Inspection on 07/02/06 for Inchmahome Residential Home

This inspection was carried out on 7th February 2006.

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

Inchmahome Residential Home 09/02/09

Inchmahome Residential Home 26/07/05

Inchmahome Residential Home 07/03/05

Inchmahome Residential Home 10/11/04

Inchmahome Residential Home 23/02/04

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Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Inchmahome Residential Home 11 The Avenue Trimley St. Mary Felixstowe Suffolk IP11 0TT Lead Inspector Claire Hutton Unannounced Inspection 7th February 2006 01:45 Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Inchmahome Residential Home Address 11 The Avenue Trimley St. Mary Felixstowe Suffolk IP11 0TT 01394 285675 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) margaret8cephas-care.co.uk Mr Christopher James Hewson Mrs Margaret McNeill Finch Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: Inchmahome was opened as a residential home for adults with learning disabilities in 1994. It is registered to accommodate and care for up to four residents. The home is part of the Cephas Community Care group. Inchmahome consists of a single storey building in a residential area of Trimley St Mary, close to all local facilities including the train station. The residents use all parts of the home. There are four bedrooms, one of which has en-suite facilities. There is a communal lounge and small dining room. There is a large garden to the rear. There is parking to the front of the home. The home is easily accessible by car and was situated off the main A14. Both the towns of Ipswich and Felixstowe were within easy reach by car or public transport. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on an afternoon in February and lasted for just over three hours. During that time nine key standards not assessed on the previous visit were looked as well as revisiting the three requirements from the last inspection dated 26th July 2005. Therefore if the reader requires a comprehensive view of this home the two reports should be read together. During this visit all four residents were met and two were spoken with. Both of these residents were happy with the care they received and liked their home. Two staff were spoken with and were positive about the home. All communal areas of the home were seen. Records inspected included, the staff roster, recruitment records, care plans and associated records for one resident, the record of complaints, records relating to health and safety matters and records that showed views of the residents. What the service does well: What has improved since the last inspection? The manager has ensured that the requirements and recommendations made at the last inspection have been actioned. Since the last inspection professionals external to the home have been consulted and their advice followed by staff with in the home. There have been environmental improvements with equipment being updated and replaced. All recruitment records were available for inspection with a good system of recording in place. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key standard 2 was assessed at the last inspection as met. There have been no changes in the resident group since then. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Residents can expect to have their assessed and changing needs with personal goals reflected in their individual plan with risk assessments completed. EVIDENCE: The care plans and associated records for one resident was examined. This showed development since the last inspection with aims and objectives being reviewed. There has been a development for the resident as staff had attended training in communication methods to support the resident communicating with people around them. The total communication system being introduced will have a new board for the person to use and flash cards available. Additional support hours had been funded and were seen to be in place. Therefore, development of activities within the house and external opportunities were seen in place. In order that these activities were safe, risk assessments had been conducted and were recorded. The documentation clearly showed the duty of care of staff and allowed for independence and choices to be made by the resident. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 10 Discussion was held around one other residents risk assessments and what had led that to being reviewed. The member of staff was quite clear that the level of independence but also protection of the resident was a balance that had to be defined. In addition one other resident’s needs were discussed as these had recently changed. The home had sought the appropriate professional advice through the learning disability health services. This advice was seen to be shared with care staff and implemented. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 and 17 Residents can expect to have opportunities to take part in appropriate activities and to develop and maintain relationships. EVIDENCE: Staff spoken with explained the activities that were on offer to residents. These were a mixture of activities within the home and garden and external to the home. The residents could choose from a variety of games and crafts regularly held. One resident enjoyed art and craft so much they had their individual box of equipment. Craft items were on display around the home. There was a list of places and forthcoming dates of clubs and outings, which, included the Cephas drop in, day centres, mix and match club, bowling, out for dinner, an evening with a befriender and a visit to church on Sunday for those who chose it. The home had also purchased a new trampoline for use in the garden. One resident spoken with was very happy as to where they went and opportunities to socialise. The home had a policy on relationships and this was discussed with one member of staff. There was evidence of a good understanding of relationships that were encouraged and maintained. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 12 There was an individualised approach to relationships with families and evidence that staff supported the residents to write to people with letters, cards and emails. In some cases relatives visited, took residents out for lunch or stayed for lunch. Some resident chose to go and stay with relatives on occasions. The home has a two weekly menu available that is based around healthy eating principles but with items such as fish fingers, burgers and pizza. On the evening of this inspection the meal consisted of sweet and sour chicken with rice. This was the choice of all four residents, but the home does cater for one special diet usually. The staff member explained that the special diet is always made similar to that of the other residents. One resident said the food was good. One staff member thought the rotation of the menu every other week was a little monotonous and could be expanded further to include more choices. The weekly shop was said to be done with a resident at a local supermarket. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 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 Residents can expect to receive personal support in the way they prefer and require. EVIDENCE: In relation to personal care it was explained that female residents are given personal care by female staff and where possible the male residents are cared for by same sex staff. This was confirmed as possible by viewing the roster. There is always a female member of staff on duty. Care plans were seen to set out the preferred daily routines of the residents so that staff can have a consistent approach based upon individual resident needs and wishes. Two staff spoken with knew the residents well and were aware of residents likes and dislikes and how they preferred their personal care routines. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 14 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 People who use this service can expect to have their concerns and complaints taken seriously and acted upon. EVIDENCE: Since the last inspection the CSCI had received two concerns about Inchmaholme. One was explored with the manager on the day. The manager was aware of the matter, as it had come to light using the internal complaints form that had been developed. The manager explained that they had investigated and resolved the matter. The second concern had been sent to the home and the organisation had investigated the matter appropriately. There was evidence of investigation and action points made. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 15 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 and 30 Inchmahome environment is comfortable and suits the needs of the individuals who live there. EVIDENCE: Inchmahome is a comfortable environment for people with a learning disability to live. The environment is safe and such precautions as radiator covers are in place. These would benefit from a coat of paint. The kitchen has a locked stable door and residents who are capable have their own access, but those residents who are assessed as at risk are supervised at all times. The home is clean throughout. Bedrooms have a wash hand basin and one has en-suite facilities. There is a bathroom with toilet, bath and separate shower. There was a staff toilet. The lounge is large and has comfortable seating of differing descriptions. The garden, mainly laid to lawn is large and private. The home has a number of pets. Since the last inspection a number of electrical equipment have been replaced. A staff member confirmed electrical items were in good working order and met the needs of the home. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 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 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 and 35 Residents at Inchmahome are supported by competent, appropriately trained and qualified staff that allows staff to meet service users individual and joint needs. EVIDENCE: The current staff roster in use and the roster for the month of January were examined. It was explained that in January there was an exceptionally high level of staff sickness and that the home had managed to operate within the agreed staffing levels for the home. The roster showed that in the month of January there had always been a minimum of two staff on duty at all times during the day and at night one awake member of staff with a person on call. The home had not used any agency staff, but had used in house staff. Two new staff had started work the previous day. All the recruitment records were in line with the regulations. The records for staff were in good order and information was easily accessed. Evidence was seen of a training plan in place for each member of staff. This plan ensured that once induction training was completed updates on certain training such as manual handling were completed in a timely fashion. One member of staff had undertaken health and safety training and manual handling training in December 2005 and had completed first aid training two months previously. Four care staff had completed NVQ level 2 in care, one had completed level 3 and the other three staff had commenced level 3. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 17 Two staff had completed the four-day Unisafe training that is a course to enable staff to work with people whose behaviour may be challenging. It is the intention of the home to have all staff complete the four-day course and dates were being set. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 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 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 and 42 Residents at this home can expect to have their views, health and safety and welfare promoted and protected. EVIDENCE: The manager of Inchmahome has achieved NVQ level’s 3 and 4 in care and had completed the Registered Manager Award. She has a training and development plan and partakes in training periodically to update her knowledge. Staff spoken with said they find the manager approachable and open to new ideas, staff were appreciative of the training opportunities that the manager was able to access on their behalf. In relation to quality assurance matters, a member of staff explained that they facilitate a residents meeting once a month. Minutes are kept. Topics that were discussed were matters relating to staff, other residents and outings. In addition relatives are sent a survey for them to comment upon the care received by their relative at the home. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 19 These covered various topics with open questions. The last one was sent out in September 2005. The CSCI regularly receives Regulation 26 notices. This is a report prepared by a designated monthly visitor to the home (in this case another home’s manager). The report is copied to both the CSCI and the owners of the home for their information. In relation to health and safety matters it was explained that once a month a checklist of health and safety matters around the home along with repairs is completed. If any action is required this is then faxed through to the main Cephas office. There was evidence of both health and safety and fire policies and procedures. The manager had ensured each member of staff had signed these to show they had read them thereby making health and safety a matter for all staff. There was evidence of bath temperatures recorded to ensure safe hot water limits were maintained, however there was no evidence of the shower being regularly checked. All records relating to fire testing and servicing were examined and found to be in order. Suffolk Fire Service last visited the home in December 2005. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 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 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 3 X 3 X X 2 X Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 YA42 Regulation 13 (4)(a) Requirement Shower hot water temperatures must be fitted with a fail-safe device and then monitored to remain within safe limits to prevent scalding of residents. Timescale for action 19/05/06 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 YA22 Good Practice Recommendations There should be a record of concerns and complaints investigations along with the action points that are recommended. Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Inchmahome Residential Home DS0000024422.V282746.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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