Inspection on 10/07/06 for Ceshma Care

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Ceshma Care 24/07/07

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Ceshma Care Ceshma House 80 Rockingham Road Kettering Northants NN16 9AB Lead Inspector Stephanie Vaughan Unannounced Inspection 10th July 2006 10:00 DS0000067054.V303246.R01.S.doc Version 5.2 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 DS0000067054.V303246.R01.S.doc Version 5.2 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. DS0000067054.V303246.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ceshma Care Address Ceshma House 80 Rockingham Road Kettering Northants NN16 9AB 01536 512091 01536 512091 ceshmacare@hotmail.com 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) Christina Smith-Haynes Christina Smith-Haynes Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (5) of places DS0000067054.V303246.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection None Brief Description of the Service: Ceshma Care is a new home, recently registered in May this year to provide personal care for 5 residents with Learning Disability and Mental Health needs. The home is in keeping with the local community and is close to amenities such as local shops, leisure facilities and transport. The premises comprise a three story Victorian house that has been converted into a care home, offering individual accommodation on each of the three floors, each room having ensuite shower facilities. The home complies with the National Minimum Standards for space and is set in safe and accessible gardens. The current fees range from £1,100 to £1,450 per week, with additional charges for day care, hairdressing, personal toiletries, items and equipment. DS0000067054.V303246.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Ceshma Care is a new facility having been registered as a care home in May 2006, by the Commission for Social Care Inspection. As such this is the first statutory inspection to have been conducted there. One hour was spent in preparation, which included a review of the conditions of registration, the registration report, the service history and associated documentation. Ceshma Care has not yet admitted any residents to the home and the Commission have received no concerns or allegations about the service. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Residents, and upon their views of the service provided The Commission also has a national focus on Equality and Diversity for all within this current year and issues relating to this are included in the main body of the report. Two prospective residents were ‘case tracked’ which involved reviewing the pre admission assessments and other associated documentation such as records of communications and contacts with residents through visits to the home. A limited tour of the premises was conducted, which involved a sample of the residents’ accommodation and communal areas. The inspector was unable to speak to any residents as they have not yet been admitted nor were they visiting the home on the day of inspection. One staff member was spoken to and the Registered Manager was present and cooperative throughout this unannounced inspection; which lasted two and three quarter hours. What the service does well: New residents have the right information to help them make a decision about whether they would like to live at Ceshma Care. They are also able to visit the home to meet the staff and to see what it is like and to have a meal there. The staff make sure that they have the right information about the care that the residents need so that they are able to look after them properly. Residents will be supported to carry on going to the places and activities that they enjoy and wish to continue. Staff will help residents to develop new interests, make use of the local facilities and to keep in touch with friends and family. DS0000067054.V303246.R01.S.doc Version 5.2 Page 6 The staff will do their best to make sure that residents are treated fairly and that they are helped to have a good quality of life by planning their care around them according to their needs and preferences. The management make sure that residents are able to see the right doctors, nurses and specialists as they are needed. The residents will be able to have one of the staff as a Key Worker who takes a special interest in them and will help with the things that are needed. The manager makes sure that the medicines are stored and given to residents safely. There are systems in place to make sure that residents are able to complain and that they are protected from all types of abuse. Residents will be able to make choices about the decoration of their rooms and furniture. The rooms have showers and have privacy locks. The manager will make sure that there is enough staff to meet the needs of residents and that they have the right training to make sure that the residents are well looked after and are safe. The manager has the right qualifications ad experience to run the home. The manager is developing systems to make sure that the residents are satisfied with the service and that the service is developed. The garden area is now safe and work is going on to improve the appearance. The manager is going to fit safety catches on the upstairs windows when the residents needs and wishes have been obtained. What has improved since the last inspection? What they could do better: The manager has agreed to make sure that they have the Local Authority Guidelines on the Protection Of Vulnerable Adults DS0000067054.V303246.R01.S.doc Version 5.2 Page 7 The Manager has agreed to make sure that the fridge, freezer and dishwasher will not be used while the laundry is being done. The manager has agreed to make sure that the staff have the right references before they start working in the home. The manager has arranged to replace the broken glass in one of the upstairs bedroom windows. 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. DS0000067054.V303246.R01.S.doc Version 5.2 Page 8 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 DS0000067054.V303246.R01.S.doc Version 5.2 Page 9 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&4 The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. Residents are able to make informed decisions about the service provided before deciding whether they would like to live there. EVIDENCE: There are currently no residents living at Ceshma Care, however the admission procedures were reviewed for two prospective residents. Records evidenced that appropriate documentation is provided, such as the Statement of Purpose and the Service Users Guide. The Registered Manager has obtained copies of the assessments that have been conducted by the funding authority and has conducted her own detailed preadmission assessments to ensure that the service is able to meet the needs of the prospective residents. The Registered Manager is mindful of the need to ensure that residents are admitted are within the appropriate categories of registration. In addition records evidenced that prospective residents are able to visit the premises to meet and get to know the staff, have a meal and to view the available accommodation. DS0000067054.V303246.R01.S.doc Version 5.2 Page 10 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): EVIDENCE: As yet no residents have been admitted and it is not anticipated that this will be achieved during the next few weeks. It was therefore not possible to make an assessment of the Standards within this section on this occasion. DS0000067054.V303246.R01.S.doc Version 5.2 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): 12, 13, 15 & 16 The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service Evidence indicates that residents will be supported to maintain and develop fulfilling lifestyles. EVIDENCE: Information included in the Statement of Purpose, Service Users Guide and the Charter of rights indicate the residents will have the opportunity to continue with their existing activities and to develop educational opportunities, links with the Community and relationships. The Charter of Rights indicates that the service will promote Equality and Diversity for the residents. The philosophy of the service indicates a commitment to a person centred approach to care, which supports the rights of residents to be treated as individuals in all aspects of their daily lives and incorporates their views and wishes regarding their personal preferences and routines. DS0000067054.V303246.R01.S.doc Version 5.2 Page 12 DS0000067054.V303246.R01.S.doc Version 5.2 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 the following standard(s): 18, 19 & 20 The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service Evidence indicates that residents will be supported to maintain their health and receive appropriate support in their personal care. EVIDENCE: Detailed pre admission assessments indicate that resident’s health, personal and social care needs will be addressed. For example one of the assessments has identified that a potential resident has some physical needs relating to mobility. The Registered Manager has sought guidance from a qualified Occupational Therapist to ensure that the resident’s needs can be met within the environment and for any aids and adaptations, which may be required. The assessment also indicated that management were aware of the need to access specialist advice from the District Nursing Service and other health care professionals. Staff spoken to have an understanding of the key worker system and their responsibilities in the provision of care. DS0000067054.V303246.R01.S.doc Version 5.2 Page 14 The management have identified an appropriate medication system for use once residents are admitted and there are appropriate arrangements in place for the safe storage of medication. DS0000067054.V303246.R01.S.doc Version 5.2 Page 15 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 The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service Appropriate policies and procedures are in place to ensure that residents are able to express their views and are protected from abuse EVIDENCE: The management have developed appropriate policies and procedures for the service. These include the management of Complaints and Safeguarding Adults policies. However as yet there is no copy of the local authority guidelines on the Protection Of Vulnerable Adults, this was discussed and Registered Manager has agreed to obtain this. The Registered Manager has appropriate training materials available and is aware of the need to ensure that staff have appropriate induction training and training in the Safeguarding of Adults. Through discussion with the Registered Manager it was established that there are appropriate policies and procedures in place to ensure that residents money is appropriately managed and that residents are protected from identity fraud. DS0000067054.V303246.R01.S.doc Version 5.2 Page 16 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, 26, 29 & 30 The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. The environment is suitable for its stated purpose and is in keeping with the local community. EVIDENCE: Satisfactory reports have been received from the Environmental Health Officer and Fire Officer. The premises comply with the National Minimum Standards regarding space, heating, lighting and ventilation. Privacy locks and lockable facilities have been provided for the residents’ individual accommodation. Some of the rooms are still in need of redecoration and furnishing, however through discussion with the Registered Manager it was established that in line with the philosophy of person centred care, residents will be able to participate in the decisions yet to be made regarding decor, furnishings and fittings. The premises were clean and hygienic throughout. There are separate laundry facilities located behind the kitchen with an additional separate entrance. However the fridge, freezer and dishwasher are also located in this area. DS0000067054.V303246.R01.S.doc Version 5.2 Page 17 Through discussion with the Registered Manager it was established that the Environmental Health Officer has approved this arrangement and the Manager has agreed to develop risk assessments regarding this arrangement in order to manage any potential risks to hygiene and infection control. DS0000067054.V303246.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service. Staffing, training and recruitment ensure that residents are in safe hands at all times. EVIDENCE: The Registered Manager is mindful of the need to ensure appropriate staffing levels base on the assessed dependency levels of residents. Currently one other member of staff is employed and two others have been recruited and will commence employment before the residents are admitted to enable appropriate training to be conducted. Existing staff are over 18 years of age and have an appropriate level of National Vocational Qualifications in Care, this will enable the service to achieve the required level of 50 at the time of becoming operational. A selection of staff files were viewed and these evidenced appropriate recruitment practices with the inclusion of appropriate Criminal Records Bureau Clearances and two written references. However one of the files indicated that two references had been supplied and sought from the most recent employment which was not within the care sector. Whereas the staff member had until two years previously worked in a care provision environment. DS0000067054.V303246.R01.S.doc Version 5.2 Page 19 Through discussion with the Registered Manager it was agreed that a further reference should be sought prior to the commencement of employment and that all future recruitment would ensure that appropriate references are obtained. The Registered Manager confirmed a commitment to staff training and is in the process of developing an appropriate induction training programme. In addition she is mindful of the need to ensure that staff have access to timely mandatory training such as Fire Safety, First Aid, Food Hygiene, Movement and Handling, Safeguarding Adults, Safe Administration of Medication and Health and Safety. One staff member was able to confirm access to appropriate training through previous employment and the expectation that further training was to be made available as more staff commence employment. DS0000067054.V303246.R01.S.doc Version 5.2 Page 20 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, 40 & 42 The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service The conduct and the management of the home is good ensuring that residents are cared for in a safe environment. EVIDENCE: The manager is appropriately qualified and experienced to manage the service. She is very near to the completion of appropriate policies and procedures as specified within the National Minimum Standards. Quality Assurance systems are currently being developed for the service, which will include seeking the residents’ views on a systematic and regular basis to inform service development and the development of audits for internal systems such as medication and the environment. The Registered Manager confirmed that staff will have access to appropriate and timely mandatory training pertinent to Health and Safety once the service is operational. DS0000067054.V303246.R01.S.doc Version 5.2 Page 21 Following the site visit for the Registration of the premises the hazards identified in the garden area have been made safe and further work is to be commissioned to enhance the area. The recommended window restrictors have not yet been fitted to the first and second floor windows. The Registered Manager has confirmed that these will be fitted before residents are admitted and take into account the individual needs and wishes of the residents to be accommodated once this has been established. The glass to window of the rear bedroom on the first floor was noted to be cracked and therefore unsafe. The Registered Manager made arrangements for this to be repaired during the inspection. DS0000067054.V303246.R01.S.doc Version 5.2 Page 22 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 3 3 X 4 3 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 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X DS0000067054.V303246.R01.S.doc Version 5.2 Page 23 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. 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. Refer to Standard Good Practice Recommendations DS0000067054.V303246.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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