Inspection on 08/11/05 for Fame Care Ltd

This inspection was carried out on 8th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fame Care Ltd 04/04/08

Fame Care Ltd 31/07/07

Fame Care Ltd 08/08/06

Fame Care Ltd 26/08/05

Fame Care Ltd 20/01/05

Fame Care Ltd 16/08/04

Fame Care Ltd 30/01/04

Fame Care Ltd 05/12/03

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Fame Care Limited 24 Dunstall Gardens St Mary`s Bay New Romney Kent TN29 0QT Lead Inspector Geoff Senior Announced Inspection 8th November 2005 10:00 Fame Care Limited DS0000023421.V250668.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 Fame Care Limited DS0000023421.V250668.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. Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fame Care Limited Address 24 Dunstall Gardens St Mary`s Bay New Romney Kent TN29 0QT 01303 874747 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) Beacon Care Holdings PLC Mrs Sarah Jane Hussey Care Home 4 Category(ies) of Learning disability (3), Physical disability (1) registration, with number of places Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 1 resident with a physical disability should also have a learning disability 26th August 2005 Date of last inspection Brief Description of the Service: Fame Care is registered as a Care Home for up to four adults with a learning disability. Fame Care Ltd. is the registered Provider with the Registered Manager, Ms. S. Hussey in day-to-day control of the functioning of the Home. The home is a detached property set in a residential area of the seaside village ofSt. Mary’s Bay. The accommodation comprises four ground floor single bedrooms for resident’s use. There is a large lounge dining room providing communal day space. Service users may also access the enclosed garden to the rear of the house. Car parking is available to the front of the property. Local facilities (shops, pub, GP, church and post office are all within a short drive. Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and was undertaken on 08/11/05. The inspector met and spoke with all staff on duty and with the Manager. The level of functioning of some of the service users precluded the opportunity for any meaningful verbal interaction. However the inspector observed, throughout the visit, the staff’s attention to the service users’ immediately expressed needs, their patient, friendly and respectful manner and their treatment of each service user as an individual. The duty rota indicated a reasonable level of staff, when the manager is also in attendance, during the day for the number of service users. This may need to be reviewed given the increasing level of dependency. The Inspector viewed the premises and inspected a range of records. The inspection identified areas of good practice and where action is still required in order to comply with the Standards. Details are incorporated in the body of the report. The cooperation of the staff throughout the inspection is acknowledged. What the service does well: What has improved since the last inspection? What they could do better: Some staff have attended short training courses and workshops. NVQ training at an appropriate level now needs to be actively pursued and completed by staff, in sufficient numbers, to satisfy the requirements of the NMS. The home aims to provide a specific service to individuals. It needs therefore to be mindful of the increased dependency levels of service users and the impact they may have on staff resources. This applies particularly at ‘peak’ times such as meal and personal care support and when the manager, who shares her duties between two homes, is not present. Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 6 Although the environment is generally adequate, consideration may be given to the provision of more appropriate office and storage areas and visitors space that does not impinge upon the service users communal space. 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. Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 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 Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 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): 1,2,3,5. There is written information available for prospective clients and their representatives when considering admission to the home. There is a system in place for making pre-admission assessments of prospective clients. This needs to be further explored to ensure that the judgements made are based on all available information and ensure that the placement will be compatible and that service user needs can be appropriately met. EVIDENCE: There is an Organisation procedure for admissions that includes the completion of assorted documentation. The manager acknowledged the limitations and omissions identified following a recent admission. Steps were taken to address the issues and seek further professional advice and guidance. The trial period has allowed for re-assessment as to the suitability and continuation of the placement. The Manager agreed to ensure that, in future, all avenues are explored and consulted prior to admission. There is a standard organisation contract on file for the service users. The content generally addresses the requirements of the NMS. Some detail still needs to be included: reference NMS 5.2 (i) Room to be occupied; (iv) cost of facilities not covered by fees. 5.5: The contract is signed by the service user and registered manager. Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 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): 6,9. The care planning and report system provides staff with an accessible, clear and consistent vehicle for monitoring the delivery of services. The care plan documentation should include evidence of service user/representative or family consultation in the care planning process. Service user responses to changes in circumstances are noted and acted upon. Risks are generally well managed and justification is noted when restrictions to the freedom of movement is imposed. EVIDENCE: The amended care plan, recording, monitoring and review system has now been implemented. Two key workers for each client and the manager are responsible for maintaining the documentation. Staff acknowledged that the care plan guidelines could be helpful and informative to the delivery of care and support. Daily records cross-reference with the monthly goals and aspirations. These are reviewed and subsequently generate the following month’s goals. Any need for specialist guidance is identified and sought. Fame Care Limited DS0000023421.V250668.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): 14,15. Specialist advice and guidance has been sought and is being used to more appropriately meet specific needs. Leisure activities and holiday periods are structured to service user need. EVIDENCE: The inspector was informed that specialist advice and guidance has been sought and is being used to more appropriately meet specific needs. This is reviewed at monthly care plan and six monthly case reviews. It was decided that rather than cause possible disruption and distress to service users by going away on holiday, the home sets aside a specific period for special days out. All costs in this period are covered by the holiday budget. Service user families are welcomed to the home and may visit without restriction subject only to the service user wishes. Some relatives are in regular phone contact for updates and may also be involved in service reviews. Space for private visits is limited to resident’s own room. Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 11 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): Not inspected at this visit EVIDENCE: Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 12 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 home has a complaints procedure with written information available to service users and visitors. Staff have received training in the protection of vulnerable adults in the past 12 months. EVIDENCE: There is written information relating to complaints, on display in the entrance hall. A company complaints procedure and record form is held in the policy folder. The hard back note book used for recording complaints received and the homes response was blank when viewed. Staff have attended training in the understanding of adult protection issues in order to protect service users from possible harm or abuse. A whistle blowing policy is in place for staff reference. Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 13 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): Not inspected at this visit. EVIDENCE: Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 14 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): 31,32,33, 35 Staff ratios need to reflect the service users level of need at all times and not compromise the opportunity for choice. EVIDENCE: Staff members were clear about their roles and responsibilities within the home and the care of the service users. They are provided with job descriptions. Staff spoken with were not familiar, nor had they been provided, with the standards of conduct and practice set by the General Social Care Council.(GSCC). Two staff have been identified to undertake NVQ level 2 training with an organisation that will also offer appropriate induction and foundation courses. The manager reported that some of the long established staff are reluctant to undertake NVQ training but have a wealth of experience and short course training to inform their practice. The manager agreed to check on current status of staff statutory training. There is a high level of commitment on the part of staff to ensure minimum levels on duty. However, the home aims to provide a specific service to individuals. It needs therefore to be mindful of the increased dependency levels of service users and the impact they may have on staff resources. This applies particularly at ‘peak’ periods such as meal preparation and serving times and personal care support and when the manager, who shares her duties between two homes, is not present. Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 15 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): 37,38,40,41,42. The home is well managed and promotes a caring and supportive service to the resident service users. EVIDENCE: The registered manager holds the City and Guilds 325/03 in advanced management for care and is now seeking to develop further by the completion of a National Vocational Qualification at level 4 in management and care (or equivalent). It appeared from conversations with staff and from observation that the Management is approachable and an open supportive atmosphere has been well established within the Home. A representative of the company visits the home regularly each month and completes a feedback form. The Manager reported that the required policies and procedures are provided by Beacon Care and are subject to constant review and amendment. Information received prior to the inspection indicated that maintenance certification is satisfactory and up to date. It was reported that there are no oustanding requirements of the Environmental Health and Fire Safety Officers following their most recent visit. Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 2 X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fame Care Limited Score X X X x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 x DS0000023421.V250668.R01.S.doc Version 5.0 Page 17 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. 2 Standard YA33 Regulation 18 Requirement The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Timescale for action 31/12/05 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 32 & 35 Good Practice Recommendations 50 of staff achieve a care NVQ 2 (by 2005). Staff working in LD services use LDAF training to underpin knowledge for progress to NVQ. Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Fame Care Limited DS0000023421.V250668.R01.S.doc Version 5.0 Page 19 - 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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