Inspection on 21/02/06 for Sedgemoor & Framley

This inspection was carried out on 21st 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sedgemoor & Framley 14/11/08

Sedgemoor & Framley 28/11/06

Sedgemoor & Framley 09/08/05

Sedgemoor & Framley 09/03/05

Sedgemoor & Framley 18/05/04

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

CARE HOME ADULTS 18-65 Sedgemoor & Framley 2-4 Mill Road Eastbourne East Sussex BN21 2LY Lead Inspector Nigel Thompson Unannounced Inspection 21st February 2006 09:30 Sedgemoor & Framley DS0000021207.V267115.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 Sedgemoor & Framley DS0000021207.V267115.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. Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sedgemoor & Framley Address 2-4 Mill Road Eastbourne East Sussex BN21 2LY 01323 725825 01323 412118 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) Eastbourne & District Mencap Miss Paula Wheeler Care Home 23 Category(ies) of Learning disability (23) registration, with number of places Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is twentythree (23). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be admitted. That one (1) service user with a physical disability may be accommodated in Sedgemoor (2 Mill Road). 9th August 2005 Date of last inspection Brief Description of the Service: Sedgemoor and Framley is a care home for 23 adults with learning disabilities. The registered providers are Eastbourne and District Mencap. The premises have been converted into one home from two large Victorian houses. The home also provides a bungalow which offers two service users more independent living arrangements. There are two lounges, one which has recently been redecorated and furnished, two dining rooms and two large kitchens. One dining room opens onto a raised terrace area that looks out to a large well-maintained rear garden. Sedgemoor and Framley continues to provide a safe and happy environment whereby young people can learn to live as independently as their disability will allow, within their own home. Service users are enabled to access work placements, college courses, day centres and a range of leisure activities within the home and in the local community. Sedgemoor & Framley DS0000021207.V267115.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 over five hours in February 2006. It found that all of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users and relatives spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. On the day of the inspection there were twenty three service users living at the home. The inspection involved a tour of the premises, examination of the home’s records and discussion with the Registered Manager and Deputy Manager. Five service users and three members of staff were also spoken with. The focus of the inspection was on the quality of life for people who live at the home. In order that a balanced and thorough view of the home is obtained, this report should be read in conjunction with previous inspection reports. What the service does well: The relaxed, homely and welcoming environment has evolved over many years and reflects the stability and commitment within the staff team and the open and inclusive management style of the established and clearly dedicated Manager and Deputy Manager. The well maintained décor and good quality furniture and furnishings continues to provide a comfortable, pleasant and homely environment for service users. Effective systems are in place for the admission and ongoing care of service users. High quality individual care plans developed from comprehensive preadmission assessments ensure that an individual’s needs are met in a structured and consistent manner. Communication and consultation with service users’ family members is effective and ongoing. Relatives have the opportunity to partake in individual assessment, care planning and reviewing processes. Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Sedgemoor & Framley DS0000021207.V267115.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 Sedgemoor & Framley DS0000021207.V267115.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): These standards were not inspected on this occasion. All key standards were assessed during the previous inspection carried out on 9 August 2005. EVIDENCE: Sedgemoor & Framley DS0000021207.V267115.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, 7 & 9 Improved, high quality service users’ care plans, developed from a comprehensive assessment of an individual’s support needs, enable staff to meet such needs in a structured and consistent manner. Service users are enabled and supported to take acceptable risks and encouraged to make decisions about their day to day living. The person centred approach to care and effective systems for service user consultation and participation provide opportunities for individuals to be directly involved in many decision making processes and aspects of life within the home. EVIDENCE: High quality service user care plans, ‘Person centred plans’ (PCPs), have recently been further improved. Plans have been reviewed and amended by an experienced member of staff, working closely with individual service users and their key worker. Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 Page 10 As previously documented, the effective use of pictures, photographs and diagrams in the revised plans ensure the assessment and ongoing care planning process is more clearly focused on and accessible to the individual service user. The Manager confirmed that service users and, where appropriate, a relative or representative continue to be directly involved in annual care plan reviews. It was evident that these reviews are recorded and plans are amended appropriately to reflect changing needs or circumstances. As part of the routine ‘personal assessment’ of service users, risk and the potential for risk is assessed, addressed and recorded through various ratings, including: ‘Independent’ and ‘verbal’ or ‘physical’ prompt. Risk assessments are in place relating to certain behaviour, including: ‘selfinjurious’, ‘self neglect’ and ‘absconding’. In accordance with the person centred approach to care planning, it was noted that risks are recorded in the first person and provide evidence of regular and effective consultation with service users. Individuals are clearly enabled and supported to make decisions about many aspects of their life and are made aware of and understand the reasons for specific action being taken: ‘If I didn’t choose soft food, it could make me choke’. Monthly ‘Residents’ Meetings’ provide all service users with the opportunity to discuss any issues or concerns they may have. From the minutes of the most recent meeting, it was evident that items for discussion included the forthcoming Valentine’s Party, a member of staff who was due to retire (Not mentioning any names!) and the washing up rota. Independence and individuality continue to be encouraged and promoted within the home and are reflected in the personalising of service users’ rooms, the choice of bedclothes and colour schemes and individual preferences for menus and activities. One to one support is a feature of the weekly ‘Training day’, when individual service users remain in the home and have the opportunity to catch up with their personal laundry and shopping. In care plans that were examined it was noted that the ‘Key Worker Role Chart’ includes visual prompts in the form of diagrams and pictures of the service user’s individual interests and choices. Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 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): These standards were not inspected on this occasion. All key standards were assessed during the previous inspection carried out on 9 August 2005. EVIDENCE: Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Staff have developed positive relationships with service users and demonstrate a sound understanding of their care and support needs. EVIDENCE: As previously documented, revised care plans focus on a ‘Person centred’ approach to care and plans that were examined were found to contain detailed information, clearly developed through close consultation with and direct involvement of service users and their relatives. Comprehensive needs assessments and details of staff intervention and action to be taken, ensures a structured and consistent approach to individual care and support. The Manager confirmed that close and effective working relationships between service users and their key worker ensured that any subtle change in an individual’s mood or behaviour can be identified and addressed at an early stage. Since the previous inspection, an ‘Annual Healthcare Assessment’ has been introduced for each service user. In plans that were examined, it was evident that the assessment contains a comprehensive record of many aspects of an Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 Page 13 individual’s personal healthcare, including weight, mobility, eyesight and hearing and any identified mental health issues. Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 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 not inspected on this occasion. All key standards were assessed during the previous inspection carried out on 9 August 2005. EVIDENCE: Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 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, 25, 26, 27, 28 29 & 30 The service remains accessible, safe and clean and is clearly suitable for its stated purpose. Service users continue to benefit from pleasant accommodation that is comfortable, well maintained and decorated to a satisfactory standard. EVIDENCE: It is evident that there has been little change in the physical environment at Sedgemoor and Framley since the previous inspection and standards remain high throughout. The well maintained décor and good quality furniture and furnishings continues to provide a comfortable, pleasant and homely environment for service users. The Manager confirmed that the health, safety and welfare of service users remains a priority. Environmental adaptations and specialist equipment are provided as necessary and includes hoists, ripple mattresses, electric thermaposture beds, audio loop system and assisted baths. Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 Page 16 The minibus has been fitted with a tailgate lift, enabling service users who use a wheelchair to go on outings. Independence continues to be promoted within the home, as far as is practicable, and this is evident from the personalising of service users’ rooms, which clearly reflects individual tastes, preferences and interests. Infection control procedures are in place and clearly adhered to and levels of cleanliness remain high throughout. Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 Page 17 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): These standards were not inspected on this occasion. All key standards were assessed during the previous inspection carried out on 9 August 2005. EVIDENCE: Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 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): These standards were not inspected on this occasion. All key standards were assessed during the previous inspection carried out on 9 August 2005. EVIDENCE: Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 Page 19 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 X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 X 4 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sedgemoor & Framley Score 3 3 X x Standard No 37 38 39 40 41 42 43 Score X X X X X X x DS0000021207.V267115.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement Timescale for action 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 Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Sedgemoor & Framley DS0000021207.V267115.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!