Inspection on 13/12/05 for 1 Sheepfold Avenue

This inspection was carried out on 13th December 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

1 Sheepfold Avenue 27/06/08

1 Sheepfold Avenue 23/08/06

1 Sheepfold Avenue 16/07/05

1 Sheepfold Avenue 07/02/05

1 Sheepfold Avenue 24/08/04

1 Sheepfold Avenue 28/01/03

Similar services:

Lyncol House

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Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1 Sheepfold Avenue Rustington Littlehampton West Sussex BN16 3SQ Lead Inspector Mrs J Aston Unannounced Inspection 13th December 2005 09.30 1 Sheepfold Avenue DS0000014264.V268322.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 1 Sheepfold Avenue DS0000014264.V268322.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. 1 Sheepfold Avenue DS0000014264.V268322.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 1 Sheepfold Avenue Address Rustington Littlehampton West Sussex BN16 3SQ 01903 785753 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) H4MO42Mellor@Mencap.org.uk Royal Mencap (Housing & Support Services) Ms Josi Mellor Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 1 Sheepfold Avenue DS0000014264.V268322.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only persons aged between 18 and 65 years may be accommodated Date of last inspection 16th July 2005 Brief Description of the Service: 1 Sheepfold Ave is a care home registered to provide personal care support (PC) and accommodate up to six service users with a learning disability (LD) between the ages of eighteen and sixty-five. It is a detached property located within a short distance from Angmering and Rustington. The property provides accommodation consisting of all single rooms, lounge, dining room, sensory room and easy access to the garden at the rear of the property. The service provides personal care assistance to service users who have a profound learning disability and physical disability. Support and assistance is also provided to enable service users to access facilities and activities at home and in the community to ensure they lead an active lifestyle. The Royal Mencap Society owns the service. The Responsible Individual operating on behalf of the organisation is Ms Janine Tregelles. The Registered Manager responsible for the day-to-day running of the home is Ms Josi Mellor. 1 Sheepfold Avenue DS0000014264.V268322.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken on Tuesday the 13th December 2005 from 9.30am to 1.30pm. This was the second visit to the home this year and completes the annual inspection programme for the year 2005. This report should be read in conjunction with the last inspection report of the 16th July 2005. The home has recently changed the registration to allow six residents to be accommodated. Currently only five residents are accommodated. On arrival all residents were in the home and were seen by the Inspector. The Inspector was unable to speak with all residents to obtain their views of the home due to their level of disability and communication difficulties. Prior to the inspection comment cards were sent to relatives and the Managers of the day centres where residents attend. Seven were received from relatives and one from the Manager of a day centre. This inspection concentrated on how the home meets the health needs of residents, medication, complaints, adult protection, training and health & safety. The Inspector looked around the home and examined a sample of records. What the service does well: What has improved since the last inspection? The level of agency staff working in the home has reduced significantly, which has improved the continuity of staff for residents. The organisation is again supporting members of staff to undertake National Vocational Qualifications after a freeze in training budgets. 1 Sheepfold Avenue DS0000014264.V268322.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. 1 Sheepfold Avenue DS0000014264.V268322.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 1 Sheepfold Avenue DS0000014264.V268322.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): 1. 2. Prospective residents and their relatives have sufficient information about the home to make an informed choice about where to live. The organisation has a comprehensive admission procedure to follow with prospective residents. EVIDENCE: The Registered Manager has recently supplied an updated copy of the Statement of Purpose and the Service User Guide to the Commission as part of the application to change the registration of the home. The written guides provide all the required information about the home. There have been no new service users admitted to the home for some time and it is therefore difficult to assess how Standard 2 is met. However as the home now has a new room to be occupied this Standard will be looked at again once a new resident has moved into the home. The organisation has a comprehensive admission procedure for Registered Managers to follow and how this has been followed with be considered at the next inspection. 1 Sheepfold Avenue DS0000014264.V268322.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, Individual care plans provide clear information about each resident. Residents make decisions about their lives with assistance as needed. EVIDENCE: Two care plans were examined at this inspection. They contained a good level of information about each resident. The Registered Manager is in the process of updating and improving all residents care plans to include more detailed information about how a resident should be supported to move and aims and goals for residents. Once all residents care plans have been updated clear and concise records will be in place with efficient working guidelines for members of staff. It is recommended that the Registered Manager complete this work by the next inspection where care plans will be looked at again. Due to the level of disability of the service users accommodated decisions and some choices have to be made by the Manager and staff team in the best interests of the service user. The information held in the Service User Plans indicates a resident’s likes and dislikes that have been observed over time. 1 Sheepfold Avenue DS0000014264.V268322.R01.S.doc Version 5.0 Page 10 The Inspector gains the view that the staff team assist a resident as much as possible to make choices and decisions. The home has good relationships with relatives. Comment cards received from relatives indicated that they were kept informed and consulted about their relatives care. 1 Sheepfold Avenue DS0000014264.V268322.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): 16. Standards 11,12,13,14,15 and 17 in this section were assessed at the last inspection and were met. Standard 16 was assessed at this inspection. EVIDENCE: Individual care plans indicated a residents likes and dislikes and daily routine. Routines within the home are dependent upon service users’ choices. The day revolves around day care activities however residents’ choices are respected. Times for getting up and going to bed are very much dependent upon the wishes of the residents and their behaviour. Meal times are usually taken altogether however again this is dependent upon residents’ choice and behaviour. The Inspector gains the view that the staff team encourage a resident to lead a busy and fulfilling lifestyle but respect their right to choose how they wish to spend their time. 1 Sheepfold Avenue DS0000014264.V268322.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. There are good individual care plans for all residents that ensure their health is monitored and personal support is provided in an appropriate and sensitive manner. There are good systems in place to ensure a resident’s medication is monitored and administered appropriately. EVIDENCE: Two care plans were examined which demonstrated that a record of health appointments, advice or treatment is recorded and these are kept up to date. Daily records of some aspects of a resident’s health are also kept. The staff team have effectively supported a resident who has recently had an operation. This has taken a great deal of planning and preparation to ensure that the resident has understood as much as possible about the operation and aftercare. The staff team have ensured that the hospital have had adequate records about the needs of the resident and have supported both the resident and hospital by visiting the resident in hospital sometimes twice daily. A comprehensive rehabilitation period has had to be undertaken before the resident was able to return to the home. This has been undertaken with full co-operation and support from the staff team. The Inspector has scored this as commendable under Standard 19. 1 Sheepfold Avenue DS0000014264.V268322.R01.S.doc Version 5.0 Page 13 The Inspector noted that each resident has a medication profile that gives information about the type of medication and what the medication is for and any possible side effects. Medicines are stored safely and appropriate records kept. Members of staff receive basic training in handling medication as part of their induction training. Most members of staff are now undertaking an accredited comprehensive training programme in all aspects of the administration of medication as part of the Mencap Learning Programme. 1 Sheepfold Avenue DS0000014264.V268322.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): 22,23. There are appropriate procedures for dealing with complaints. The Registered Manager ensures the staff team have awareness about signs of abuse and know how to report any allegations. EVIDENCE: All relatives who responded to the inspection through comment cards indicated they were aware of the complaints procedure and had not made any complaints. There had been no complaints made to the home since the last inspection. The Commission for Social Care Inspection had not received any complaints or concerns about the service. The organisation has an adult protection policy and procedure and work in line with the West Sussex Multi-disciplinary Adult Protection Procedure. There have been no allegations of abuse made to the home or about the home. Induction training for new members of staff includes recognising signs of abuse, types of abuse and the procedures to report any allegations. Seven members of staff have received refresher training in adult protection this year four still need updates. 1 Sheepfold Avenue DS0000014264.V268322.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): All Standards in this section were assessed at the last inspection. The home was found clean and well maintained on the day of the inspection. EVIDENCE: 1 Sheepfold Avenue DS0000014264.V268322.R01.S.doc Version 5.0 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): 34, 35 The organisation operates a robust recruitment procedure. Residents are supported and protected by an effective staff team who have received appropriate mandatory training and have had the necessary recruitment checks undertaken. EVIDENCE: From the records examined it was clear that new members of staff had received job descriptions and have had the necessary references and Criminal Record Checks undertaken prior to employment. Training records demonstrated that the organisation provides a corporate induction programme for new members of staff. The home provides a practical introduction to the home and new members of staff work mainly with the Registered Manager before working alone. The organisation provides a rolling programme of mandatory training topics such as moving and handling, food hygiene, first aid etc and refresher training in these topics to keep staff up to date. Funding for training in National Vocational Qualifications (NVQ) has now started again. 1 Sheepfold Avenue DS0000014264.V268322.R01.S.doc Version 5.0 Page 17 Currently two members of staff have achieved NVQ 2, two are working on NVQ 2, one on NVQ 3, and three have undertaken NVQ 3 and are awaiting certificates. The home has achieved 30 of the staff team trained to NVQ level 2 by 31st December 2005 and are in line to achieve 50 . 1 Sheepfold Avenue DS0000014264.V268322.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42. The home is well run and in the best interests of the residents. The residents’ Health and Safety is promoted and protected. EVIDENCE: The Registered Manager is experienced and has the skills required to undertake the work and has completed the NVQ level 4 training and the Registered Managers Award. There is clear leadership and direction provided to members of staff that ensures residents receive a good quality of care and lead varied and fulfilling lives. The documentation held in the home in relation to safety checks confirmed that the Registered Manager ensures that that the residents live in a safe environment. However documentation in respect of the fire risk assessment for the home and gas safety check could not be found. The Registered Manager confirmed that a fire risk assessment had been undertaken along with the gas safety check but was asked to confirm to the Inspector in writing that these had been undertaken and documentary evidence was now in place. 1 Sheepfold Avenue DS0000014264.V268322.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1 Sheepfold Avenue Score 3 4 3 x Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 x DS0000014264.V268322.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 1 Sheepfold Avenue DS0000014264.V268322.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Worthing LO 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. 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