Inspection on 20/09/05 for Magdalen Close

This inspection was carried out on 20th September 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

Magdalen Close 26/10/06

Magdalen Close 24/02/06

Magdalen Close 03/03/05

Magdalen Close 12/10/04

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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 Magdalen Close 1-5 Magdalen Close Clacton on Sea Essex CO15 3LS Lead Inspector Gaynor Elvin Unannounced Inspection 20th September 2005 10:30 Magdalen Close DS0000030726.V252801.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 Magdalen Close DS0000030726.V252801.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. Magdalen Close DS0000030726.V252801.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Magdalen Close Address 1-5 Magdalen Close Clacton on Sea Essex CO15 3LS 01255 432951 01255 422784 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) Essex County Council Dennis Bateman Care Home 18 Category(ies) of Dementia (1), Learning disability (18) registration, with number of places Magdalen Close DS0000030726.V252801.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 18 persons) One person, under the age of 65 years, who requires care by reason of a learning disability and dementia, whose name was made known to the Commission in March 2004 The total number of service users accommodated in the home must not exceed 18 persons 3rd March 2005 3. Date of last inspection Brief Description of the Service: Magdalen Close is a local authority residential home, which provides accommodation, personal care and support for people with a learning disability. The property is located at the end of a cul de sac in a residential area, on the outskirts of the town of the seaside resort of Clacton on Sea, Essex. The home is within walking distance to the post office, shops, pubs, GP surgeries, cinema, local theatre and the seaside. The home is made up of four separate houses, each providing more specific services, two units are for people with more complex needs, one for people aiming towards independence and one is a short stay care unit. Each unit is as domestic, unobtrusive and ordinary as is compatible with fulfilling their purpose and includes a kitchen, utility room, bathroom, lounge and dining area, individual bedrooms and a rear and front garden. Magdalen Close DS0000030726.V252801.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in September 2005, over six hours. All of the service users except one were out participating in varied leisure, therapeutic or learning activities. Due to profound learning difficulties and high communication needs it was not possible to acquire the personal views of the remaining service user. This inspection focused on the outcomes of the National Minimum Standards not assessed in the previous inspection, looking at working practices, supporting documentation and records, as well as progress made in addressing the statutory requirements and good practice recommendations made in the previous inspection report. An opportunity also arose to speak to a parent, collecting a service user from a short break at Magdalen Close. What the service does well: What has improved since the last inspection? What they could do better: The Registered Manager must ensure that the Department of Health guidelines are followed with regard to POVA First clearance and stringent arrangements for the employment of staff in the interim period whilst awaiting a satisfactory enhanced CRB disclosure. Magdalen Close DS0000030726.V252801.R01.S.doc Version 5.0 Page 6 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. Magdalen Close DS0000030726.V252801.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 Magdalen Close DS0000030726.V252801.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 & 4 The home operates a thorough pre-admission process, giving care and attention to ensuring the home is admitting individuals whose entire assessed needs could be fully met. The home promotes the opportunity to visit the home as an essential part of the admission process. Appropriate information is given to prospective residents and their families, enabling an informed choice. EVIDENCE: Magdalen Close had produced and regularly reviews a Statement of Purpose and Service User Guide, which contained all the information, including photographs to enable prospective service users to make an informed choice. The manager is currently producing these documents onto disc as an additional format, enhancing sections of these documents with photographs and a voice over in line with the services’ move towards Total Communication. Unplanned admissions were avoided and prospective residents were offered a trial visit. The manager described a thorough pre admission process, through which an assessment was carried out to ensure the home was able to meet the individual’s needs. Appropriate management of an enquiry from a Care manager for a prospective resident was observed during the inspection. Magdalen Close DS0000030726.V252801.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 & 10 The care planning process and supporting documentation was being progressed positively detailing the care and support required by each individual. Information about residents was handled in accordance with the home’s written policies and procedures and the Data Protection Act 1998. Records were accurate and secure protecting residents confidentiality. EVIDENCE: Progress was being made in addressing the shortfalls previously highlighted with regard to the content of care plans. New care plans viewed were service user focused and person centred; providing clear information gained in partnership with the resident, developed according to assessed needs and detailing how the resident is to be supported in achieving outcomes. Enabling staff to provide appropriate, consistent and continued support. Policies and procedures were in place with regard to confidentiality and the manager indicated that staff were made aware of these during induction and this issue was reinforced continually through supervision. Magdalen Close DS0000030726.V252801.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): 13 & 14 Residents were supported to access the community and participate in leisure and daily activities. EVIDENCE: All residents except one were out participating in various community based leisure, daily and therapeutic activities such as shopping, swimming, resource centres, exercise sessions and lunch. Respite care at Magdalen House is for short duration of one to two weeks. Respite residents were supported to continue their usual programme of daily activities throughout their stay. The parent of one service user confirmed access to day resource services was supported, enabling the service user to continue in a supported work placement packing boxes. Magdalen Close DS0000030726.V252801.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): 20 Residents were protected by robust policies and procedures for dealing with medicines and staff handling medication had received and completed appropriate training. EVIDENCE: The home’s Administration of Medicines policy contained the relevant information for staff to follow for the receipt, recording, storage, handling administration and disposal of medication. Staff had successfully completed the combined Essex County Council and NHS medication workbook ensuring appropriate knowledge and skills for safe practice and responsibility in medication administration. Current residents did not retain, administer or control their own medication, although the manager indicated that some respite residents may do so within a risk management framework. Magdalen Close DS0000030726.V252801.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 Complaints were responded to and dealt with appropriately. Robust procedures for responding to suspicion or evidence of abuse or neglect were in place. EVIDENCE: A complaints policy and procedure was in place, also in appropriate formats for service users. Two complaints had been received by the home within the last twelve months. Neither complaint was about care practice. Each had been dealt with appropriately with a record kept including details, action taken and outcome. One complaint had been upheld with regard to a room with an offensive smell. The manager is reviewing cleaning strategies and management to ensure smells of this nature are eradicated. In contrast the home had received four written compliments within the last twelve months from visitors to the home and relatives of residents. The home had an Adult Protection policy and procedure in place, including Whistle Blowing, which complied with the Public Disclosure Act and the Department of Health guidance ‘No Secrets’. Staff had received individual copies of the Essex local guidelines, informing of the appropriate procedure to alert Essex Vulnerable Adult Protection Committee in response to a suspicion, allegation or evidence of abuse. Staff had received training in managing challenging behaviour and protecting vulnerable adults. Magdalen Close DS0000030726.V252801.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): 24 The home’s premises are suitable for their stated purpose; accessible, safe and well maintained, meeting residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: The four individual houses are in keeping with the local community, domestic and unobtrusive, offering access to local amenities, local transport and relevant support services. The home has a planned maintenance and renewal programme for the upkeep of the properties and internal redecoration of the properties was evident. A new assisted bath with electronic chair has recently been installed for the purpose of comfortable and safe bathing of the residents and safe assistance for staff with moving and handling. Magdalen Close DS0000030726.V252801.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): 34 Robust employment procedures were not followed to protect residents from abuse. EVIDENCE: Recruitment files for newly appointed staff were examined. The Registered Manager had been authorised by external corporate management to start new employees prior to receipt of a satisfactory CRB disclosure and a POVA First clearance, other required pre-employment checks had been carried out and were satisfactory. Stringent arrangements for the continued supervision of these employee’s, by a named person, appropriately qualified and experienced, following induction until the full CRB Disclosure has been completed satisfactorily was not in place as per Department of Health guidelines. Magdalen Close DS0000030726.V252801.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, 40 & 42 The Registered Manager continued to demonstrate a positive and pro active attitude towards the development of the home. Health and Safety issues are addressed to promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: Since the previous inspection the Registered Manager had progressed in addressing quality assurance and quality monitoring systems to look at service provision, care practice and outcomes. Although still in preliminary stages, the first element will focus on Communication within the home looking at; different formats, staff training and implementation, resident participation in evaluating assessments of communication needs, objectives and outcomes. The results will be formulated to identify future service development and will be fully assessed in the inspection process. Magdalen Close DS0000030726.V252801.R01.S.doc Version 5.0 Page 16 Policies and procedures relating to working practice were in place, however files required reorganisation for easier access for staff to use as a resource within their working environment. Records indicated that fire drills had taken place regularly, fire alarms and equipment had been serviced this year and risk assessments and evacuation procedures were in place. The Registered Manager had progressed in accessing and implementing appropriate in house fire safety training for staff. Records with regard to inspection and testing of electrical wiring and appliances, servicing of gas boilers, cleaning and chlorination of cold water tanks, environmental health and safety certificate were current. Magdalen Close DS0000030726.V252801.R01.S.doc Version 5.0 Page 17 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 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Magdalen Close Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X 3 X DS0000030726.V252801.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34.3 Regulation 19. Schedule 2(7) Timescale for action The Registered Manager must 01/11/05 ensure new staff do not commence employment prior to receiving a POVA First clearance and put in place stringent arrangements for the training and supervision of the employee until a satisfactory CRB check has been received. Requirement 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 Magdalen Close DS0000030726.V252801.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Magdalen Close DS0000030726.V252801.R01.S.doc Version 5.0 Page 20 - 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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