Inspection on 09/09/05 for Zacchaeus

This inspection was carried out on 9th September 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 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

Zacchaeus 28/10/06

Zacchaeus 18/02/06

Zacchaeus 16/12/04

Zacchaeus 12/07/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

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 Zacchaeus 37 Servite Close Bognor Regis West Sussex PO21 2DE Lead Inspector Annie Taggart Announced Monday 9 September 2005 2:30pm th 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. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Zacchaeus Address 37 Servite Close, Bognor Regis, West Sussex, PO21 2DE 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) 01243 828532 L Arche Mrs Hanna Lizakowska- Campkin Care Home 5 Category(ies) of PC Care Home only registration, with number of places Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: T Date of last inspection 16/12/04 Brief Description of the Service: Zacchaeus ia a care home providing personal care and accommodation for five adults with learning difficulties. The home is one of three homes oparated by the LArche organisation in West Sussex. The building is owned by The Servite Housing Association and consists of two adjoined semi-detached houses. There is a communal lounge, a dining room and a kitchen. Private accommodation for service users consists of five single bedrooms. The house is located in a cul-desac in a residential area of Bognor Regis, close to shops and other amenities. Zacchaeus was first registered with the previous registration authority in July 1989. The Responsible individual is Kathleen OGorman and the registered Manager is Mrs Hanna Lizakowska-Campkin. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out at 2:30 in the afternoon and lasted for 3.5 hours. The inspector met with all of the people living in the house and spent time talking to three residents. One resident was away on holiday. A tour of the building was undertaken during which all communal and private bedrooms were seen. Four care plans were seen with specific issues being tracked which included risk assessments and incidents forms. Five staff files were seen and all were in good order. Records for the running of the service were seen and these included health and safety and fire records and also maintenance records. The pharmacist inspector also attended the visit and tracked the storage, recording and administration of medication. Prior to the visit, the last two inspection reports were read along with any other correspondence or documentation relating to the service. The manager of the home had completed a pre- inspection questionnaire and information from this document has also been used in the report. Four relative comment cards have been returned and all made positive comments about the service. The responsible individual Christopher Bemrose was present in the home and the registered manager Mrs. Lizakowska-Campkin assisted with the inspection. What the service does well: The home offers a comfortable and homely environment for the people who live there. There are a wide variety of educational and leisure activities available to offer interest and stimulation for residents. Residents say they are very happy in the home and that they are treated kindly by the staff team Complaints and concerns from residents are taken seriously and acted upon. The staff team are kind and caring and say they are committed to providing a good service for the people they support. The home is managed by a competent and caring manager, who runs the home in an open and inclusive manner. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 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. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 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 Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 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 6 Prospective residents and their families are given sufficient information to allow them to make a choice about the home. Needs are assessed and visits to the home encouraged. EVIDENCE: There is a Statement of Purpose and Service User Guide available, which set out the facilities and services available in the home. Both documents have recently been reviewed and updated. The home has also produced an accessible version of the Service User Guide, using photographs and pictures, in order to assist non-verbal residents. Prospective residents receive a comprehensive pre-admission assessment which includes input from families and other professionals involved in the person’s care and visits and short stays in the home are encouraged. Each new person coming to live in the home receives a contract setting out the terms and conditions of residency and the document is signed by the resident or their representative. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 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 standard(s) 6 7 8 9 10 Comprehensive care plans are in place in order to inform staff members of the support needs of each person living in the home. Residents are encouraged to make decisions about their lives and information is securely stored. EVIDENCE: There is a comprehensive care plan in place for each person living in the home. The plans contain information gained from the assessment process and covers all areas of life, including risk assessments. One resident has a full personcentred plan in place and another person has had a pictorial communication book compiled which can be used in the home and out in the community. The plans are reviewed and updated on a regular basis. Residents in the home are supported to make decisions about their chosen lifestyles and agreed personal goals are included in the care plans. There is a house meeting every Monday evening where residents are encouraged to express their feelings and the organisation also has a monthly community meeting which includes the views of residents. Residents confirmed that they participate in household chores and in the running of the house and there are articipation charts posted in the home. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 Page 10 The L’Arche organisation has a confidentiality policy in place and all documents in the home were securely stored. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 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 standard(s) 11 12 13 1213 14 15 16 17 There are a variety of activities available to offer residents opportunities for personal development. Residents access the community and leisure facilities on a regular basis and are encouraged to keep in touch with families and friends. EVIDENCE: During the care planning review process personal development goals are agreed for each resident and staff members support people to work towards attaining these. There is evidence of a wide variety of activities being undertaken which includes day-care facilities, education opportunities and leisure pursuits. During the visit residents returned from day-care and said that they had enjoyed their day. One resident said, “I am happy because this is where I live, I get good food, go to the Wrenford Centre, go shopping to Asda and go on holiday. My cousins come to visit and we sometimes have parties”. Another person said, “ I am happy, I can go to the pub for a meal, go to the cinema and the club and sometimes I go for a walk”. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 Page 12 The ethos of the L’Arche organisation is one of community and Christian worship but people are free to choose whether or not they attend church. The house mandate, which is agreed by all residents and staff members sets out the roles and responsibilities of everyone in the house and residents are encouraged to act in a supportive manner towards the other people they live with. Menus are agreed each Monday at the house meeting with one resident choosing a main meal for each day. A pictorial menu book has been compiled to assist people who have verbal communication difficulties. Menus show a variety of healthy fresh food with alternatives being made available. At the present time there are no special diets being catered for within the home. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 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 standard(s) 18 19 20 ` Residents receive support in a sensitive and appropriate manner and have access to a variety of healthcare professionals. Attention to detail in recording would improve medication handling EVIDENCE: Personal care needs are assessed and form part of the care plan and people are encouraged to be as independent as possible. Where personal care is needed the home has a policy of same-sex support. There is evidence of input from a variety of healthcare professionals including doctors, psychiatrists and the local community learning disability team. Residents have access to health screening, chiropody and opticians and are supported to attend appointments. The locked medication storage was tidy. An external company provides training on medication. Records of receipts and disposal of medicines were incomplete. The supplying pharmacy provides printed medication charts. Handwritten items added to these charts lacked some details, such as the strength of tablets. Dates on repeat prescription request forms indicate when a medication review by the G.P. is due. Records are kept in a separate book, of contacts with prescribers and any change in medicines. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 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 standard(s) 22 23 Residents can be confident that their views will be listened to and acted upon. The policies and procedures of the organisation are designed to protect residents from abuse. EVIDENCE: The home has a complaints procedure which forms part of the Statement of Purpose and Service User Guide. An accessible format using words and symbols is also available and a copy is posted in the home. There is a copy of the West Sussex Adult Abuse policy in the home and staff members receive the appropriate training. Staff spoken to during the visit were aware of their responsibilities should they suspect abuse had taken place. During the last few months there have been ten complaints recorded, all have been from residents complaining about the behaviour of one of their peers. The complaints have been fully investigated by the manager and responsible individual and after consultation with families and other professionals appropriate action has now been taken. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 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 standard(s) 24 25 26 27 28 29 30 The home offers a pleasant and comfortable environment for the people who live there. There are adequate bathing facilities and residents have personalised their private bedrooms. EVIDENCE: There is a light airy lounge and dining room available, both of which are furnished in a comfortable manner. The kitchen is in need of refurbishment but the manager said that this was about to be undertaken by landlords of the property in the near future. Residents bedrooms had been personalised with pictures, posters and music centres and people said that they were very happy with their private space. There is a large well-maintained garden to the rear of the building which residents enjoy in good weather. Sufficient toilet and bathroom facilities available, the manager said that as the needs of one resident was changing, an occupational therapist’s assessment would be carried out to ensure their needs could be met. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 Page 16 The home was generally clean and hygienic but consideration should be given to cleaning carpets in the communal areas. The water in one tap was found to be of a high temperature and to ensure the safety of residents at all times, it is recommended that water temperatures are recorded on a weekly basis. There was a wedge in one of the bedroom doors, the resident said she liked to keep her door open during the day when she was at home. To ensure safety in the event of a fire occurring, the wedge should be removed, a risk assessment undertaken and consideration given to fitting a magnetic closure to the door. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 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 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 33 34 35 36 Residents are supported by a committed and competent staff team. Recruitment procedures are robust and the staff team receive training and supervision. EVIDENCE: New staff members receive a job description, setting out their roles and responsibilities. There is a comprehensive induction and foundation process in place during which time staff attend mandatory and other training including the needs of people with a learning disability. There is also a programme of ongoing training available which includes managing challenging behaviour and adult protection. A robust recruitment procedure is in place and all of the staff files seen contained the required documentation, including two references and current criminal bureau checks. Staff spoke to during the visit said that they were committed to providing a good quality of care to the people they support. There were records regarding staff supervision on file which showed evidence of discussions on work practices and personal development. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 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 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 40 41 42 43 There is a committed and competent manager in place who manages the home in the best interests of both the residents and the staff team. Records were in mainly in good order but would benefit in respect of a review of medication and hot water recording. EVIDENCE: The manager of the home is caring and committed and attends training to update her skills, as yet she has not completed the NVQ4 or Registered Manager’s Award. It is recommended that Mrs. Lizakowska-Campkin registers to complete the awards as soon as possible. Both the residents and staff at the home spoke very highly of the manager and said that she managed the home in an open and inclusive manner. Residents and their families have a variety of forums available to discuss the developments of the organisation and the home and comment cards from Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 Page 19 families stated that they were kept informed of their relative’s care and were invited to attend organisational meetings. Records were seen regarding the running of the business and these included health and safety and maintenance checks. Records for fire, gas, insurance, electrical checks and risk assessments were also seen. Most of the records were in good order but as previously stated in the report the following considerations should be addressed Review of medication records Recording of water temperatures to ensure safety. Risk assessment for resident who wishes to keep their door open and consideration given to fitting a magnetic opener. The responsible individual confirmed that there are financial and developmental plans in place for the organisation which are reviewed and updated annually. Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 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 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 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Zacchaeus Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 2 2 3 H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 Page 21 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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. 2. 3. 4. Refer to Standard YA 20.4 YA 24 YA 26 YA 38 Good Practice Recommendations There should be complete and clear records of all medicines received, administered and leaving the home. Water temperatures should be tested and recorded weekly Risk assessments should be carried out for residents who wish to keep their bedroom doors open and consideration should be given to fitting magnetic closures. The manager of the home should register on the appropriate management qualification courses Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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 Zacchaeus H60-H11 S14866 Zacchaeus V240153 050905 Stage 4.doc Version 1.40 Page 23 - 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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