, sensory and relaxation, gardening, social group and other skills sessions. In addition, staff at the home support service users to access the local community to use amenities and for leisure purposes. This includes church, walks, shopping, pub and meals out. One service user has refused a number of activities offered recently. Staff reported that his activities did not occur as frequently as other service users due to his specialist needs. This individual would benefit from a review of his interests and needs with regard to meaningful occupation. When at home service users can watch TV in the lounge or their bedroom if they choose. They all enjoy a weekly aromatherapy massage session and 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 Page 10 relaxation groups. Service users can use the large garden at the rear of the house in the summer. Service users dietary needs have been assessed and where necessary specialist support has been obtained to meet their individual needs. The menu runs over 4 weeks and is currently under review. Service users can choose to have snacks and drinks when they wish. During the inspection lunch was served, but service users were only just arriving home from their activities. This meant that meals were left standing for some time before they were served. 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 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): 19, 20, 21 Service users health needs are fully met. They are protected by the homes procedure for managing their medication. Service users needs as they get older have been addressed in their plan. EVIDENCE: Service users health needs are identified through a health action plan. They have their health needs met by the Primary Care Team and clear records are kept for all interventions. Professionals involved in the care of the service users include, dietician, psychologist, physiotherapist, speech and language therapy and district nurse. Service users require staff to retain and administer their medication. They are protected by the homes system for managing medication. Safe administration procedures were observed and storage of medicines is appropriate. All staff are required to undertake training and an assessment of their competence before they are allowed to administer medicines. The home is not currently using any medication that requires storage in a fridge. If this changes they will purchase an appropriate medication fridge. Service users needs as they grow older have been identified in their person centred plan. The home agrees to support service users for as long as their needs can be properly met. 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users and relatives know how to complain, if needed, and their concerns are responded to appropriately. Service users are protected from abuse by robust procedures in the home and trained staff. EVIDENCE: The home uses The Avenues Trust complaints procedure. This is displayed on the notice board in the home, included within the Service User Guide and presented on CD for service users. A record is kept of any complaints received into the home and any action taken to address the concerns. There have been no complaints received recently. Compliments are also recorded in the log. Relatives have praised the service and staff at recent care reviews. All staff receive training in the protection of vulnerable adults. Staff were able to describe the reporting process they should follow if they suspect any abuse of a person in the home. The Kent and Medway Adult Protection policy is available in the home and The Avenues Trust has its own policy that is in line with this. There have been no referrals made under the adult protection policy. 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 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, 25, 26, 27, 28, 29, 30 Service users benefit from a comfortable and clean home. They have access to sufficient private and shared space and bathroom facilities to meet their needs. The home is maintained to a high standard of décor and furnishing. EVIDENCE: The home is domestic in style and located within a residential street. There are 4 single bedrooms, a lounge, kitchen, dining room and an adapted bathroom. Service users can access the spacious rear garden in the summer months. The dining room was in the process of being redecorated. The home is kept clean and hygienic with the exception of some service users personal armchairs. Service users bedrooms have been decorated to their own taste. One service user was having his room decorated at present and had chosen the colours he wanted. Bedrooms are personalised with individual’s belongings, are comfortable and meet their needs. Each bedroom is fully furnished. All bedrooms are carpeted with the exception of one person who has a soft lino flooring as this better meets his individual needs. Although service users do not have ensuite facilities there are sufficient toilets and bathroom facilities available for communal use. There is a large bath and separate shower both suitable for people with mobility difficulties. 2 hoists are available to support the 3 service users who require these. 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 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): 32, 33, 35 Service users are supported by sufficient numbers of trained and qualified staff to meet their needs. EVIDENCE: Rotas evidenced that staff numbers are appropriate to the needs of the service users. There is always a trained shift leader on duty who takes responsibility for planning the shift and managing medication. Staff do not work excessive hours and are provided with the time they need to undertake study and attend training courses. Three new members of staff have been recruited since the last inspection, ensuring that service users can be supported by regular staff without the use of agency workers. New staff undertake The Avenues Trust induction which consists of all basic statutory training sessions and orientation to the home. New staff do not work alone until they are fully inducted. The training plan for the home was displayed in the office and most staff have competed the training they need to effectively support service users. Over 60 of care staff have completed or are completing an NVQ award. This exceeds the recommended standard and is very positive for service users. The Manager and one senior member of staff are NVQ assessors and hope to register new employees to do an NVQ this year. 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 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): 37, 38, 42 Service users benefit from a home that is effectively managed by a qualified and experienced Manager. Service users health, safety and welfare are promoted and protected. 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. Service users are supported by staff that are trained and competent to do their jobs. There are clear policies and procedures, risk assessments and safety checks within the home. Records showed the fire system is tested regularly and all equipment used in the home had been serviced. 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 x 5 3 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 3 28 3 29 3 30 2 STAFFING Standard No Score 31 x 32 4 33 3 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 x 16 x 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 3 3 3 x x x 3 x 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 Page 17 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 Standard YA30 Regulation 23(2)(d) 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, service users armchairs must be kept clean. Timescale for action 07/04/06 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 Refer to Standard YA12 Good Practice Recommendations It is recommended that a review of service users occupation and activities be undertaken. This is in particular relation to one service user who is currently not participating in many fulfilling activities. It is recommended that an independent advocate be sought for one service user. It is recommended that meals are not served in the DS0000023299.V277779.R01.S.doc Version 5.1 Page 18 2 3 YA7 YA17 6 Coleman`s Stairs Road kitchen before service users are ready to eat. 6 Coleman`s Stairs Road DS0000023299.V277779.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Kent and Medway Area Office 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. 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