Inspection on 28/09/05 for 74 Sir Evelyn Road

This inspection was carried out on 28th September 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

74 Sir Evelyn Road 22/02/08

74 Sir Evelyn Road 01/11/06

74 Sir Evelyn Road 01/02/06

74 Sir Evelyn Road 24/03/05

74 Sir Evelyn Road 12/05/04

74 Sir Evelyn Road 03/12/03

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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 74 Sir Evelyn Road 74 Sir Evelyn Road Rochester Kent ME1 3LZ Lead Inspector Anne Butts Announced 28 September 2005 10:00 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. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 74 Sir Evelyn Road Address 74 Sir Evelyn Road Rochester Kent ME1 3LZ 01225 444 596 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) The Robinia Group PLC Mrs Helen Elsie Gardner Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Two residents under the age of 18: (1) 6/4/1985 (2) 13/11/1985 Date of last inspection 24 March 2005 Brief Description of the Service: Sir Evelyn Road provides a specialist service for young adults with Autistic Spectrum Disorder. The home is registered to offer residential care for a maximum of six service users, and at present provides care and support to four service users. The home is situated in a quiet residential area near to Rochester Town Centre, and has easy access to the local bus route. The home also has its own transport which is used for the benefit of the service users. The accommodation comprises of a large communal lounge/dining area, dining room, spacious kitchen, laundry room, toilets, bathroom, office. It has six bedrooms (four of which are en-suite). There is a large private garden that can be accessed from either the dining area or a seperate door. The home offers high levels of staffing so as to enable 1:1 support to service users so that they have access to community, leisure and educational amenities. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place on 28th September 2005 and was carried out by Anne Butts – who was supported throughout the inspection process by the registered manager, Helen Gardner. All service users were observed moving freely around the home during the day and making choices about their activities, meals and general daily living. The rapport, which was observed between the manager, staff and service users, was excellent and it was evident that there is genuine respect and regard between all parties. There were two requirements made at the previous inspection and these had both been met, and of the three recommendations made – the manager has worked towards meeting these. She had some concerns with regards as to how the home shares their confidentiality statement with partner agencies and as the home has produced a fully informative statement of purpose and service users guide (which is available to all interested parties) – it was recommended that they reflect the confidentiality statement. What the service does well: What has improved since the last inspection? A new complaints procedure has been introduced in a pictorial format that is suitable for the service users. Service users are being supported with their needs through person centred planning and these are very reflective of the important matters in the individual’s lives. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 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. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.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 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.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) 1, 2 and 3. Service users can be confident that they and their representatives will be provided with enough information about making a decision about moving into the home and that they will be continually monitored and assessed in order to ensure that their ongoing needs are met. EVIDENCE: The statement of purpose and service users guide were viewed, and both documents contained all the information that service users and their families or representatives needed to be able to make a fully informed decision about the home – as identified in the summary of this report it was recommended that the home includes the statement of confidentiality as this will make it readily available to all. The service users guide is also in a format that meets service users needs. Prior to any service user moving into the home there is a full needs assessment that is carried out and supported by the individuals care manager. This is then supported by an assessment made by the home that involves the appropriate person visiting the service user prior to admission in their current environment – an important part of accepting new service users is that they are able to live in the home with current service users and that their individual needs can be met. The manager is under no pressure to take service users who are not appropriate and whose needs they cannot meet. It is the needs of the individual which takes priority and is not about ‘bums on beds’ and ensuring that money is the key. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.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 and 9 Service users benefit from comprehensive care plans which are aimed at supporting them in meeting individual needs and they can be confident that comprehensive risk assessments protect and promote their rights to lead a fulfilling lifestyle. EVIDENCE: All service users have a care plan, and these are formed from the initial needs assessment and then supported by ongoing assessments carried out at regular intervals. The care plans are built around behavioural patterns and personal needs. The home has also had input from a person centred care planning approach team who are working with the service users on building individual person centred plans and one in particular reflected significant important associations in one service users life – and was something that the service user was extremely proud of. The home has extensive risk assessments that are also an integral part of the care plans and are under constant review. As hazards or risks are identified they are fed into the care plans and used to support the service users in maintaining a fulfilling lifestyle as possible. There are individual risk assessments for service users that encompass their daily routines within the home and supports them in undertaking outside activities. This particular 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 10 service user group need a high level of constant support and care and the risk assessments reflect this. Risk assessments are also used in a pro-active manner, in which at the end of each outing or activity a risk assessment is completed about the event and any issues are cascaded into the care plans and ongoing support needs. The home demonstrates overall good practice by involving the members of staff in the risk assessment process. The only recommendation with regards to this area is that as staff are made aware of changes to care plans and updates on risk assessments that they sign to say that they have read and are aware of any changes and updates to risk assessments and care plans. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.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) 11, 12, 13, 14, 16 and 17. Service users benefit from support and care in their daily living routine that is flexible to suit their needs and preferences. Choices of meals and a balanced diet are offered by the home and those service users requiring specialist diets are well catered for. EVIDENCE: The home provides care to service users who are in need of ongoing constant supervision and support. Their ability for personal development is limited due to the nature of their condition and the home endeavours to meet their needs through a support programme that ensures they have a continuity that is related to their needs. Service users are encouraged to be part of the local community by being supported by staff in going shopping, visiting locals cafes and other amenities on a regular basis. Many of the service users enjoy water based activities and they are supported in going swimming and attending hydrotherapy. They also go skating and have had visits to the beach and the zoo. Within the home there is a lightly structured activities programme that allows for changes 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 12 dependent on daily needs. This includes leisure activities such as puzzles, art, sensory programmes and also involves helping out around the home with daily living skills such as cleaning their own rooms, helping with the washing up and cooking light meals or snacks. Much of the programme is based on continuity and repetitiveness as this promotes the ongoing needs of the individuals. Information provided to service users about activities is done in a pictorial format so allowing them to be able to make their own choices. It is not appropriate for service users to attend educational or work based activities but they are well supported through other activities as previously mentioned. Service users do not have a key to their own room – but have access as required, and evidence seen on files showed that this had been risk assessed. Service users are able to open their own post and staff were observed in helping an individual read a letter which he had received. Meal times are relaxed and are set around general times that suit the service users. There is a full list of likes and dislikes and also special diets available for staff so that they are aware of individual preferences. The home encourages a healthy eating syndrome and the menus are placed in the dining room and are in a pictorial format. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.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) These standards were not inspected on this occasion but had been met at the last inspection. EVIDENCE: 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 14 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 Service users can be confident that there is a robust complaints procedure in place that is in an appropriate format for their needs. EVIDENCE: There have been no complaints made since the last inspection. The home has introduced a new complaints procedure for service users that is in a pictorial format and is more user friendly for those living in the home. Complaints are also checked through the organisations regulation 26 visits – in which a senior member of the management team visits the home and carries out internal inspections. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 15 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, 25, 26, 27, 28, 29 and 30 Service users benefit from living in an environment that is largely well maintained and reflects their choices and lifestyle. The kitchen would benefit from some refurbishment in order to improve safety and hygiene. EVIDENCE: The home is set in a large semi-detached property close to Rochester Town Centre. It has private and secluded gardens to the rear and is spacious and generally well maintained. Overall the home is comfortable and homely. Although the main living area is fairly sparsely furnished and decorated this is in keeping with the service users needs. The main forms of decoration are paintings and artwork including hanging mobiles and banners prepared by the service users. The manager and staff actively support them in this activity and the artwork is changed on a regular basis as they choose their different themes. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 16 The kitchen is in need of some attention, as some of the cupboard doors do not fit properly, the manager stated that this was part of a redecoration programme. Individual bedrooms were all of a sufficient size and suited service users needs, they reflected their own personalities and contained many personal possessions. Service users had chosen their own colour schemes and also how their bedrooms were set out. The bedroom on the ground floor is in need of new carpeting, but this is also being addressed. Risk assessments accompanied by hazard analyses are in place to ensure that a safe environment is maintained in the bedrooms for individual service users. As stated some of the rooms are en-suite and of those that are not – only two service users share a bathroom. Currently there are no special adaptations, although the one service user whose mobility needs are more restricted has a bedroom on the ground floor. Laundry facilities are separate and are kept locked, and any hazardous substances (cleaning fluids for example) are also kept in a locked cupboard in this room. There is also a separate room for a larger fridge and freezer and supplies from this are transferred into the kitchen so that service users are able to access snacks and drinks. The freezer contained a good range of fresh meats and a variety of foodstuffs. Temperatures are taken twice and day and are recorded. An approved contractor collects any clinical waste on a regular basis. The home has an ongoing decoration and maintenance programme in place for the general upkeep and has also made provisions for other improvement work, and it is recommended that any areas identified within this report are addressed as soon as possible. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 17 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) 31, 33 and 34 Service users are protected by the home’s recruitment procedures and can be confidant that staff are supported in their role by the management team. EVIDENCE: Staff are provided with job descriptions which clearly define their roles and responsibilities. There is a key worker system in place and the care plans, which set out the support to be provided to the service users, are read and used by staff in the support of the individual. Staff were seen to relate well with the service users and support them with activities and daily tasks, including preparing lunch. The rotas showed that there is sufficient number of staff to support service users within the home, and also to escort service users on outings. Staff are trained in the use of communication methods including Makaton and were seen communicating well with the service users and showing an understanding of their needs. Staff support the service users with their personal needs and support individual in learning general daily living skills. There is a robust recruitment policy and procedure in place, and prior to a position being offered a prospective member of staff spends a ‘shift’ working in the home with service users, supported by an appropriate senior staff member. CRB and POVA checks are fully carried out, references are obtained along with proof of ID and any gaps in employment are explored. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 18 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) 37, 38 and 39. Service users can be confident that they supported by a manager and larger organisation that are committed to providing specialist support to meet their individual needs. EVIDENCE: The manager has a nursing background and has completed her NVQ level 4 in management and is a trained assessor. She is currently completing her NVQ level 4 in care. Her overall responsibilities include the day-to-day running and organisation of the home and ensuring that the service continues to meet the needs of the service users. She was seen to work well with both staff and service users and it was evident that there is genuine regard and respect from all parties with good working relationships in place. The manager and the larger organisation are committed to providing support to this particular service user group only, and the statement of purpose and aims and objectives reflect this. In this way they provide a high level of 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 19 support and quality care to service users who have very specific needs and high dependency levels. There is an annual quality assurance process in place and the outcomes are published and made available. Throughout the home any information that service users needed such as activities programme, staff who are on duty, menus, complaints and fire procedures are in a pictorial format which all the service users can use and understand. This is an important information sharing process which enables service users to feel secure in their environment. 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 20 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 3 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score 3 x 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 74 Sir Evelyn Road Score x x x x Standard No 37 38 39 40 41 42 43 Score 4 3 3 x x x x 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 21 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 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. Refer to Standard YA10 Good Practice Recommendations It is recommended that in order to ensure that all partner agencies are in receipt of a statement of confidentiality it is incorporated into the Statement of Purpose and Service Users Guide, as this is made available to all interested parties. It is a good practice recommendation that as risk assessments are updated all staff sign to say that they have read and are aware of any new hazards. It is strongly recommended that any maintenance which is required in the kitchen is carried out as soon as possible. 2. 3. YA9 YA24 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent 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 74 Sir Evelyn Road 20060127 H56-H06 S40213 74 Sir Evelyn Rd V244074 280905 Stage 4.doc Version 1.40 Page 23 - 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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