Inspection on 22/03/06 for Sevenoaks

This inspection was carried out on 22nd March 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sevenoaks 11/02/09

Sevenoaks 22/02/07

Sevenoaks 16/08/05

Sevenoaks 15/02/05

Sevenoaks 01/12/04

Sevenoaks 16/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Sevenoaks Lords Hill Coleford Glos GL16 8BG Lead Inspector Mrs Helen James Unannounced Inspection 22nd March 2006 09:45 Sevenoaks DS0000016575.V284788.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 Sevenoaks DS0000016575.V284788.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. Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sevenoaks Address Lords Hill Coleford Glos GL16 8BG 01594 832679 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) The Orchard Trust Mrs Elizabeth Jones Care Home 10 Category(ies) of Learning disability (11), Sensory impairment (5) registration, with number of places Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16th August 2005 Brief Description of the Service: Sevenoaks is a modern detached split-level bungalow situated within half a mile of Coleford Town Centre in the Forest of Dean. The home accommodates up to ten people with learning disabilities, five of whom may have a sensory impairment. The accommodation comprises of 10 single bedrooms, six of which have en-suite facilities. The house is separated into two wings, known as Phase 1 and Phase 2. Each has its own separate dining and lounge areas, kitchen, offices and communal bathrooms. The original home retains sleepingin facilities for staff and a small laundry. The newer home has a larger laundry. At the rear of the property there is a parking area and landscaped garden. Residents have access to three vehicles. The home is part of the Orchard Trust group. Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and a quarter hours on one day in March 2006 and was completed by one inspector. Fourteen standards for Younger Adults were looked at on this occasion eleven standards were met and three were almost met. The inspector spoke to the Deputy Manager Julie Evans and the Manager Elizabeth Jones joined them later in the inspection. Residents and four care staff were spoken with and appropriate records and care plans, relating to two people living at the home were seen. People living at the home were observed with staff during the inspection. Observation of care and interactions of staff with people living at the home were caring, appropriate and respectful, people living at the home were unable to communicate their satisfaction with the service due to their complex needs. What the service does well: What has improved since the last inspection? The Manager and Deputy Manager have now clearly defined their roles within the home, which ensures that nothing is overlooked. The Manager deals with the administration of the home and the resident careplans. The Deputy Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 6 Manager oversees the Senior Carers and works alongside staff and the care practice. The deputy manager also draws up the activity plans for all the people living at the home. This is work well and ensures delegation and responsibility at all levels. It also allows the Managers their management audit trails within the home. 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. Sevenoaks DS0000016575.V284788.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 Sevenoaks DS0000016575.V284788.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 examined at the last inspection and were met. EVIDENCE: The Manager to send a copy of the reviewed Service Users guide to the inspector at the Commission. Sevenoaks DS0000016575.V284788.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 & 9 Improvements have been made to the care planning system to ensure that staff have the information they need to care for people living at the home. A variety of communication tools are used at the home to assist people living at the home to communicate their needs. Risk assessments are documented for individuals to ensure that they are protected in their daily lives. Information is now stored securely. EVIDENCE: The inspector observed that people living at the home were treated with respect and dignity and that they were assisted in their choices and daily routine. It was observed that they were addressed by staff in a manner that was polite, respectful and considerate and a variety of communication tools were used. Since the last inspection care plan documentation has been updated to make it more streamlined and easier to use (they have reverted to the old system they Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 10 used). This has made it easy to read and understand. There is an assessment of need with all the care needs identified in a format that makes it easy for care staff to know what the individual needs are and how they are to be met whilst ensuring that what the individual is able to do is preserved. These care plans are reviewed six monthly or as the needs change. Risk assessments were well documented in those care files examined, determining the area of risk and the action to be taken. Daily records were clear and concise. All professional visits were recorded with relevant actions to be taken and the outcome of the visit. All the people living at the home have a comprehensive individual activity programme that is reviewed regularly and as their needs change. These were seen for some individuals during the inspection. In discussion with staff it was ascertained that they had a good understanding of the needs of the people living in the home in the area they were working and knew how to deal with specific challenging behaviour that was evident at this visit. The staff also knew what their responsibilities were in respect of care planning and ensuring that documentation such as food eaten etc by residents was recorded. Staff were able to explain to the inspector the specific communication needs of people living in the home when the inspector was touring the building and interacting with people living at the home. Explaining to the inspector the use of specific signs, objects of reference, photographs and symbols. The inspector engaged with one person in drawing communication and another in using objects of reference. Sevenoaks DS0000016575.V284788.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): 12,14 & 17 People living at the home are enabled to live a fully inclusive lifestyle accessing a range of local community facilities and activities. The rights and responsibilities of people staying at the home are respected enabling them to participate in a range of activities. EVIDENCE: People living at the home have a range of educational, social and leisure activities. Some attend the Barn, which is owned by The Orchard Trust, and run in conjunction with Gloscat. Others attend the local College and other day centres. Other activities include shopping, swimming, hydrotherapy, music therapy, running at the local race track, walking, out to the local teashop and other excursions. The home has a range of entertainment equipment, interactive and sensory equipment that can be used in a group or with individuals. Staff were observed spending time with individuals in a variety of ways which gave the Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 12 environment a lively relaxing feel to it. The people observed appeared to be happy and relaxed in their interactions with staff. Meals are prepared for individuals depending on their individual specialist diet and around their commitments at lunchtime. What is eaten is recorded for the individual. The dietician is involved with some of the people living at the home. In the evening there is a set meal and special diets are catered for. Each person at the home now has a consistent record of what has been eaten and weights are monitored and recorded. In discussion with staff they understand the importance of this and appear at the present time to adhere to recording every persons dietary intake and the fluid intake for specific people. Sevenoaks DS0000016575.V284788.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): 18 The way in which the people staying at the home would like to be supported is clearly recorded. EVIDENCE: The way in which people living at the home like to be supported is clearly identified in their records. Case records seen confirmed this. People observed at the home were observed receiving support from staff in an appropriate manner, contentiously and unhurried with a lot of patience when the individuals required help. Most of the people living at the home require total support and guidance and this was clearly being given. Staff appeared to have a good understanding of the individuals needs and dealt with them appropriately and patiently. Medication was not examined but the development of a Homely Remedies policy/agreement with the GPs and Pharmacist was a requirement from the last report. It was reported by the Manager that they did not want to sign up to an agreed homely remedies list so the only Homely remedy that is kept at the home is cod liver oil for one person. All requests for Homely remedies go through the GP and this is reported to work well. Sevenoaks DS0000016575.V284788.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): The Key standards were not examined at this inspection. EVIDENCE: Sevenoaks DS0000016575.V284788.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): 30 People live in a homely and comfortably furnished environment, which benefits from an ongoing maintenance programme ensuring that the home continues to meet the needs of the people living there. EVIDENCE: Sevenoaks has an ongoing programme of decoration and replacement of furniture. All the required furnishings are supplied in the home as appropriate. The home was clean and tidy on the day of the inspection and no infection control issues were identified. The laundry was not examined on this occasion. Each person staying at the home has their own room with en-suite facilities and access to nearby bath/shower rooms, which are appropriately equipped. Rooms seen were personalised for the individual as much as they could be depending on the individuals needs in relation to ensuring their safety and preventing harm to the individual. A range of specialist adaptations and equipment are provided for the people living at the home that are specific for this particular client group. The home has regular contact with the Physiotherapist and Occupational Therapist to ensure that as needs change the equipment available continues to meet the needs of the individuals and the staff caring for them. Sevenoaks DS0000016575.V284788.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): 32, 34 & 36 The procedure for the recruitment of staff needs slight improvements to ensure the system is robust and protects the people living at the home. Staff have access to a training programme enabling them to gain competence and skills necessary to support people living at the home. EVIDENCE: On the day of the inspection, there were eleven people living at the home although one was in hospital as their care needs had changed. In the morning, 7-30am until 3-30pm, there were seven care staff for phase one and two and the Manager and Deputy Manager were on duty. From 13-30 until 21-30 there were six care staff. Domestic staff and a handyman were also on duty. At night for phase 1 there was a member of staff who slept from 23-00pm until 7am. In phase 2 from 21-30pm until 07-30am there were two waking care staff and there was always central on-call Manager for the night. These staffing levels appeared adequate for the present resident group even though staff also deal with catering duties. Three new members of staff have been appointed since the last inspection. Their personnel files were examined. These contained the required information the only concern raised by the inspector was the fact that although POVA Firsts were received on the computer email, there was not always a copy of this on Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 17 the personnel file. It is required that when the information comes through that it is always printed off and put on the personnel file. All Staff have their CRB/POVA status renewed every three years by the company. A comprehensive induction is undertaken with all new staff and this is recorded. The Deputy Manager starts the induction and then she allocates the new staff member to a senior carer for two weeks, they are then reviewed at this point. The supervision begins with the area manager seeing them monthly for two months and then supervision is allocated to a senior carer at the home. Supervision records seen for the new staff were very comprehensive with clear objectives for individuals set and dates for achievement. Both parties involved signed these. Mandatory training for all staff is given through Stroud College now and whilst it is good sometimes staff are waiting up to three months to do. The Orchard Trust needs to ensure that during induction basic instruction in ‘moving and handling’, food hygiene etc is given and recorded on the induction and that the new staff member is always working with an experienced member of staff until they start the induction. A comprehensive training matrix is maintained by the Managers confirming that staff have access to core training and developmental opportunities such as the Learning Disability Award and NVQ Care Awards. The home strives to ensure that training specific to the needs of people living at the home is pursued and given to include areas such as challenging behaviour, strategies for management of challenging behaviour and sensory awareness. Discussion with members of staff confirmed that they had the knowledge, skills and experience necessary to support the people residing in the home at the inspection. Staff spoken with confirmed that they have many developmental opportunities and that any needs identified during supervision/appraisal are addressed. Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 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): 38 There is good leadership, guidance and direction to staff. This ensures that people living at the home receive consistent quality care and results in practice that promotes and safeguards the health, safety and welfare of the people using the service and the staff. Residents are protected from accidents and appropriate action is taken when they do occur. A system of management auditing of the in-house accidents needs to be undertaken as part of the Quality Assurance system EVIDENCE: The Manager and Deputy Manager have now clearly defined their roles within the home, which ensures that nothing is overlooked. The Manager deals with the administration of the home and the residents careplans with the deputy informing her of changes in care and keyworker. The Deputy Manager oversees the Senior Carers and works alongside staff and the care practice. The deputy also draws up the activity plans for residents. This is reported to work well and ensures delegation and responsibility at all levels. It also allows the Managers to audit ‘what’ and ‘where’ things may go wrong. Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 19 The Area Manager visits the home twice weekly and does the regulation 26 report. A senior manager also visits the home twice weekly. The supervision and appraisal system is well established with a defined structure of responsibility for each group of staff. The inspector saw the supervision schedule planner and records during the inspection. This complied with the standards set. The home has the keyworker system in place for residents and they are responsible for careplan checks and keeping the daily records up-to-date, they are overseen by the senior carers. Care is allocated daily and who is responsible for the shift in each area, so that there is an audit trail of responsibility on each shift so that issues can be addressed. This assists in identifying issues that need to be addressed at supervision and also in identifying training needs. The Fire Officer visited the home two weeks ago and there were no issues identified the Manager is to send a copy of the report to the Inspector. The home has a documented Fire Risk Assessment in place. A care worker is identified as the homes’ Fire Officer and they are updated yearly and ensures that all the staff receive their mandatory training. This is then recorded in the training records. Accident records were examined they were well recorded for staff and people living at the home. A risk assessment is documented of the accident, which records any action taken by staff following the accident. But there is no evidence that the Home Manager audits the accidents to identify any areas of improvement that may need to be made or to identify patterns of accidents etc. This would be part of the Quality assurance within the home, with any actions taken recorded by the Manager. All accident records are kept on the individual files. There have been no accidents requiring RIDDOR reporting since August 2005. The Area Manager audits accidents as part of his weekly visits for his regulation 26 report. Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 20 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 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X X 3 2 X X X X Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 21 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. 2. Standard YA1 YA39 Regulation 6 24(1) Requirement Timescale for action 31/05/06 A copy of the reviewed service user guide to be sent to the Commission. A system of management 30/06/06 auditing of the in-house accidents needs to be undertaken as part of the Quality Assurance system. When POVAFirst information comes through on the email it must always be printed off as evidence and put on the individual personnel file in the home. 31/05/06 3. A34 19(1)Sch 2.7 4. YA32 13(5) Basic instruction in ‘moving and handling’ must be given until staff receive their formal mandatory training and this must be recorded. 30/06/06 Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 22 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 YA19 Good Practice Recommendations Training in pressure sore prevention should be arranged. Sevenoaks DS0000016575.V284788.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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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