Inspection on 29/09/05 for Betsham Road (84)

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Betsham Road (84) 13/09/07

Betsham Road (84) 18/05/06

Betsham Road (84) 20/04/05

Betsham Road (84) 28/10/04

Betsham Road (84) 22/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Betsham Road (84) 84 Betsham Road Erith Kent DA8 2BG Lead Inspector Peter Daniel Unannounced Inspection 29th September 2005 9:15 Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Betsham Road (84) Address 84 Betsham Road Erith Kent DA8 2BG 01622 769100 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) MCCH Society Limited Mrs Christina Lesley Harris Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (2) of places Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2005 Brief Description of the Service: Betsham Road is a Care Home managed by Maidstone Community Care Housing. The service provides 4 self-contained flats for adults of both genders, aged 18 to 65 years with moderate/severe learning difficulties. The flats are joined at a central point and are staffed at all times. The home accommodates 9 service users in total. Betsham Road is situated in a small cul-de-sac in a residential area close to Erith Town Centre. There are bus routes and local shops near by. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the 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. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 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 Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 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): 1,2,4,5 Service user’s needs are assessed. Perusal of resident’s files showed that some care plans need to be regularly updated. The home still does not hold a copy of the service user’s contract. EVIDENCE: NMS 1 and 4 Prospective users have information they need to make an informed choice about where to live. Admissions are planned and prospective service users are invited to ‘test drive’ the home. The Inspector checked the care plan/goals/aims of the newest resident. He had made introductory visits and had stayed for the weekend stay before he moved in. The placement is reviewed after a trial period and an assessment of his placement will be done in October. NMS 2 Service user’s needs are assessed. The inspector saw service users’ individual care plans. It was noted however that for one service user the monthly care plans still had to be completed for the previous three months. A requirement has been set for the home to ensure that records are kept up to date. See requirement 1 NMS 5 The last two inspections set a requirement for a copy of the contract/agreement to be held locally on all service user’s files. The original contracts are still being held at head office and this has still not been expedited. See requirement 2 Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 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): Service user’s needs are reflected in their individual Plan and each individual also undergoes a risk assessment. EVIDENCE: NMS 6 Service user’s individual needs are reflected in their individual plan and in the risk assessment. An interim and a full IP meeting is held each year. The inspector saw evidence of this on the file and also a ‘Strengths and Needs’ list. Each resident also has a personal diary that contains records of daily information. NMS 7 Service users make decisions about their lives with assistance from the key worker or other staff. The key worker plays an important role in understanding the service user’s wishes and feelings and will represent the service user’s views. The service user and key worker/member of staff will communicate with each other using signs or through the communication passport. NMS 9 Service users are supported to take risks. The inspector saw evidence of risk assessments on service user’s files. One risk assessment concerned Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 9 issues around bathing and guidelines for safety around a service user’s personal care. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users have opportunities for personal development and an active lifestyle. EVIDENCE: NMS 12 and 13 Service users take part in appropriate activities and are involved in the local community. Three service users attend day centres and one goes to a local college. Two residents go swimming at local pool. Some residents attend a pop in parlour. Three attend church every week. The home had a garden party in August. Each service user will go out on a one-to-one with staff for lunch. Two went bowling during today’s inspection. Two residents recently went on holiday to Camber sands. The inspector saw service user’s activity sheets that demonstrated evidence of these activities. NMS 15 Service users have appropriate personal and family contact. Two residents go home to visit their parents on a weekly basis and they are supported by the home with transport. Another resident has weekly phone contact with a parent and one parent visits the home every Saturday. These arrangements were confirmed by a member of staff. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 11 NMS 16 Service users rights are respected. As a means of communication/consultation, each service user fills out a form ‘things I like most’ and ‘things I don’t like’. Evidence was seen on service user’s files. NMS 17. Service users are offered a balanced diet. The inspector saw a menu as evidence and also viewed the contents of the fridge. Food in the fridge was appropriately labelled. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 12 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): Service users receive excellent support and their physical and emotional needs are being met. EVIDENCE: NMS 18 Service users receive personal support through the key worker system and staff in general. There is a good ratio of staff to service user, often 1:2. The inspector observed staff providing sensitive care towards service users and offering appropriate support and guidance. NMS 19 Service users physical and emotional health needs are met. Each service has a personal health profile that was seen on file. The inspector observed the communication book. It showed evidence that a service user had attended a local health centre and had been referred for an eye test, chiropody, checks regarding diabetes and an update of his medication. The file also showed evidence that a referral had been made to the Learning Disability Team that was monitoring the situation. Further evidence was noted on file of other service users being referred to the dentist and for chiropody. NMS 20. The home has an effective policy and procedures regarding the control and administration of medication. None of the service users selfmedicate and all medication is administered by two staff. Medication is held in bubble packs and kept in locked cabinets in each flat. Staff have access to PRN Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 13 medication. The inspector noted that the incident book had recorded a failure to administer medication on two separate occasions – in May and August. The manager has explained this was down to human error. The staff members concerned have been taken off administering medication until they have received further training. The home has now changed the system whereby two members of staff administer medication and two signatures are required. MARS sheets and evidence of signatures were seen. Staff are currently attending a health facilitation course. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 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 the following standard(s): There is an Adult Protection Policy and service users are protected from abuse. Service users have opportunities to convey their views. EVIDENCE: NMS 22 Service users views are listened to. ‘Informal’ flat meetings are held at regular intervals. The key worker will support the resident and represent their views as appropriate. IP meetings are held twice a year – see above. NMS 23 The home has an Adult Protection Policy and a Whistle Blowing Policy. Some staff are attending refresher training regarding adult protection. The inspector saw evidence of this in the home’s communication book. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 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 the following standard(s): 24,30 Service users live in homely, comfortable surroundings. EVIDENCE: Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 16 NMS 24 Service users live in a homely, comfortable and safe environment. The home has two ground floor and two first floor flats. All are self-contained. There is a communal corridor and staircase. The carpet on the stairs to flats C and D has been replaced since the last inspection. The office near the entrance has been improved in terms of shelving and desk space. The flats in contrast are spacious and homely. Some improvements have been made since the last inspection: bath panel in Flat D has been replaced, there are two new carpets in two of the service users bedrooms in Flat B, the shower room in flat B has been refurbished and the overflow pump in flat B has been remedied. There are still some outstanding refurbishments to be addressed–the cooker in flat C needs to be relocated as it is situated in an unsafe position; the ceiling in flat D and GD’s bedroom still needs artexing. Access from the front door needs to be dealt with- this has been agreed but must be given priority. These matters have been set out as a requirement. See requirement 3 NMS 25 and 26 Service users’ bedrooms were observed and there was evidence that residents are able to promote their independence and individual lifestyles. Each service user is allowed to have their own personal possessions in their rooms and this allows them to express their identity. NMS 30 The home was observed to be clean and hygienic and kept to a good standard. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 34,35,36 The home has a committed and well -trained staff group. There are sound recruitment policies in place. A requirement has been set to ensure staff receive more regular supervision and that appraisals take place annually. EVIDENCE: NMS 31 The home has reasonable clarity of staff roles. The Centre Manager had been allocated two days a week doing management duties and three days doing Senior Care Worker duties. The home recently appointed a deputy manager who works part time. The appointment of a deputy manager has relieved the Centre Manager of some of her management duties. Two Senior support workers share the responsibility for supervising the nine support worker staff, each of whom has key worker responsibility for a service user. NMS 32 and 35 Service users are supported by competent and qualified staff. The home has a well-trained workforce that has the skills to meet service users individual needs. The manager has an NVQ level 4 qualification, a registered Manager’s Award and a Certificate in Management. One of the Senior Support Workers has an NVQ level 2 qualification and studying for level 3. The other has recently finished a Certificate in Health and Social Care equivalent to an NVQ level 3-4 and is now doing the registered manager’s award. Three support worker staff have an NVQ level 3 qualification and two are currently studying for an NVQ level 2 qualification. That will leave one person without an NVQ Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 18 qualification. There are two bank staff. One has finished doing a degree in Nursing. The requirement that 80 of care staff in the home need to achieve a qualification in care NVQ 2 by 2005 has been met. File showed staff had attended the following training in past 18 months: health facilitation, Hep B and HIV, medication, epilepsy, Rectal diazepam, diabetes and Adult Protection. NMS 34 Service users are supported by the home’s recruitment policy and practices. The staff records are kept in good order. Staff files include records of all persons employed in the care home and include their qualifications and experience, records of interviews, references, job title, correspondence, reports and other records in relation to his/her employment including CRB check numbers. NMS 36 Staff supervision notes were seen on staff files. There appeared to be some inconsistency about the frequency of supervision. It was noted that one staff member was receiving supervision about every 6-8 weeks. Another had not received supervision for 12 weeks although had presented problems around timekeeping and recording. The inspector did not see evidence of annual appraisals taking place. The home needs to ensure that supervision is offered at least 6 times a year i.e. every 8 weeks and appraisals held once a year. See requirement 4. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 19 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, 39,41,42 Service users benefit from a well run home and there is excellent quality of care. There is scope for the home to improve its filing and record keeping systems. The home should also implement ‘quality’ monitoring systems and seek the views of service users. It was noted for example that Regulation 26 visits have not been happening on a regular basis although this has been set as a previous requirement. EVIDENCE: NMS 37 The home is well run. Staff told the inspector that they feel supported by the home’s manager. There is scope to improving filing systems and getting files in better order. Some improvements have already been made in this area. NMS 38 There is good management of the home. The inspector observed a committed staff group, good moral and a relaxed, informal atmosphere. Minutes were seen that confirmed that Team meetings are held monthly and that the manager communicates with staff. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 20 NMS 39 No responsible person reports (Regulation 26 visits) have been received at the CSCI since April 2004. This has been set as a requirement. See Requirement 5 NMS 41. Although record keeping was generally in good order some gaps were noted. See NMS 2 that sets a requirement to keep records up to date. Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 21 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 2 x 3 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 x 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Betsham Road (84) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 1 x 2 x x DS0000037836.V253899.R01.S.doc Version 5.0 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA41 Regulation 17.3a Timescale for action The registered manager must 31/10/05 ensure that records required by regulation for the effective running of the home are maintained, up to date and accurate The registered person must 31/10/05 ensure that a copy of the contract/agreement is held on all service user’s files The registered manager must 31/12/05 ensure that refurbishments or modifications regarding the cooker in Flat C, easy access from the front door and artexing of ceilings are given priority. This is a requirement that has not been met from the previous inspection. The registered manager must 30/11/05 ensure that all staff are appropriately supervised appraised The registered provider must 30/11/05 ensure that Regulation 26 visits are carried out and reports sent to the Commission monthly. This requirement. This is a requirement that has not been met from the previous inspection. DS0000037836.V253899.R01.S.doc Version 5.0 Page 23 Requirement 2 YA5 5.3 3 YA24 23 4 YA36 18 5 YA39 26 Betsham Road (84) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Betsham Road (84) DS0000037836.V253899.R01.S.doc Version 5.0 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. 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. 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