Inspection on 11/01/06 for Peterborough Avenue

This inspection was carried out on 11th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Peterborough Avenue 15/01/07

Peterborough Avenue 19/12/05

Peterborough Avenue 21/03/05

Peterborough Avenue 08/07/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Peterborough Avenue 71 Peterborough Avenue Cranham Upminster Essex RM14 3LL Lead Inspector Harbinder Ghir Unannounced Inspection 11th January 2006 10:00 Peterborough Avenue DS0000027888.V277229.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 Peterborough Avenue DS0000027888.V277229.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. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Peterborough Avenue Address 71 Peterborough Avenue Cranham Upminster Essex RM14 3LL 01708 225196 01708 225196 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) Ms Rita Antoinette Lewis Ms Rita Antoinette Lewis Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: Cara Linn Care Home at 71 Peterborough Avenue is a care home registered to provide long term care, support and accommodation to 3 adults with learning disabilities. Residents’ independence is promoted at all times and are enabled to live as independently as possible. The home is a semi deteched house with car parking facilities to the front of the building. The home is located in a residential area of Cranham, close to shops in the Upminister area, public transport and the M25, A127 and the A12. The home employs staff, working a roster, which gives 24-hour cover. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection was represented by Harbinder Ghir, Regulation Inspector, who was at Peterborough Avenue from 12.45 pm until 2.15 pm. This inspection was the second unannounced inspection carried out as part of the annual inspection plan. The visit concentrated on standards that had not been tested at the previous inspection. During that time residents had gone out for the day. Their comments and feedback can be read in the last inspection report, which was completed on the 12th December 2005. Staff had gone out with the residents and therefore were contacted via telephone. Relatives were not contacted at this inspection as their views were sought at the last inspection and again can be read in the last inspection report. As part of the inspection process the home and some records were inspected. Two requirements were set at the previous inspection and the home has time to meet the timescale for action date specified which will be tested at the next inspection. This was the second statutory inspection for 2005/6, and across the two visits all core standards have been assessed. What the service does well: What has improved since the last inspection? What they could do better: The homes Statement of Purpose and Service User Guide must be updated to provide the information required by the regulations. The Complaints Procedure also needs to be amended to include that the Commission for Social Care Inspection can be contacted at any time of someone making a complaint. The storage of medication requiring cold storage needs to be reviewed. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 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. Peterborough Avenue DS0000027888.V277229.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 Peterborough Avenue DS0000027888.V277229.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): 1 The homes Statement of Purpose and Service User Guide are good but need to be updated to be in compliance with the Care Homes Regulations 2001, to ensure that service users and prospective service users have the correct information about the service that the home provides. Standards 2,3,4, and 5 were assessed as fully met at the last inspection, so were not covered on this visit. However evidence from the last inspection was that: Service users’ needs are fully assessed prior to admission, ensuring that their needs can be met by the home. Service users have access to specialist services if they need them. EVIDENCE: The Statement of Purpose and Service User Guide were seen, which were provided as two separate documents. However, the Statement of Purpose does not include all the information specified in Schedule 1 of the Care Homes Regulations 2001. The complaints procedure within the document also needs to be amended to specify that the Commission for Social Care can be contacted at any time or stage of someone making a complaint, as required by the regulations. The Service user guide focused on person-centered care but only partly provided the information required by the National Minimum Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 9 Standards. Both documents must be amended to meet the requirements of the Care Homes Regulations 2001.This is Requirement 1. Copies of the documents are given to all residents prior to admission and are readily accessible via the manager. The documents were also not provided in pictorial formats. It is recommended that these documents are provided in pictorial formats, which would make them more appropriate to the communication needs of residents. This is Recommendation 1. At the time of the last inspection, all of the outcomes for standards 2,3,4,and 5 were assessed as met. These standards will be re-tested at a future inspection. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 10 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): Standards 6, 7, 8, 9 were assessed as fully met at the last inspection, so were not covered on this visit. However evidence from the last inspection was that: There is a comprehensive, clear and consistent care planning system in place, which provided staff with the information they needed to meet the needs of residents. Residents are supported to make active choices and decisions throughout their daily living and areas of risk are assessed. EVIDENCE: At the time of the last inspection, all of the outcomes for standards 6,7, 8, and 9 were assessed as met. These standards will be re-tested at a future inspection. Peterborough Avenue DS0000027888.V277229.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): Standards 11, 12, 13, 14, 15, and 16 were assessed as fully met at the last inspection, so were not covered on this visit. However evidence from the last inspection was that: Residents are provided with the support to maintain their independence and in areas of personal development according to their needs and wishes. Residents are engaged in community life; enjoy a range of leisure activities and a varied and nutritional diet. EVIDENCE: The above standards were not specifically tested on this visit. The home has time to reach the timescale of 19/03/06 for the outstanding requirement in relation to standard 17 set at the last inspection and will be tested at the next inspection. At the time of the last inspection, all of the outcomes for standards 11, 12, 13, 14, 15, and 16 were assessed as met. These standards will be retested at a future inspection. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 12 Peterborough Avenue DS0000027888.V277229.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): 20 Residents are protected by clear and comprehensive arrangements for the administration of medication. However, the storage systems for temperature controlled drugs needs to be improved. Standards 18, 19 and 21 were assessed as fully met at the last inspection, so were not covered on this visit. However evidence from the last inspection was that: Personal, physical and emotional healthcare is provided in a way that meets residents’ needs. Residents’ wishes in the event of death are established and are handled with respect and as the individual would wish. EVIDENCE: Medication is managed well by the home. MAR sheets viewed were completed in full and double signed by staff. All staff administering medication have undergone training in medication by the Registered Manager who is a qualified nurse and holds a Foundation Certificate in the Care of Medicine. The home has an appropriate medication policy and procedure in place, which protects all service users and ensures the safety of those who can self-medicate by using Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 14 risk assessments where necessary. Residents are provided with a personal lockable drawer where they are to able self- administer medication. Currently, none of the residents are able to administer their medication independently. Drugs requiring cold storage are stored in the fridge but were not found to be stored in a locked container. It is advised a separate, secure and dedicated container is made available in the home to be used exclusively for the storage of medicines requiring cold storage. This is Recommendation 2. At the time of the last inspection, all of the outcomes for standards 18, 19 and 21 were assessed as met. These standards will be re-tested at a future inspection. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has a clear complaints procedure but it needs to be amended to fully comply with the Care Homes Regulations 2001. Policies, procedures and staff training were provided that protected residents from abuse. EVIDENCE: The complaints procedure displayed in the home needs to be amended to include that the Commission for Social Care Inspection can be contacted at any time or stage of a complaint being made. This is Requirement 2. The home had a clear system for logging complaints and had identified timescales for action. The complaints procedure was also provided in a pictorial format, which was very simple and easy to follow, making it appropriate to the communication needs of its residents. Policies and procedures regarding the abuse of vulnerable adults were provided. Records seen identified all staff were booked to attend training on adult abuse, provided by Havering Local Authority, within the forthcoming month. The manager had also obtained comprehensive policies and procedures from placing Local Authorities. Evidence was also seen of Adult Protection issues comprehensively covered in the homes induction programme. From conversations with staff it was evident that staff are aware of the homes adult abuse policies and procedures and understand the definitions of abuse and what to do in the event of abuse, ensuring that residents are protected from abuse. One member of staff spoken to explained the types of abuse and Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 16 how he would report any incidents of abuse to his manager and follow the homes whistle blowing policy. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 17 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): Standards 24, 25, 26, 27, 28, 29 and 30 were assessed as fully met at the last inspection, so were not covered on this visit. However evidence from the last inspection was that: Residents’ benefited from living in a safe, well-maintained and clean environment. Décor, furnishings and fittings are of a good standard and provide a homely and pleasant living environment, which enhances residents’ comfort. EVIDENCE: At the time of the last inspection, all of the outcomes for standards 24, 25, 26, 27, 28, 29 and 30 were assessed as met. These standards will be re-tested at a future inspection. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 18 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): Standards 31, 32, 33, 34, 35 and 36 were assessed as fully met at the last inspection, so were not covered on this visit. However evidence from the last inspection was that: Staff were aware of their and other’s job roles and responsibilities, providing clarity of roles to residents. There is a good match of qualified staff offering consistency within the home. Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their quality of life. Recruitment processes need to be more robust to ensure the protection of people living at the home. The staff group receive adequate training to meet the needs of residents. Staff receive supervision on a regular basis. EVIDENCE: The above standards were not specifically tested on this visit. The home has time to reach the timescale of 19/02/06 for the outstanding requirement in relation to standard 34 set at the last inspection and will be tested at the next Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 19 inspection. At the time of the last inspection, all of the outcomes for standards 31, 32, 33, 35 and 36 were assessed as met. These standards will be re-tested at a future inspection. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 20 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): 42 The welfare of staff and service users is promoted by the home’s policies and procedures at all times. Standards 37, 38 and 39 were assessed as fully met at the last inspection, so were not covered on this visit. However evidence from the last inspection was that: Residents’ benefit from an experienced manager who recognises their needs and manages the home well. The manager has a clear vision for the home, which she has effectively communicated to residents, relatives and staff. The systems for Service User consultation are good with evidence that Service User views are sought and acted on. EVIDENCE: Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 21 The manager and staff take overall responsibility for ensuring relevant maintenance checks are carried out throughout the home. It is clear from the records seen that all relevant legislation is complied with and reportable incidents are reported to the appropriate authorities. Fire signs and safety posters are evident throughout the home. Residents participate in fire drills regularly and in the event of a fire the home has made arrangements for residents to be accommodated at a local hotel. All members of staff have health and safety training as part of the induction process. At the time of the last inspection, all of the outcomes for standards 37, 38 and 29 were assessed as met. These standards will be re-tested at a future inspection. However, members of staff spoken to made positive comments in relation to the above standards. One member of staff spoken to informed that the manager is very supportive and consistently keeps them updated of any policies and procedures. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 22 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 2 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 2 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 x STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X X 3 X Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation Requirement Timescale for action 11/04/06 2 YA22 Schd The registered person is 1(4)(1)(5)(1) required to review and update the Statement of Purpose and Service User Guide to include the information required by the Care Homes Regulations 2001 22 (6) (a) The complaints procedure (b) must be updated to ensure that the Commission for Social Care Inspection can be contacted at any time or stage of someone making a complaint in compliance with the Care Homes Regulations 2001. 11/04/06 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 YA1 Good Practice Recommendations It is recommended that the Statement of Purpose and Service User Guide are provided in pictorial formats DS0000027888.V277229.R01.S.doc Version 5.1 Page 24 Peterborough Avenue 2 YA20 appropriate to the communication needs of its residents. It is recommended that a secure and dedicated container is made available in the home to be used exclusively for the storage of medicines requiring cold storage. Peterborough Avenue DS0000027888.V277229.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. 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