Inspection on 15/02/06 for Blakeney House

This inspection was carried out on 15th February 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Blakeney House 14/08/07

Blakeney House 01/11/06

Blakeney House 25/09/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Blakeney House 33-35 Park Road Westcliff On Sea Essex SS0 7PQ Lead Inspector Ann Davey Unannounced Inspection 15th February 2006 12.30 Blakeney House DS0000062585.V278142.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 Blakeney House DS0000062585.V278142.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. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Blakeney House Address 33-35 Park Road Westcliff On Sea Essex SS0 7PQ 01702 335724 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) rowan.house@achuk.com Aitch Care Homes Limited Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2005 Brief Description of the Service: Blakeney House is registered to accommodate 10 young adults with a learning disability. The premises is a large detached property situated within walking distance of Southend town centre. All bedrooms are single and have ensuite facilities. There are adequate lounge, dining and communal rooms. The home has a good-sized car park and a rear garden/patio area. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of 3.45 hours. At present there is no registered manager in post, but the Commission is currently processing an application. At the time of the inspection, the home was accommodating 6 residents. The inspection focused mainly on the progress the home had made since the last inspection, although other standards were assessed. A partial tour of the home took place. Staff and residents were spoken with. Records were selected at random and various elements viewed. A notice was displayed in the main entrance advising any visitors to the home that an inspection was taking place with an open invitation to speak with the inspector. The inspector provided the acting manager with a full and detailed feedback from the inspection with opportunity for clarification and/or further discussion. The home is now owned and managed by Consensus Healthcare Ltd. As a consequence, the stated web address is now incorrect. These details will be amended and reflected within the ‘service information’ section in the next report. The contact telephone number remains the same. What the service does well: What has improved since the last inspection? The home now has an acting manager. The Commission is currently processing the application for registration. Various documentation systems/processes have been reviewed. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 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. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 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 Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 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 the following standard(s): 2 Adequate pre admission and admission documentation was not in place. EVIDENCE: Three residents had been admitted since the last inspection. In 2 cases, the pre admission documentation was adequate. The third resident had been admitted 5 days before the inspection took place, but the home could not evidence any current pre admission assessments, admission, care plan or risk management assessment documentation. This is not acceptable. The acting manager said that the admission had been arranged and agreed to by the previous registered person (ACH Ltd). It was stated that insufficient time had been given to the acting manager by the previous registered provider to carry out an adequate assessment. There was no protocol/agreement in place between the previous and new provider about such arrangements. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 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 the following standard(s): 6,7,8 & 9 Not all residents had a care plan. There was evidence that residents are consulted and their opinions sought. Risk assessments were in place. EVIDENCE: Six residents were accommodated and three care plans were viewed. Two were adequate in detail and content, but the third did not have any care plan documentation. Staff did not have any current information and /or documentation relating to their current care needs, there were no written directions or instructions informing staff of care needs requirements and/or how to meet them. There were no current risk assessments in place for this resident. The acting manager said that the resident was admitted without any documentation and no documentation had been put in place since admission. This is not acceptable as it places not only the resident at risk, but also other residents accommodated and staff. The inspector spoke to ACH Ltd during the inspection, who agreed to forward documentation that afternoon. The acting manager agreed to put a care plan in place that day. In other case records, risk assessments were in place, but the acting manager agreed that the staff lack risk/conflict management strategy training. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 10 The acting manager agreed that the home must review the current system by which care plans are reviewed. The ‘next review date’ shown on care plans was sometimes confusing and was not always an accurate reflection of practice within the home. Care plan documentation was in a secure environment and maintained in an orderly manner. Documentation evidenced that residents according to ability, play an active part in the daily routines of the home. Residents are provided with adequate support and assistance to enable them to enjoy as an independent lifestyle as possible. This was reflected in individual care plans. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 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 the following standard(s): These standards were not assessed at this inspection. EVIDENCE: These standards were not assessed at this inspection. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 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): 20 The home was not following current medication policies and procedures. EVIDENCE: At the previous inspection it was noted that staff were not signing entries when they had manually transcribed medication administration instructions onto MAR (medication administration record) sheets. Direct reference at that time was made to the home’s copy of The Royal Pharmaceutical Society of Great Britain Guidance. It was disappointing to note that at this inspection, this inadequate practice remains. Furthermore, it was of concern that the home could not locate their copy of the current guidance. The inspector provided the home with a photocopy of the document. Current PRN (as/when required) medication protocols were in place. Although not inspected, the storage facility for medication was orderly, clean and secure. The acting manager updated the inspector on proposed ‘update’ medication training for all staff within the home. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 13 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 Staff awareness of POVA reporting procedures requires review. The complaints recording procedure has been amended. EVIDENCE: The acting manager agreed that staff training concerning POVA awareness and reporting procedures requires review. The various levels of training were discussed and it was agreed that training would be arranged. The acting manager said that since the last inspection, no complaints have been received. Assurances were given that any future complaint(s) would be documented in accordance with guidance. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 14 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 & 30 The overall quality of the environment, furnishing, fitments and decor was of a good standard. EVIDENCE: Bedrooms seen were personalised, individual, comfortable and contained all the necessary aids/adaptations required by the respective resident. Communal areas were well furnished and comfortable. The home was clean, warm and had a friendly atmosphere. The kitchen area was safe and all COSHH materials substances were secularly locked away. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 15 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): 33,34 & 35 The home has an established core group of staff. Staffing numbers during the inspection were adequate for the number of residents accommodated. Staff recruitment records were maintained better than before. Training is being reviewed. EVIDENCE: The home benefits from an established core group of staff. The home is currently recruiting additional staff. The staff rota was accurate and clear. Staff numbers were adequate on the day to provide care for the 6 residents accommodated. Staff recruitment records had been reviewed since the last inspection. The registered provider must ensure that recruitment records (or copies of) pertaining to the acting manager are in the home. The acting manager said that Consensus Healthcare (new provider) are to review and assess the current system by which staff recruitment records are maintained and held, as there was considerable duplication and this could lead to confusion. Staff are now employed by Consensus Healthcare and the current processes require review. The acting manager said that staff training needs are currently being reviewed. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 16 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): 37,38,39 & 43 A robust transition management protocol agreement needs to be developed, agreed and implemented for the general wellbeing of residents and staff. EVIDENCE: The home is now owned and managed by Consensus Health Care, yet the previous owner ACH Ltd, are continuing to assess and place residents in the home. The inspector was informed by ACH Ltd that this was part of the ‘transition agreement’. The acting manager said that she had not seen any written protocol about such arrangements. The situation is now quite confusing to the home. There must be clarification about management responsibility, accountability and decision making processes. Staff are now employed by Consensus Healthcare, yet feel obliged to follow direction from ACH Ltd. Understandably, they feel ‘torn’ between the two. On a day-to-day basis, the majority of residents do seem not directly affected by the transition period. However, the significant issue remains that one resident was admitted to the home by the previous provider without ensuring Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 17 that the required assessment documentation was in place. This was not in the home’s or the individual resident’s best interest. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 18 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 1 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 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 2 2 3 X X X 2 Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 19 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 YA2 Regulation 14 Timescale for action The registered person(s) must 15/02/06 not admit any resident to the home until a full current assessment has been made, the home has a copy of the assessment and has agreed that it can meet the assessed needs. This process must be carried out in accordance with regulatory and the nation minimum standard requirements. This was with immediate effect. The registered person(s) must 15/02/06 ensure that all residents admitted have a current plan of care which contains all the required and necessary documentation and information. This process must be carried out in accordance with regulatory and the nation minimum standard requirements. On this occasion, this requirement related to the identified incident as detailed within the report, as is therefore with immediate effect. Version 5.1 Page 20 Requirement 2 YA6 15 Blakeney House DS0000062585.V278142.R01.S.doc 3 YA20 13 The registered person(s) must 15/03/06 ensure that all staff responsible for dealing with medication are aware of and follow laid down guidance as detailed within the report. The previous timescale of 7/11/05 to meet this requirement has not been achieved. The registered person(s) must 07/03/06 review the current ‘transition period’ and put in place clear arrangements that will enable to home to be managed in a more effective manner during this period. There must be clear lines of management responsibility and accountability. This is for the wellbeing of residents and staff. A copy (draft if necessary) of any agreement must be sent to the Commission within 7 days of receipt of this report. 4 YA38YA43YA37 10 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 YA23 Good Practice Recommendations The registered person(s) should review and ensure that all staff are fully aware of (according to level of line management and/or line responsibility) the correcting reporting procedures for any suspected POVA matters. Appropriate training will need to be provided. The registered person(s) should review the current system by which staff recruitment records are kept/maintained as detailed within the report. DS0000062585.V278142.R01.S.doc Version 5.1 Page 21 2 YA34 Blakeney House 3 YA35 The registered person(s) should review and arrange (where necessary) appropriate training for staff. Adequate records should then be held on file. Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Blakeney House DS0000062585.V278142.R01.S.doc Version 5.1 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. 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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