Inspection on 24/10/05 for Z & M Care

This inspection was carried out on 24th October 2005.

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

Z & M Care 09/03/07

Z & M Care 03/06/05

Z & M Care 23/11/04

Z & M Care 21/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Z & M Care 12 Lyndhurst Road Hove East Sussex BN3 6FA Lead Inspector Linda Khot Unannounced Inspection 24th October 2005 02:30 Z & M Care DS0000014112.V250536.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 Z & M Care DS0000014112.V250536.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. Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Z & M Care Address 12 Lyndhurst Road Hove East Sussex BN3 6FA 01273 323814 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) Z & M Care Limited Mrs Zara Fatemeh Moussavi Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is seven (7). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Only service users with a learning disability to be accommodated. Date of last inspection 3rd June 2005 Brief Description of the Service: This report has been written for the Younger Adults home of Z&M Care. This home is registered for seven service users with learning disabilities between the ages of 18-65 years; it is adjacent to the larger home that provides care for thirty-seven service users all of which are older people.The homes are integral and staff are able to work between the two. Policies and procedures are shared thus providing comprehensive reference and guidance for staff, flexibility of working and continuity of care. Z&M Care has the Investors in People Award and Clean Food Award.The home is part of an Edwardian terrace that has been extended and renovated to accommodate service users in both homes. It is in a quiet residential road, near to the busy Seven Dials area of the city that has facilities for shopping including a bank and a post office. The home is also close to both Brighton and Hove mainline stations and local buses stop nearby for all parts of the city. Parking is available in the roads near to the home and is either resident only parking or via a meter system for 4 hours at any one time. The home has a parking bay outside for service user transport. The area is well serviced for parks, churches, pubs and leisure activities including the Sussex County Cricket Ground.The main ethos of the home is to promote independence and both the Registered Manager, Deputy Manager and care staff are pro-active in maintaining and supporting a residentled service. Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the afternoon and was a joint inspection with the older peoples home that is also part of Z&M Care. Mrs Zara Moussavi the Registered Provider/Manager and Mr Jess Marsden the Deputy Manager facilitated the inspection. There are seven residents in the home, one resident formerly had a bedroom in the older people’s home but a variation agreement was made when an agreement to change rooms with a resident from the Younger Adults home took place. The Inspector was able to spend time with the residents on their return from their day centres and colleges as well as look at the environment. On the day of inspection the home was clean and tidy and the residents appeared happy in a homely atmosphere and keen to socialise with each other and the staff. What the service does well: What has improved since the last inspection? Since the last inspection the home has employed a new person to undertake all maintenance and cleaning duties. Some areas of the home have been decorated and upgraded giving a fresher and cleaner appearance. Relationships between residents have also improved since two residents decided to change rooms; this was done following a variation being granted by the Commission for Social Care Inspection. Person centred Planning is being incorporated into the care plans; staff are undertaking stage 2 of the training. During the summer months residents told the Inspector they used the garden as it has been altered to suit their social requirements. Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 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. Z & M Care DS0000014112.V250536.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 Z & M Care DS0000014112.V250536.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): All standards were assessed in June 2005. EVIDENCE: Z & M Care DS0000014112.V250536.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, 7,8 and 9. The home makes every effort to involve residents in all aspects of their care and is pro-active in encouraging them to make decisions on their daily lives taking risks as appropriate. Staff ensure that all residents have an awareness of the right to privacy and confidentiality. Care plans are well kept, comprehensive and reflect resident’s needs. EVIDENCE: All standards were assessed in June 2005 however, the Inspector was able to look at care plans and have conversations with the residents about their lives in the home. All were positive in their views in that they are allowed freedom of choice in what they wear, what they buy for themselves and how they arrange their individual rooms. Some reported enjoying helping in the home whilst others preferred to do other things. Some residents preferred to undertake their own washing however staff said this was always monitored especially as the laundry is situated outside the home. All residents care plans show reports of reviews and risk assessments; residents are keen to be involved in the review process. In addition to this details of chosen chiropodists, hairdresser, dentist and optician are recorded. Daily record Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 10 sheets show any incidents, visits, or medical appointments that the residents have. There are also records of monitored smoking, where appropriate, social life and activities, family involvement, medication to be administered, and communication from other agencies and support services. Each file has a photograph of the individual resident. All residents have control of their own finances; where appropriate support is given by staff. Z & M Care DS0000014112.V250536.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): 14 and 17. Residents are encouraged to have both a social life and take part in leisure activities that they enjoy. They are supported in eating healthily and being involved in the decision making process of what meals are prepared in the home. EVIDENCE: The Inspector was able to speak to residents about their views on their leisure activities and meals in the home. All were enthusiastic about the food and some said they enjoyed helping with cooking whilst others said the preferred not to but did help with the clearing away. All said they could eat what they wanted but that the Care Manager helped them choose meals that are good for them. Residents spoke to the Inspector about their holidays during 2005. Two went to Butlins and also the Isle of Wight, which they enjoyed, whilst three others will be going to Tenerife with a member of staff, but within a larger group, early in November. Z & M Care DS0000014112.V250536.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): 18,19,20 and 21. The home is pro-active in ensuring that residents receive care and support for their physical and emotional needs in a way that meets their individual needs. The home has policies and procedures in place for the administration of medication thus ensuring residents are protected. EVIDENCE: Times for getting up and going to bed in the home are flexible; staff told the Inspector that generally all residents get up and are ready for their day centres or college by 9am. Residents are encouraged to give their views and opinions on all aspects of their day centre arrangements and examples were given where residents had decided either not to attend or change the centre they attended. The Registered Provider had kept the inspector informed of any such changes that were being planned prior to the Inspection, especially where there had been an impact on the resident’s well being or behaviour. Meals are taken together in the dining room although on occasions some residents choose to eat in their own room or the communal sitting room. All residents are given choice of clothing and hairstyles and this was confirmed during discussion with residents later in the day. The home has a key worker system in place and staff and residents are gender matched. The home has access to all healthcare professionals, which is Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 13 enhanced by involvement with the Community Learning Disability Service, Advocacy Services, Day Centres and Community Colleges. No one in the home self-administered his or her medication at the time of inspection. The Senior Carer or Deputy Manager undertakes all ordering of medication and Brighton and Hove Council undertake staff training. The medicine cupboard was tidy and well organised with no evidence of stock piling or out of date medication. Z & M Care DS0000014112.V250536.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): 22 and 23. Residents are protected by the homes attitude towards complaints. Staff are aware of their responsibilities in the protection of the vulnerable adult. EVIDENCE: The Inspector spoke to residents about their views on being listened to by staff and management. They all said that they could talk to the Registered Provider, Deputy Manager, Care Manager or any of the staff each of whom they named. They also supported that the Care Manager visits them individually once a week to have a chat with them, talk about any problems they may be experiencing with either their health, diet, socially or life in the home generally. The Registered Provider and Deputy Manager told the Inspector that they aim to ensure that holistically the residents are card for. Records showed that there had not been any complaints since the last inspection. The home has a policy and procedure in place for the protection of vulnerable adults, all staff attend training and updates with Brighton and Hove Council. Both the Registered Provider/Manager and Deputy Manager have attended training for managers. The policy was updated in August 2005. Where residents have disagreements the staff address the situation with immediate effect and individual records show that the Registered Provider informs the necessary agencies and instigates strategy meetings with the relevant funding authorities. Evidence of this is held in the home’s service file at the Commission for Social Care Inspection. Z & M Care DS0000014112.V250536.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 and 30 The home is comfortable and residents enjoy living in a homely environment. Staff are aware of the importance of residents health and safety. On the day of inspection the home was clean and tidy and attention had been paid to freshening up areas discussed at the last inspection improving the internal decoration. EVIDENCE: All areas of the home on the day of inspection were clean and hygienic. Bedrooms seen by the Inspector with the residents’, were personalised and residents told the Inspector that they chose their own furnishings. Decorating has been undertaken since the last inspection to the ground floor bathroom that also has a new floor, the kitchen walls have been painted and a new fridge freezer has been purchased, the dining room and corridors have been freshened up with a coat of paint. Aids and equipment are fitted where appropriate. All rooms have single occupancy and one has an ensuite toilet. There is a non-smoking policy throughout the home however one resident who occasionally likes to smoke is accompanied by a member of staff to the smoking lounge of the older people’s home that is integral. Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 16 All maintenance, servicing and testing to electrical and gas installations and the water system are undertaken regularly and in conjunction with Z&M Care’s Older peoples home that is part of the same building. Cleaning agents used are domestic in character. The Inspector spoke to residents about fire safety and they confirmed that the home had fire drills to make sure they knew how to leave the home, all said they were asked to evacuate the home during fire practices. During the inspection the Inspector noted that a radiator cover had been removed from the radiator in one of the top floor bedrooms and that some radiators were not as warm as they needed to be. This was discussed and the Deputy Manager agreed to ask the maintenance person to address the problem. The frosted window in the ladies first floor bathroom requires curtaining to improve privacy when the light is on. Requirements will be made in this report relating to these findings. Z & M Care DS0000014112.V250536.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): 33 and 34 Residents are protected by the home’s recruitment policies and selection of staff. The outcome for residents’ is good and staff have excellent training opportunities and continuous support from the management. Both management and staff roles are clearly defined and understood by both care staff and residents. EVIDENCE: The Registered Provider reported that there had been no change in staffing levels since the last inspection however one resident was currently receiving one to one support due to changing needs. It was not anticipated that this would be required for very long, as the situation had improved. Later the Inspector was able to speak with the resident who appeared very cheerful and happy with the new arrangements. The home has a policy in place that was seen by the Inspector. Staff files showed evidence of CRB checks, suitable references (verbal and written), completed application forms, terms and conditions of employment, supervision records and records of past and present training. The Registered Provider told the Inspector that all visas and permits for foreign staff are checked as far as possible for legality to work in the UK. Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 18 It was discussed that staff terms and conditions of employment be revised to include that staff who have a conviction during employment in the home inform the Registered Provider/Manager. A recommendation will be made in this report. Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 19 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): 38,39,41, and 43. The management structure in the home ensures that residents are protected and that their views are listened to and their best interests safe-guarded. The home is well run. Residents are protected by the homes policies and procedures and cared for by staff who are trained to ensure that the residents’ health and safety is a priority. EVIDENCE: The Registered Provider/Manager communicates a clear sense of direction through staff and to the residents. Communication in the home is a priority and the Inspector was able to speak to residents about staff roles and support the residents received from both management and care staff. Records were seen of staff meetings that take place for both the older peoples home and the group home. All attending staff sign and an agenda is posted for their ideas and to promote participation. The last staff meeting took place Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 20 on 16/09/05. A management meeting took place on 24/10/05 and residents meetings take place on specific Sundays when everyone is at home. The equalities policy was reviewed in August 2005. The Deputy Manager takes responsibility for all policies and procedures and updates them in August of each year; he is supported with this task by the Registered Provider/Manager. Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 21 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 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 x 3 2 x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Z & M Care Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x 3 3 x 3 x 3 DS0000014112.V250536.R01.S.doc Version 5.0 Page 22 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 2 3 Standard YA24 YA24 YA27 Regulation 13(4)abc 23(2)cp 12(4) Requirement The radiators are checked to ensure they provide enough warmth. The radiator cover in the top floor bedroom to be replaced. Nets or similar to be fitted in the ladies first floor frosted windows in the bathroom to promote privacy when the light is on. Timescale for action 01/11/05 01/11/05 01/11/05 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 YA34 Good Practice Recommendations A clause to be added to staff terms and conditions of employment that the Management is informed of any conviction occurring during employment in the home. Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 23 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 Z & M Care DS0000014112.V250536.R01.S.doc Version 5.0 Page 24 - 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. 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