Inspection on 09/08/05 for Sedgemoor & Framley

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 21/02/06

Sedgemoor & Framley 09/03/05

Sedgemoor & Framley 18/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

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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 Sedgemoor & Framley 2 - 4 Mill Road Eastbourne East Sussex BN21 2LY Lead Inspector Nigel Thompson Announced 9 August 2005 9:30 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 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 Stationary 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 H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 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 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 (LD) 23 registration, with number of places Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The maximum number of service users to be accommodated is twenty-three (23). 2. Service users must be aged between eighteen (18) and sixty-five (65) years on admission. 3. Service users with a learning disability only to be admitted. 4. That one (1) service user with a physical disability may be accommodated in Sedgemoor (2 Mill Road). Date of last inspection 9 March 2005 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 H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over six and a half hours in August 2005. It found that all of the thirty National Minimum Standards that were assessed had been met and the overall quality of care provided was good. Service users spoken to during the inspection expressed satisfaction with the home, the staff and the service provided. A tour of the premises took place and documentation, including service user and staff files was inspected. Three of the staff on duty and seven of the twenty two residents were spoken with. What the service does well: What has improved since the last inspection? Two new care staff have been appointed since the previous inspection and service users’ social and recreational opportunities have been further increased by the acquisition of a third minibus. Redecoration and refurbishment to the lounge and dining room is currently ongoing and work has recently been completed on upgrading three residents’ rooms, which has included the installation of fitted wardrobes. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 & 5 Documentation, including a comprehensive ‘Statement of Purpose’ and ‘Service Users’ Guide’ ensures that prospective service users and their relatives have sufficient information about the home and the services provided. The thorough admission policy and procedure ensures that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. EVIDENCE: Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 9 Comprehensive information is made available to all prospective service users and it was noted that the quality and accessibility of the home’s ‘Statement of Purpose ‘ and the ‘Service User Guide’ is further enhanced by effective use of photographs and diagrams. Following a referral to the home, the manager will visit the prospective service user and carry out a pre-admission needs assessment, including any personal care needs, mobility issues, social and cultural needs and family involvement. Assessments that were examined were found to contain a detailed and informative ‘Individual Profile’, effectively completed in the first person. In addition to establishing whether the individual’s care and support needs can be met within the home, the manager also stressed the importance of ensuring compatibility with existing service users. For individuals referred through Care Management arrangements, the manager insists on a completed Social Care Assessment being provided. As well as being invited to visit the home to look around and meet with existing residents and staff, prospective service users have the opportunity to stop overnight or occasionally for a weekend stay before moving in. The manager confirmed that new service users undergo a three month trial period at the home, during which time their suitability and compatibility are fully assessed and it is established whether their identified care and support needs are able to be met. A contract, including a full statement of terms and conditions of residency is provided to all new service users. It was noted that this document contains both the organisation and the resident’s ‘obligations’. This represents good practice and is a clear and concise agreement of what each party can expect of the other. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 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 standard(s) 6, 7 & 8 Service users’ care plans are developed from a comprehensive assessment of an individual’s needs and enable staff to meet such needs in a structured and consistent manner. Service users are encouraged and supported to make decisions about their day to day living and benefit from effective consultation systems. EVIDENCE: The existing high quality service user care plans are currently being further improved. An experienced member of staff is working closely with individual service users and their key worker to review, amend and develop ‘Person centred’ plans. 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. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 11 It was evident that service users and, where appropriate, a relative or representative are directly involved in an annual care plan review. It was noted that these reviews are recorded and plans are amended appropriately to reflect changing needs or circumstances. The manager confirmed that service users are consulted regarding many aspects of their day-to-day living, including choosing colour schemes for their room and communal areas, menu planning, recreational and leisure activities and holidays. It was also noted that service users are involved in staff recruitment and individual residents often sit on the selection panel during an applicant’s second interview. From all accounts it is evident that service users involved in this process take their role and responsibilities very seriously. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 12 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 standard(s) 12, 13, 15 & 17 Service users are supported and encouraged to lead healthy and fulfilling lives and are enabled to engage in appropriate leisure activities. Family and community links are good and support and enrich service users’ social opportunities. Service users benefit from menus that are balanced and nutritious and reflect their individual likes and preferences. EVIDENCE: The recreational and leisure interests of service users are identified and recorded in their individual care plan, as part of the initial assessment process. It was evident that activities, including seafront walks, bowling and theatre trips reflect these interests and effectively meet service users’ individual and collective social care needs. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 13 Key workers are clearly committed to supporting service users in their personal development. One service user was proud to show off her individual ‘Life Book’, which reflected her personal history in words and photographs but also demonstrated the time and effort spent and close relationship formed between her and her key worker. Another service user had enjoyed an exciting flying lesson, arranged as a 40th birthday ‘experience’. The manager confirmed that, where appropriate, links with family and friends are encouraged and supported and many service users enjoy regular contact with their relatives. Although, unfortunately, it was not possible to meet personally with any service users’ relatives during the inspection, comment cards received expressed, without exception, a very high level of satisfaction with the home, the manger and staff and the care services provided: ‘She is one in a very happy community and is always very happy to return to her ‘home’ after a visit to our home’. ‘..is very happy at Sedgemoor and Framley and is always eager to return after a visit with me’. ‘A very happy home and well looked after. The people are all so happy and relatives are made welcome at all times’. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 14 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 standard(s) 18, 19 & 20 Staff have developed positive relationships with service users and demonstrate a sound understanding of their care and support needs. Policies and procedures for the control and administration of medication are effective with clear and comprehensive systems being in place to ensure service users’ medication needs are met. EVIDENCE: Service users’ personal care and support needs are clearly documented in their individual care plan. 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 residents 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 a Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 15 resident’s mood or behaviour could be picked up on and addressed at an early stage. Policies and procedures, relating to the control and administration of medication, are in place and were found to be accurate, well maintained and up to date. The manger confirmed that only senior staff are directly involved in these procedures. The home operates a ‘Monitored Dosage System’ (MDS) and regular monitoring of procedures as well as guidance and advice is provided by a local pharmacist. The deputy manager confirmed that, following assessments, one service user currently maintains responsibility for the control of her own medication, within a risk management framework. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 16 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 standard(s) 22 & 23 The open and inclusive atmosphere within the home enables service users, staff and visitors to feel able to express any concerns, confident that they will be listened to. Service users are safeguarded from abuse through robust policies, procedures and relevant staff training. EVIDENCE: A clear and accessible complaints procedure is in place. Service users and members of staff spoken to during the inspection confirmed that, should they have a concern or complaint, they would have no hesitation in speaking to the manager or deputy manager and each person was confident that they would be listened to. Policies and procedures relating to abuse, including whistle blowing are in place and were found to be up to date and well maintained. The manager confirmed that staff are made aware of these and other key policies and procedures as part of their induction and foundation training and they are also reinforced during regular supervision and staff meetings. Abuse training is provided for all staff and this was evidenced by training records and certificates in staff files and confirmed by members of staff themselves. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 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 standard(s) 24, 25, 26 & 30 The service is accessible, safe and clean and is clearly suitable for it’s stated purpose. Service users benefit from pleasant accommodation that is comfortable, well maintained and decorated to a satisfactory standard. EVIDENCE: There has been little change in the physical environment of the home since the previous inspection and standards remain high throughout. The well maintained décor and good quality furniture and furnishings provide a comfortable and pleasant environment for service users. The deputy manager confirmed that 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 H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 35 & 36 There are sufficient trained and competent staff on duty at all times to meet the assessed, complex and often high dependency needs of the service users. Thorough recruitment procedures help to ensure the safety and protection of service users. Effective supervision and training has resulted in high staff morale and an enthusiastic and motivated workforce with a sound understanding of the support needs of the service users. EVIDENCE: The home operates a thorough recruitment procedure. Staff files that were examined were found to be generally well maintained, containing all necessary information, including two written references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. New staff are initially appointed on a three month temporary contract before Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 19 being confirmed in post following a successful completion of this probationary period. All new employees are provided with a comprehensive job description and receive full induction and foundation training. The stable and dedicated staff team is clearly able to meet the assessed, individual and collective needs of service users within the home. A full and comprehensive staff training programme is in place and includes both mandatory and service specific topics, including fire safety, safe handling of medicines, first aid, abuse training and food hygiene. All training is certificated and is recorded in individual staff files. All care staff continue to receive individual supervision sessions every two months, which are documented and kept in accordance with Data Protection requirements. The manager confirmed that all staff receive an annual appraisal to review performance, discuss service requirements and agree personal career development plans. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39 & 42 Staff are aware of and adhere to up to date policies and procedures relating to health and safety, ensuring the health, safety and welfare of service users and staff. Service users benefit from continuous quality assurance and self-monitoring that takes place at Sedgemoor and Framley. EVIDENCE: Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 21 The manager confirmed that the health, safety and welfare of service users and staff is of paramount importance within the home and staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is recorded. COSHH assessments and guidelines are in place. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. The established management team have clearly worked hard to develop a relaxed, open and inclusive atmosphere within the home. Staff and service users, spoken with during the inspection confirmed how approachable and supportive the manager and the deputy manager are. Staff meetings are held every six weeks and residents’ meetings are held monthly. Staff and service users are encouraged to make suggestions on how the home is run. Effective quality monitoring systems are in place, including satisfaction questionnaires for service users and their relatives. Representatives from Eastbourne and District Mencap continue to carry out monthly monitoring visits to the home. Comments cards received from service users’ relatives expressed a high degree of satisfaction with the manager, her deputy and staff team and the overall level of care services provided: ‘The manager and her staff treat all the residents with respect and dignity and the standard of care is superb’. ‘Excellent care from a dedicated team of carers - in a top quality home’. ‘We are more than happy about all the kind care and consideration that is given to………and could not wish for more. He is extremely happy there and would not like to live anywhere else’. ‘……in spite of his disabilities, his life has been enriched and gives me such comfort to see his joy spent with all there’. Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sedgemoor & Framley Score 4 3 3 x Standard No 37 38 39 40 41 42 43 Score 4 4 3 x x 3 x H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 23 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 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. 1. Refer to Standard Good Practice Recommendations Sedgemoor & Framley H59-H10 S21207 Sedgemoor Framley V229876 090805 stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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. 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