Inspection on 05/07/05 for Fen Grove (76)

This inspection was carried out on 5th July 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fen Grove (76) 07/02/07

Fen Grove (76) 04/10/05

Fen Grove (76) 06/01/05

Fen Grove (76) 30/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Fen Grove (76) 76 Fen Grove Blackfen Kent DA15 8QQ Lead Inspector Elizabeth Brunton Announced 5 July 2005 10:00 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. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Fen Grove (76) Address 76 Fen Grove Blackfen Kent DA15 8QQ 01622 769 100 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) www.mcch.co.uk MCCH Society Ltd Mrs Tina Donna Morgan Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6 January 2005 Brief Description of the Service: 76 Fen Grove is a care home which provides care for up to four adults with learning disabilities. It is operated by Maidstone Community Care Housing Ltd (MCCH). The home is a detached bungalow, situated in a residential area and within easy reach of local transport, services and shops. There is a large kitchen/diner, a lounge with patio doors, which open onto the garden and a small utility room. There is no dedicated office, so the utility room is also used as an office. The home has a bathroom with toilet and an additional toilet. There are two single and one double bedroom and a large rear garden. At the time of the inspection, there were four service users in residence and no vacancies. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and started at 10am. One inspector was in the home for seven hours. One service user was at home all day and the other three service users returned home during the afternoon. However, it was not possible to find out the views of service users due to communication issues. A visiting relative was spoken to and pre-inspection questionnaires were completed by two relatives. A pre-inspection questionnaire was also completed by a health professional, who attended service users in the home. The manager and other staff on duty during the day were spoken to. The communal rooms, garden and service users’ bedrooms were seen. Records were looked at, including service users’ individual case files. What the service does well: What has improved since the last inspection? Few requirements were made at recent inspections. The lounge looked much better since the carpet and chair covers had been cleaned. A stained bedroom carpet and radiators had also been cleaned. Service users’ individual plans and risk assessments were available to staff and healthcare appointments had been recorded. Service users had been weighed regularly and all medicines, including skin creams, had been given out at the right times. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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 Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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) 1, 2 & 5 Information for service users about the services offered was being developed. Excellent assessment information was on file but contracts for service users were still needed, in order to provide full information about the services to be provided. EVIDENCE: The home had a statement of purpose and the manager was developing a service users’ guide, incorporating symbols and photographs. There was a great deal of information about service users on their files. This included their likes and dislikes, how they preferred to spend their day and how they would like to be supported. Staff spoken to clearly knew the service users well. No new service users had come to live in the home for several years. Any new service user would be admitted on the basis of a full assessment undertaken by professionals from the Bexley Social Services Learning Disability Team. Comprehensive contracts for service users were still needed. Relatives and their relatives or representatives needed clear information about the terms and conditions of residence in the home. (see requirements 1 & 2) Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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 & 8 Service users had taken part in regular planning meetings, where goals had been set. Service users were involved in the day-to-day running of the home and staff were supporting service users in developing their communication skills. EVIDENCE: Individual planning meetings had been held with service users and their relatives twice a year. The manager and staff were committed to the person centred approach and had worked hard at making planning meetings meaningful to service users. Varied and achievable goals had been set. Staff wanted service users to lead as full lives as possible, to develop their interests and activities and to be as involved, as much as possible, in the running of the home. One service user sat in the kitchen/diner with staff and clearly enjoyed being part of the group. Staff encouraged him to choose what he wanted for lunch and how he wanted to spend his time during the day. Communication passports were on service users’ files and staff took time to communicate effectively with service users. Risk assessments had been completed for service users’ participation in activities. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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) 12,14,15 & 17 Service users participated in activities but this aspect of their lives could be further developed. Staff supported service users in maintaining contact with relatives and friends. Varied and nutritious meals were served and good support and assistance was given with feeding and nutrition. EVIDENCE: Service users attended day centres on a number of days each week. They enjoyed activities at home such as aromatherapy, listening to and making music, watching videos and TV. Goals set at individual planning meetings had included the development of new interests and activities. Staff had noticed that one service user liked dancing and had worked hard at trying to find a suitable place for him to watch/participate in line dancing. Service users also went shopping, out for meals and on occasional day trips. However, daily records showed that service users’ involvement in activities outside the home, apart from attendance at day centres, was limited and not in line with their individual activity plans, displayed in the notice board. The manager said this was due to the shortage of permanent staff and particularly of staff who were drivers. However, she was hoping to use the taxi card scheme, which should Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 Page 11 enable service users to go out more regularly. recently been away on holiday with staff. All the service users had A visiting relative and relatives who completed the pre-inspection questionnaire said that they could visit whenever they chose and were always made welcome by staff. Relatives also said that they were kept informed about service users by staff. A goal set at one service user’s recent individual planning meeting had been to invite friends to the home and this had been achieved. Menus seen showed that varied and nutritious meals had been served and variations from the menu had been recorded. Lunchtime on the day of inspection was a relaxed and sociable occasion and assistance was sensitively given. The advice of the speech and language therapist was being sought for two service users and eating and drinking guidelines were in place. Service users had been regularly weighed and had been successful in either gaining or losing weight. (see recommendation 1) Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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) 18,19 & 20 Service users’ health care and personal needs were well met. Medication was safely stored and properly administered. EVIDENCE: Personal care was provided discreetly and with respect for service users’ privacy and dignity. Service users were well dressed and staff and a visiting relative said that service users chose their own clothes. Information about service users’ health care needs was seen on file and health care needs had been discussed at service users’ individual planning meetings. Records showed that staff supported service users in attending the doctor, hospital, dentist and optician. Staff and a visiting relative said that one service user had been carefully prepared and supported through recent dental treatment, which had benefited her greatly. A health care professional, who regularly attended service users, said that staff carried out her instructions and demonstrated that they understood service users’ health care needs. Medication was safely and properly stored. A sample check of medication and administration records was made and this was satisfactory. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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 Relatives had been told how to complain but service users did not have this information. Service users were protected from harm and abuse. EVIDENCE: There had been no complaints since the last inspection. There was a form available for service users to make a complaint, which included pictures and symbols. Relatives confirmed that they were aware of the home’s complaints procedure. No adult protection concerns had been reported since the last inspection. Staff spoken to were aware of safe practice and seemed committed to the protection of service users. The manager and senior support worker were in close touch with service users, staff and with day-to-day events in the home. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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 & 30 The home was sufficiently spacious, comfortable and generally well maintained. However, some work was needed on the house and garden. Maintenance and repairs should be promptly carried out and staff should not be expected to undertake maintenance and decorating. EVIDENCE: The home was clean, bright and generally well decorated and maintained. Bedrooms were sufficiently spacious and highly personalised. There was adequate communal space for four service users, though private facilities for visits to service users were limited. There was still no office or private facilities for staff supervision or other meetings. The garden was attractive with flowers and mobiles. However, external paintwork, broken brickwork in the garden and rubbish down the side of the house needed attention. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 Page 15 Staff and one relative expressed concern about the long delays in maintenance and repair work being carried out by MCCH. An example of this was that the cooker had recently been out of action for over a month before it was repaired. It was also of concern that staff reported that they were expected to undertake an increasing amount of decoration and maintenance work themselves and that this inevitably reduced the amount of time available for the care and support of service users. Staff and their families had recently decorated the hall and lifted radiator guards, so that radiators could be cleaned. (see requirements 3,4 & 5 and recommendations 2,3 & 4) Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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) 33, 34 & 35 Staff were committed and able but too many bank/agency staff were being used. Staff training was being provided but NVQ training was delayed. Not all the required staff recruitment records were available to be checked or were retained in the home EVIDENCE: Staff on duty worked hard at communicating effectively with service users and seemed committed to meeting their needs. Relatives thought there were enough staff on duty at any time but were concerned about the number of bank/agency staff working in the home. There were six staff in post, in addition to the manager and 2.5 staff vacancies. Recent rotas showed that a number of different bank and agency staff had been used to cover shifts and not all temporary staff had been familiar with the home and service users. Attempts had already been made to recruit more staff and further efforts at recruitment must be given priority. Records showed that staff had undertaken a range of training. Update training in fire safety and moving and handling was overdue but arrangements had been made to provide this. The manager said that some staff had been waiting for over six months to commence NVQ training. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 Page 17 Some staff recruitment records were retained in the home and these showed that staff had been properly recruited and checked before starting work. However, it was not possible to inspect staff application forms or CRB checks, as these were not available. There were no recruitment records kept in the home for one member of staff. (see requirements 6,7 & 8 and recommendation 5) Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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 home was well managed and the health and safety of service users had been protected. EVIDENCE: Staff and relatives praised the commitment and effectiveness of the manager. One relative described the manager as ‘superb’. The manager was also well supported by an able senior support worker. An office was badly needed, to provide more space for the organisation and storage of records and for staff supervision. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 Page 19 The building appeared to be safe and no hazards or risks to the safety of service users were identified. Gas and electrical installations and equipment had been checked within the last year. Electrical equipment had been checked in May 2004 and a further check was now overdue. Hoists had been serviced and checked six monthly. Records showed that fire equipment had been regularly tested and checked and that fire drills had been regularly held. (see requirement 9) Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 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 2 4 x x 1 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 2 x 2 3 x 3 Standard No 31 32 33 34 35 36 Score x x 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fen Grove (76) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 Page 21 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. 2. Standard 5 5 Regulation 1 5 Requirement A service users’ guide must be provided, as planned. (Previous timescale of 1/5/05 not met) Service users must have a copy of their agreement, specifying the terms and conditions between the home and the service user. The format for this agreement should include all matters listed under this standard. (This matter has been outstanding since April 2002). Adequate office facilities must be provided in the home. This should include additional storage facilities for records, facilities for staff supervision, meetings and administrative work. (Previous timescale of 1/5/05 not met) Maintenance and repairs must be promptly carried out. Care staff must not be expected to undertake decorating and maintenance work, if this reduces the amount of staff time available for the care and support of service users Priority must be given to the recruitment of additional permanent staff for this home. Timescale for action 1 November 2005 1 October 2005 3. 24 23(1) 1 December 2005 4. 5. 24 24 23(2) 18(1) 1 September 2005 1 September 2005 6. 33 18(1) 1 September 2005 Page 22 Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 7. 34 19 8. 34 17 9. 10. 42 23(2) Arrangements must be made for those documents relating to the recruitment of staff and listed under schedule 2 to the regulations, to be inspected by the CSCI. Those documennts relating to the recruitment of staff listed under schedule 3 to the regulations, must be retained in the home. Elecrical appliances used in the home must be checked annually by the contractor. 1 October 2005 1 September 2005 1 September 2005 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. 2. 3. 4. 5. Refer to Standard 14 24 24 30 35 Good Practice Recommendations Service users should be given the opportunity to participate in more leisure time activities outside the home and in line with their individual activity plans. The broken brick area in the rear garden should be repaired/removed. The rubbish should be removed from along one side of the house. The paintwork at the rear of the building and the scuffed paintwork on internal door frames should be attended to. Impermeable floor covering should be provided in the utility room. NVQ training should be promptly arranged for those staff who apply to undertake it. Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection River House 1 Maidstone Road Sidcup Kent, DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fen Grove (76) G51 G01 S38222 Fen Grove V220515 05.07.05 Stage 4.doc Version 1.40 Page 24 - 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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