Inspection on 20/02/06 for McGillicuddy House

This inspection was carried out on 20th 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

McGillicuddy House 14/09/07

McGillicuddy House 02/08/06

McGillicuddy House 13/09/05

McGillicuddy House 08/02/05

McGillicuddy House 02/11/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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 09/07/2008.

CARE HOME ADULTS 18-65 McGillicuddy House 18 Vicarage Road Strood Rochester Kent ME2 4DG Lead Inspector Anne Butts Unannounced Inspection 20th February 2006 10:00 McGillicuddy House DS0000028900.V286316.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 McGillicuddy House DS0000028900.V286316.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. McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service McGillicuddy House Address 18 Vicarage Road Strood Rochester Kent ME2 4DG 01843 580812 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) Mr Dennis Gover Payne Mrs Assumpta Ann Payne Care Home 8 Category(ies) of Learning disability over 65 years of age (8) registration, with number of places McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home to continue to monitor the 2 service users whose dates of birth are: 3.5.38 and 27.6.38 to ensure their good health mobility is maintained. 13th September 2005 Date of last inspection Brief Description of the Service: McGillicuddy House is an eight bedded home providing 24 hour care to adults who have a learning disability. The home is a large semi-detached Victorian property situated in a quiet residential road close to Strood Town centre and a short journey from Rochester and Chatham. It has easy access to a variety of amenities and shops. The accommodation is situated over four floors and consists of six single rooms and one double room. There is a large open plan communal room that provides living, dining and kitchen facilities and there is a further quiet lounge on the first floor. There is a small garden to the rear of the home with limited parking. McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out by two inspectors on the morning of 20th February 2006. This was the third visit to the home as two previous calls had resulted in no one being at home, and therefore to ensure that there were people in the visit started at 8.30 am. This was a focussed inspection that was aimed at the best outcomes for service users and time was spent talking to the manager, service users and viewing some relevant paperwork. The home provides care and support to eight service users who are fairly independent. What the service does well: What has improved since the last inspection? What they could do better: McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 6 As stated the home has improved their records, however these could still be developed further so as to be able to support the continuity of care for service users. 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. McGillicuddy House DS0000028900.V286316.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 McGillicuddy House DS0000028900.V286316.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): The key standards were inspected at the last visit and were not examined on this occasion. EVIDENCE: McGillicuddy House DS0000028900.V286316.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. Care plans, daily records and risk assessments aim to support service users needs, however, they would benefit from an improved process that reflected and monitored changing needs in order to further support the individual. EVIDENCE: Two care plans were viewed along with risk assessments and daily records. Since the last inspection the care plans have been reviewed and expanded upon – in that more detail has been added to the care plan. However this detail has been added in as a separate sheet at the back of the care plan and they need to be completely re-written as they are reviewed and each area needs to be fully detailed as to how to support the individual with their current needs. It was also noted that one service users care plan stated that he had a mobile phone for emergencies, however the service user informed the inspector that he did not have any credit on his phone and even when his phone does have credit he said he does not have any staff numbers or the homes number – however it was ascertained with the providers that he is aware of the numbers. A requirement has been made that the Home does, however, reassess what McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 10 systems are in place to support the service user when he is out alone, or Home alone and ensure that his care plan reflects the actual support and care given. Daily records have also been improved since the last inspection – significant events are still recorded for individuals, but the home has also introduced a daily diary, which gives a very brief outline of any activities the service user may have undertaken during the course of the day. These, however, are still fairly sparse and do not indicate activities in any detail and also do not identify as to the support given by staff – as the inspectors had some concerns with regards to the staff being available for service users it was strongly recommended that these daily notes are expanded upon. There is also a separate diary in place for key appointments for service users, and who accompanied them if needed. Risk assessments are in place for all key areas of care and support. There are still some areas of risk that may affect service users in their daily lives that need to be assessed and the information placed into the care plans as they are reviewed. Although care plans, daily notes and risk assessments have all improved the home still needs to further develop its recording processes in order to promote and support the continuing and changing needs of the service users. The majority of service users talked to the inspectors during the course of the visit and explained about their daily activities, which included attending day centres, work placements and generally going out and about. McGillicuddy House DS0000028900.V286316.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, 13, 14 and 16. Service users benefit from attending college and a range of community and recreational opportunities, however their choices for evening activities are limited due to the staffing structure. Service users benefit from well balanced meals that are properly discussed with them. EVIDENCE: The service users within this home are fairly independent and the care plans support them in maintaining their own self care needs and service users are also actively encouraged to participate in daily chores around the home so promoting and developing independent living skills. Service users attend a variety of activities during the day including going to college where they learn reading and writing skills as well as attending drawing and painting classes and others attend local day centres. Although the service users are fairly independent they still need the support of staff, and there are rare occasions that staff may not be available sometimes McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 12 during the day – as they may be out shopping. The rota states that the sleepin duty starts at 8.00 pm on most evenings, although in practice staff are available until at least 10 pm – the Home must ensure that both staff and service users are aware of this so as allow service users the support and choice for evening activities. Meals are recorded and service users stated that they enjoyed their meals and that they participate in shopping and menu planning. Observation also showed that service users are free to use the kitchen and are supported by staff in this. It was also evident that service users are encouraged to maintain a healthy diet. McGillicuddy House DS0000028900.V286316.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): These standards were not inspected on this occasion. EVIDENCE: McGillicuddy House DS0000028900.V286316.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): These standards were inspected on the last visit and were deemed to have been met. EVIDENCE: McGillicuddy House DS0000028900.V286316.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 Service users benefit from living in a largely well-maintained, clean and homely environment that suits their needs. EVIDENCE: These standards were not fully inspected and a full tour of the environment was not undertaken but issues that had been raised at the previous inspection with regards to some maintenance issues concerning the environment had been addressed. This had included an odour that had been detected in one of the bedrooms this had been investigated immediately following this inspection and was identified as an outside source and rectified at the time. This is a large property situated close to the town centre and has easy access to local amenities and local transport. The property, itself, is set out over four floors – on of which is at basement level. There is a large kitchen, dining and living area that all service users have full access to and overall at the time of this unannounced inspection the home was seen to be clean, reasonably decorated and furniture and furnishings had a ‘homely’ feel. McGillicuddy House DS0000028900.V286316.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): 33 The Home does not provide sufficient staff to support service users at all times. EVIDENCE: Currently the rotas state that staff finish their shift at 8pm and are then on sleep in duty. One service user told the inspector that when he gets home after 8pm he locks the door and goes up to the staff sleep in room to let staff know he is home. There was lack of clarity as to the supervision and support for service users after 8pm. Service users choice of activity, safety and quality of staff support provided in the evenings would be improved by ensuring that staff and service users are aware that ‘sleep-in’ does not actually start at 8pm but staff are on duty until at least 10pm before moving to sleep in duty and are available after this time. A requirement has been made that the Home ensures that service users are supported at all times in a manner that ensures safety and promotes their choices. It should be noted that this has been addressed by the home at the time of publication of this report. McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 17 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): These standards were not inspected on this occasion. EVIDENCE: McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 18 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 X 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 X 33 2 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X X X X McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 19 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 YA6 Regulation 14 (2) Requirement Timescale for action 30/04/06 2 YA33 The registered person shall ensure that the assessment of the service user’s needs is kept under review and revised at any time when there is a change in circumstances – in that Care plans are reviewed and rewritten at regular intervals and they are reflective of the risk assessments. 12. The registered person is required 30/04/06 (1)(2)&(3) to provide the commission with an action plan detailing how the & Home provides sufficient staff to 18. (1)(a) support service users at all times in a manner that ensures safety and promotes their choices. 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 YA7 Good Practice Recommendations It is strongly recommended that daily records contain DS0000028900.V286316.R01.S.doc Version 5.1 Page 20 McGillicuddy House 2 YA9 appropriate information with regards to the service users daily living choices and that these are then used as part of the review process and then integrated into risk assessments and the resulting care plans. All risks and hazards to service users personal safety are fully assessed - in that the written risk assessments contain more detail for outcomes for actions to be taken, and are recorded fully within the care plan and reviewed regularly. McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 McGillicuddy House DS0000028900.V286316.R01.S.doc Version 5.1 Page 22 - 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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