CARE HOME ADULTS 18-65
102A Brockhurst Road Gosport Hampshire PO12 3DG Lead Inspector
Mick Gough Unannounced 6 July 2005 - 3:30pm 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. 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 102A Brockhurst Road Address Gosport Hampshire PO12 3DG 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) Hampshire Autistic Society Miss Kerrie Louisa Clark CRH 4 Category(ies) of LD - Learning disability (4) registration, with number of places 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26 October 2005 Brief Description of the Service: 102A Brockhurst Road is a semi-detached property situated up a short drive and is close to local shops and amenities, the home is close to a local bus route, which runs into the town centre of Gosport and also into Fareham town centre. The home is run by the Hampshire Autistic Society (HAS) and is registered with the Commission for Social Care Inspection (CSCI) to provide support and accommodation for four younger adults who have a Learning Disability. The home was purpose built approximately 2 years ago and meets all of the national minimum standards with regard to the physical environment. 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on the 6 July 2005. The homes manager was not available at the time of the inspection and the 2 care workers on duty assisted the inspector throughout. The inspection was carried out over 3.5 hours and during the inspection it was possible to tour the premises and to view records, it was also possible to speak with all of the 4 service users currently living in the home and 2 members of staff who were on duty. What the service does well: What has improved since the last inspection? What they could do better:
The inspection report will make 3 requirements to the home, which will help improve the service provided for residents. It was noted that care plans are
102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 Page 6 formally reviewed at six monthly intervals and that monthly reviews are undertaken by key workers and a report is made out, however care plans did not always have monthly review reports and it is a requirement that clear records are kept to provide evidence that monthly reviews have taken place. The Gas Safety certificate expired in January 2005 and it is a requirement that gas appliances at the home must be inspected by an appropriate gas engineer and a safety certificate obtained. The homes Fire logbook showed that fire alarms were last tested on 26/5/05 and that the visual inspection of fire extinguishers were last inspected in May 2005. It is a requirement that weekly fire alarm test are carried out weekly and that there is a visual inspection of fire extinguishers carried out on a monthly basis. 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. 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.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 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.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) 4 Prospective service users have an opportunity to visit the home on a number of occasions prior to moving into the home. EVIDENCE: There has been one new service users who has moved into the home since the last inspection. This service user moved from another Hampshire Autistic Society’s home which was situated next door and he visited the home on a number of occasions and this was documented in his plan of care. The service user concerned confirmed that he had been able to visit the home and meet all of the service users before moving into the home on a trial basis. 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.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 & 10 Service users assessed needs and personal goals are reflected in their individual plan of care, however it was a requirement the records of monthly reviews of care plans are kept. Service users can be confidant that information about them is handled appropriately and that their confidences are kept. EVIDENCE: Care plans were inspected for all four service users and these were comprehensive documents and were clear and easy to follow, they contained all relevant information and formal reviews were carried out at six monthly intervals and review notes were kept on file. Key workers carry our reviews of care plans on a monthly basis and then write up a monthly report, however there was not always a record of these reviews taking place. There was evidence that service users are consulted on a one to one basis at their 1-1 sessions, however more consistency is required in the recording of key worker sessions. The home has a policy on confidentiality and staff spoken to were aware of their responsibilities in this area. 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 Page 10 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) 15 & 17 The homes visiting policy supports service users to maintain family links and friendships both inside and outside the home and service users have the opportunity for appropriate personal, family and sexual relationships. Service users are offered a healthy diet and meal times are unhurried. EVIDENCE: Visitors to the home are welcome at any time and the home has a visiting policy, which gives clear information. There are appropriate policies and procedures in place with regards to sexuality/sexual relationships. Records inspected showed that service users are offered a healthy diet and menus are made up weekly with input from service users. Service users spoken to said that they enjoyed their meals at the home and liked to be involved in the planning and preparation of meals. Staff were observed supporting service users to make up their own packed lunch, which they take with them to day service. 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 Page 11 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 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 standard(s) 18 & 19 Service users do consistently receive personal care and support in the way they prefer and require and service users physical and emotional health needs are met. EVIDENCE: Staff support service users with personal care in private and the support that is required is well documented in individual care plans and the service aims to offer same gender care where possible and the home has a policy on cross gender care. Service users are able to choose when to get up and go to bed, when to have a bath, what activities they do and when they do them and they can choose their own clothes and hairstyle with support given as and when required. Service users spoken to said that staff are always around to help and they also said that they like the staff at the home. Service users files showed that they are all registered with the same GP who is based at Gosport Health Centre, dental checks are carried out at Rowner Health centre and there was evidence of optical and foot care needs being met. There was also evidence of input from the local learning disability team who support service users as required; there was also evidence of out patient appointments. 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 Page 13 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.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 Service users views are listened to and acted upon and service users are protected from abuse, neglect and self-harm. EVIDENCE: The home has a comprehensive corporate complaints procedure, which includes details of who would investigate complaints together with timescales. The complaints procedure also gave details of how to contact the Commission for Social Care Inspection. There is also a simple to follow “in house” complaints procedure for service users, which has pictures and symbols and this is used in conjunction with the corporate policy. Service users spoken to stated that they would speak to a member of staff if they had a complaint and staff were aware of the homes complaint procedure. The home has a copy of the Hampshire Adult Protection procedure and has a whistle blowing policy and a copy of the department of health guideline “No Secrets” staff also receive training with regard to adult protection and POVA as part of their induction. Staff members spoken to were aware of their responsibilities in this area. There was a requirement made at the last inspection for the organisation to put clear terms and conditions in place which gives a breakdown of fees charged so service users can be clear of what is included in the service user’s fees and what is considered as extras that should be paid by individual service users. At present this is currently being reviewed by the organisation and therefore this has not been made a requirement at this inspection, however should the home fail to have appropriate terms and conditions in place at the next inspection, the Commission for Social Care Inspection would view this as a matter of serious concern.
102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 Page 15 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 Page 16 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) None of these standards were inspected on this occasion. EVIDENCE: 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.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) 33 There is an effective staff team in sufficient numbers to meet the needs of service users. EVIDENCE: The Staff rota showed that there are a minimum of 2 members of staff on duty at all times and at night time the home has one staff member who is awake and one staff member who sleeps in. Staff are backed up by an on call system that is able to provide advice and if necessary attend the service to give additional support. It was not possible to view recruitment records at this inspection as these were kept in locked cabinets and the care staff did not have access to these files, as they were confidential. It was therefore not possible to establish if the requirement made at the last inspection with regard to staff records being kept at the home has been addressed and this issue will be followed up at the next inspection. However should the home fail to have appropriate records as described in schedule 4 of the Care Home Regulations in place at the next inspection, the Commission for Social Care Inspection would view this as a matter of serious concern.
102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.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) 42 The home is aware of its responsibilities with regard to the health, safety and welfare of staff and service users, and these are generally promoted and protected. However requirements were made regarding the Gas Safety Certificate for the home and also for the testing of fire alarms and the visual inspection of fire extinguishers. EVIDENCE: The inspector looked at fire records and these showed that fire alarms tests were last carried out on the 26/5/05 and that the visual inspection of fire extinguishers was last carried out in May 2005. The Environmental Health Officer last visited in April 2005 and the home was awarded a Bronze certificate. The Gas Safety Certificate expired in January 2005. 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 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 x x x 3 x Standard No 22 23
ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 x x x 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
102A Brockhurst Road Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x x 2 H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 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. 1. Standard 6 Regulation 15 Requirement It is a requirement that clear records must be kept to provide evidence that monthly reviews have taken place. It is a requirement that weekly fire alarm test must be carried out weekly and that there is a visual inspection of fire extinguishers carried out on a monthly basis. It is a requirement that gas appliances at the home must be inspected by an appropriate gas engineer and a safety certificate obtained. Timescale for action 8/8/05 2. 42 13 8/8/05 3. 42 13 28/8/05 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 Good Practice Recommendations 102A Brockhurst Road H54 S28732 102A Brockhurst Road V236185 060705.doc Version 1.40 Page 21 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton Hampshire SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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