Inspection on 02/09/05 for Breakaway

This inspection was carried out on 2nd 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 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

Breakaway 10/08/07

Breakaway 15/08/06

Breakaway 27/01/06

Breakaway 31/08/04

Breakaway 23/03/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Breakaway Park Lane Aveley Essex RM15 4UB Lead Inspector Trevor Davey Unannounced 2 September 2005 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. Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Breakaway Address Park Lane, Aveley, Essex RM15 4UB 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) 01708 861520 N/A N/A East Living Limited Position vacant Care Home 4 Category(ies) of Learning disability and Physical disability - both registration, with number sexes (4) of places Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1.Service category: Care Home only. 2.Service user categories: learning disability and physical disability. 3.Maximum number of registered places: 4 (both sexes). 4.Placements must be arranged to ensure that the two categories of service users (learning disability and physical disability), are not accommodated together in the home for the same period of short-term care. 5.The home is to provide short-term care for periods of no longer than four weeks at a time. Date of last inspection N/A Brief Description of the Service: Breakaway is a detached property which has been adapted and refurbished as a care home to provide respite care for adults with a learning or physical disability. The accommodation includes four single bedrooms, a lounge and dining room, kitchen and shower facilities. The accommodation and facilities have been specifically designed for disabled people. A new purpose built bathing facility is to be included shortly. There is a large garden with a patio area to the rear of the property and off-road parking to the front. A vehicle has been ordered for the home which will be used for the benefit of residents to give them easier access to the local community and surrounding area. Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place on 2nd September 2005 lasting 4.75 hours. The inspection process included discussions with the Area Manager and deputy who is the current Acting Manager, two residents and three staff. A tour of the premises took place and a sample of policies and records were inspected. Nineteen standards were covered and requirements and recommendations are listed in the report. What the service does well: What has improved since the last inspection? N/A Breakaway I56-I06 S18070 Breakaway V247639 020905 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. Breakaway I56-I06 S18070 Breakaway V247639 020905 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 Breakaway I56-I06 S18070 Breakaway V247639 020905 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) 2 Although the needs and individual aspirations of prospective residents are assessed to determine the suitability of any intended placement to the home, not all relevant information had been included or lacked sufficient detail. EVIDENCE: Pre-admission information was available in the personal-care records which included medical, financial details and mobility needs. Some of the personal summary information provided by parents, lacked detail but pre-admission assessments are now being carried out by the Acting Manager who visits prospective residents in their homes with a member of the staff team. Where this information had been gathered, this included relevant details to assist in determining the suitability of placements. The Inspector was advised that this process is being developed an updated. Some of the community care information and summary of needs/ care plan which had been completed by social workers, lacked specific information which is necessary for the management of the home when considering prospective admissions. Breakaway I56-I06 S18070 Breakaway V247639 020905 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) 6,7, & 9 The systems for resident consultation are good with a variety of evidence in the care plans sampled, to show that residents needs are identified and met in accordance with their wishes. Some information had not been updated or included in the individual risk assessment and management forms. EVIDENCE: Some of the care plans and risk assessments inspected were more detailed whilst others, were waiting to be updated. Residents spoken to confirmed that their care plans and arrangements for support were discussed with them and they were supported by the home in pursuing their own preferred daily routines and activities. This included cooking, access to the computer as well as attending college. Other staff were observed supporting and communicating with residents with sensory impairments, with sensitivity and in a manner which was both appropriate and effective. Individual risk assessment management forms were signed by staff indicating that these had been read and noted. Key workers from the staff team as well as co-workers, are allocated to specific residents to ensure a good working relationship and to provide continuity of care and support. Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 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 standard(s) 12,16 & 17 Residents are given the opportunity of being involved in culturally appropriate activities and developing relationships both personally and socially. Residents are involved in selecting meals in accordance with personal choice. Not all residents are able to access day centre or school activities whilst staying at the home. EVIDENCE: Records were available of various social and other activities involving residents which included, souvenir photographs which had been printed out and given to them as a reminder of visits made. Records of menus and meals provided to residents were available. Staff were observed feeding residents where this was necessary and food had been prepared specially to suit their needs. Residents, who are wheelchair-bound, are taken out by staff to shopping centres and to the coast and other places of their choosing. Because of the funding arrangements by the Local Authority Social Services Department, it is not always possible for some of the residents to attend their normal day centre or school activities. It is understood that the Commissioners will not always pay for day- care provision whilst a resident is receiving respite care. This means that residents’ rights could be infringed and that freedom of choice is Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 11 restricted in pursuing educational training, and/or taking part in valued and fulfilling activities. Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 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 standard(s) 18 Residents receive personal and healthcare support in the way they prefer and which is appropriate for their needs. Not all protocols where staff are involved in carrying out clinical procedures, had been approved or signed for by the health care professional concerned. EVIDENCE: Personal-care records included information related to daily continence charts, daily log reports, nutritional assessment as well as nightly hourly checks carried out by staff on behalf of residents. Records also included medical treatment provided by district nurses and other health care professionals. It was noted that the protocol for a peg feed in respect of one resident and which had been the subject of a Regulation 37 notification recently, had not been signed by the health care professional to indicate that named staff were trained and capable of administering this clinical procedure. Records did not include times of when the feed was last connected and of any subsequent checks, which may have been made by staff. Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 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 standard(s) 22 & 23 There is an established complaints procedure of which residents are aware and a system is in place for residents to express their views. A policy and whistle blowing procedure for the protection of vulnerable adults is available but this does not include the need to notify the Commission for Social Care Inspection of such incidents as part of the reporting procedure. EVIDENCE: There have been no recorded complaints since this new service was registered. The Acting Manager advised the Inspector that parent relationships have improved and developed with the result that a number of positive comments regarding the care and improvements in resident’s quality of life, had been received. A form had also been devised to ascertain the opinions/comments of residents and parents regarding the service provided. Cards of appreciation were also available in the home which had been received from parents. The Acting Manager and over 50 of the staff have received P.O.V.A. training and records were available. However, although the Registered Provider’s whistle blowing policy has recently been updated, this did not include the need to report any incident to the Commission for Social Care Inspection under Regulation 37 of the Care Homes Regulations. The Acting Manager was advised that an updated version of the whistle blowing policy should be sent to the Commission for Social Care Inspection. Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 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 standard(s) 24,27 & 30 Residents live in a homely, comfortable and safe environment and the home is maintained to a clean and hygienic standard. Toilets and shower facilities have been provided with appropriate equipment for disabled people. At the time of inspection, an adjustable bathing facility was not available which is necessary if the individual needs of all residents to be accommodated are to be met. EVIDENCE: The home has been purposely designed to accommodate and meet the needs of adults with a learning or physical disability. Safety features, as well as the position of fitments and access within and around the building, are suitable for the purpose of providing respite care to residents within the approved registration category. Shower facilities have been provided together with adjustable chairs and other equipment. An adjustable bathing facility is needed to ensure that all the needs of residents can be met and where sufficient space is available for wheelchairs and other equipment. The Inspector was advised that this additional facility should be provided by the end of October 2005. Any changes to the fire precautions and zoned areas, have been agreed with the fire officer. Copies of approval given by the fire officer must be sent to the Commission for Social Care Inspection. The home was clean and hygienic and staff are aware of infection control procedures. Advice had recently been given Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 15 to staff as a result of a visit from a Consultant from The Essex Health Protection Unit. The interior decoration and colours selected, have taken into consideration residents who may have partial visionary impairments. Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 16 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) 32,33,34, & 35 Residents are supported and protected by an effective staff team where individual and joint needs are met. Thorough recruitment procedures were in place but some records did not include evidence of Criminal Record Bureau checks, which had been applied for. EVIDENCE: At the time of inspection, there was a full staff complement and designated staff were covering the planned rota. This included bank staff to cover sickness. The staff rota is planned eight weeks ahead and the current rota included the designated person in charge of the shift with the Acting Manager working on a supernumerary basis. There are normally three support workers plus the Acting Manager and two night staff on awake duty. At the time of inspection, the staffing cover was appropriate to meet the needs of residents and allow flexibility for staff to accompany residents when pursuing outside activities and interests. Recruitment files and procedures were well documented, easy to follow and included evidence of identity, references, probation assessment form and induction records. Records of supervision were available as well as role profiles. Staff signatures had been included on the induction checklists and five staff have completed N.V.Q.Level 2 and others are studying for this qualification. Other staff have completed N.V.Q.Level 3. Although copies of Criminal Record Bureau checks were available on some staff files, others had no evidence to show that C. R. B. checks had been applied for or that P.O.V.A. First checks had been instigated. Staff spoken to, confirmed Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 17 that they had received training on a regular basis including dealing with sensory impairments, suicide/self harm and eating disorders. Some staff had also received training in carrying out clinical procedures, conflict management and first aid. Other training included the administration of medication, moving and handling/hoist training. Prior to the home opening, staff stated that they had also been given the opportunity of visiting another care home for two weeks in order to gain experience in caring for physically disabled people. Staff confirmed that they had received contracts of employment and that they were well supported by the management and that communication was effective. A new member of staff confirmed that she had been shadowing other staff during the day and night shifts. Staff who had previously worked in the home when it was providing permanent care, stated that it had been a challenge in adjusting to the high turnover of new residents who are now admitted on a short term respite care basis and in addition, the need to keep personal care records up to date. The staff were very positive in how the team were working together as well as the training and support received. Breakaway I56-I06 S18070 Breakaway V247639 020905 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 & 42 The management of the home is effective and residents benefit from the service being offered. An official appointment has still not been made for manager of the home who also needs to be registered with the Commission for Social Care Inspection. The health, safety and welfare of residents are promoted and protected. EVIDENCE: The Area Manager has been overseeing the operation of the home since it was registered in May 2005 with the Deputy Manager, acting up as Manager in dayto-day control. Recruitment of a permanent post for the Homes Manager needs to be concluded as soon as possible. There is evidence to show that the existing management cover of the home has been both positive and effective in developing the service together with the local Social Services Department, parents and residents. Policies and procedures have been developed and improvements made to ensure monitoring systems including personal-care records, are relevant and include all necessary information. This process is continuing and staff training requirements, which have been identified as a Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 19 result of the needs of residents, are being met. Health and safety issues as well as approvals from the fire officer and environmental health officer had been taken into account when the building was newly registered in May 2005. Confirmation of the latest changes regarding smoke stop doors and escape routes as approved by the fire officer, need to be submitted to the Commission for Social Care Inspection. The home is clean and hygienic and staff are aware of C.O.S.H.H. Regulations. Breakaway I56-I06 S18070 Breakaway V247639 020905 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 x 2 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x x 3 Standard No 11 12 13 14 15 16 17 x 2 x x x 2 3 Standard No 31 32 33 34 35 36 Score x 3 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Breakaway Score 2 x x x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 21 N/A 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 37 Regulation 8 Requirement The Registered Person must appoint a manager and inform the Commission for Social Care Inspection of their detail with a supporting application to enable registration to be considered. The Registered Person shall after consultation with the fire authority, take adequate precautions against the risk of fire, including the provision of suitable equipment and adequate means of escape. Confirmation of the fire officers approval to latest modifications of the building, must be sent to the Commission for Social Care Inspection The Registered Person must ensure that all recruitment checks have been completed and documents are available for inspection in the home including evidence of C. R. B. checks and P.O.V.A. First submissions. The Registered Person shall ensure there are provided at appropriate places on the premises sufficient numbers of baths and shower facilities. The Registered Person shall Timescale for action 31/10/05 2. 42 23 31/10/05 3. 34 19 (2) 31/10/05 4. 27 23 (2) 31/10/05 5. 23 & 37 13 (6) 31/10/05 Page 22 Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 6. 18 13 & 14 7. 16 16 8. 9 13 & 15 9. 2&6 14 & 15 ensure the abuse and whistle blowing policy and procedures of the organisation, include all details as required by regulation including notification of any concerns to the Commission of Social Care Inspection and other relevant agencies in accordance with the Public Interest Disclosure Act 1998 and Department of Health guidance No Secrets. A copy of this updated policy must also be sent to the C.S.C.I. The Registered Person shall make arrangements for health care professionals to include evidence of training given to home staff on any protocol for which clinical procedures are carried out. The Registered Person shall consult residents about their social interests, and make arrangements to enable them to engage in local, social and community activities according to their individual choice and preference. Funding arrangements should be discussed and agreed with the local Social Services Department. The Registered Person shall make arrangements to ensure that care plans and risk assessments are regularly reviewed and updated to take account of any risks and hazards concerning residents. The Registered Person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so, the needs of the service user have been assessed by a suitably qualified or suitably trained 31/10/05 30/11/05 31/10/05 31/10/05 Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 23 person. Care plans must be kept under review and updated having regard to any change of circumstances, in consultation with the resident. 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 N/A Good Practice Recommendations Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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 Breakaway I56-I06 S18070 Breakaway V247639 020905 Stage 4.doc Version 1.40 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!