Inspection on 08/11/05 for 111 Eastbourne Road

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

111 Eastbourne Road 23/05/07

111 Eastbourne Road 13/09/06

111 Eastbourne Road 22/02/06

111 Eastbourne Road 01/02/05

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

CARE HOME ADULTS 18-65 111 Eastbourne Road 111 Eastbourne Road Lower Willingdon Eastbourne East Sussex BN20 9NE Lead Inspector Lucy Green Unannounced Inspection 8th November 2005 09:40a 111 Eastbourne Road DS0000061489.V256621.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 111 Eastbourne Road DS0000061489.V256621.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. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 111 Eastbourne Road Address 111 Eastbourne Road Lower Willingdon Eastbourne East Sussex BN20 9NE 01323 482174 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Regard Partnership Limited Mr David John Love Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 111 Eastbourne Road DS0000061489.V256621.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 nine (9). Only service users diagnosed with a learning disability are to be accommodated. Service users will be aged between eighteen (18) and sixty-five (65) years on admission. 1st February 2005 Date of last inspection Brief Description of the Service: 111 Eastbourne Road is a large detached two storey property situated off the main road between Eastbourne and Polegate. The home is a short walk from the local amenities and a car journey from the main town of Eastbourne. The home is registered to provide residential care to nine younger adults with learning disabilities. Local shops and public transport links are a short walk away. Service user accommodation is provided by nine single bedrooms, all of which have ensuite facilities. An additional communal bathroom is situated on the first floor. Communal areas comprise of a large lounge, separate dining room and a games/activities room. A large and well-maintained garden is situated to the rear of the property. Parking is available at the front of the home. The registered providers of the service are The Regard Partnership. This organisation owns a large number of homes across England and Wales. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three hours on Tuesday 08 November 2005. This is the first statutory inspection of this year. A tour of the premises took place, rotas, care records and staff files were inspected. The Inspector chatted with one service user in private and met with two other service users. Two staff were interviewed as part of the inspection process. What the service does well: What has improved since the last inspection? What they could do better: 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 6 The management arrangements need to be formalised to give staff clarity as to their roles and so the service can move forwards. Care plans and risk assessments need to be developed to provide comprehensive support guidelines and risk management strategies. Goals need to be identified for service users that are meaningful to them and that form part of their long term aims and objectives. Now that the staff team is fully recruited to, a greater emphasis needs to be placed on training and ensuring staff are fully equipped with the knowledge and skills to carry out their roles. 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. 111 Eastbourne Road DS0000061489.V256621.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 111 Eastbourne Road DS0000061489.V256621.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): 2, 3 & 4 Service user benefit from the opportunity to visit the home prior to accepting a permanent placement. The home would be better prepared for receiving new admissions, if all information about the service user was recorded and made available in the care plan. EVIDENCE: 111 Eastbourne Road was registered in September 2004 and since the last inspection in February 2005, the home has increased it occupancy from two to seven service users. A further two service users were admitted, but due to compatibility issues with the other service users and the level of challenging behaviour displayed, their placements at 111 Eastbourne Road were terminated. The pre-assessment information for these service users, identified needs which fell outside the Statement of Purpose for 111 Eastbourne Road and therefore the home must ensure that any future admissions are within the home’s category of registration. The Regard Partnership has a central referrals department who undertake an initial assessment of all service users. This documentation was available in care plans. The second part of the assessment process is for a representative of the home to meet the prospective service user. A record of this second stage of assessment was not found in all care plans examined and this is required to be in place as evidence that the home can meet the individual’s needs. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 9 Staff on duty confirmed that wherever possible, prospective service users and/or their relatives visit the home prior to accepting a placement. The service user most recently admitted, was reported to have visited on several occasions, including overnight stays. Details of these visits were not recorded and it is required that the home maintain a log of these visits, along with the outcome of the stay. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 10 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&9 Service users benefit from care plans which provide the reader with detailed information about their lives. Service users would be further protected if guidelines were in place for managing specific activities, which were backed-up by comprehensive risk management strategies. EVIDENCE: Service users have detailed care plans which outline their care needs. Allocated key-workers are responsible for ensuring that care plans are current and discussed with the service user. Service users have a multi-disciplinary review at least every six months and the minutes from these were in evidence. It was identified that some service users partake in activities that have not been thoroughly risk-assessed. It was therefore an immediate requirement of this inspection, that the home review these activities and ensure comprehensive risk management strategies are in place. As part of the review process, service users and their keyworker identify goals which are then monitored for the next six months. It is recommended that the home consider the long-term aims for each service user when setting these 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 11 goals, so that by achieving them they are working towards greater independence and developing new skills. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 12 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): 11, 12, 13, 14, 15 & 17 Service users are encouraged and supported to lead healthy and fulfilling lives. Service users benefit from a range of varied and nutritious meals. EVIDENCE: The activity plan for the home was viewed which provided documentary evidence that service users participate in a range of appropriate activities. One service user met with the Inspector and confirmed these activities took place and were enjoyable. This person spoke happily about her life at the home and how staff supported her to do the things she liked doing. On the day of inspection five residents had been out for a lunch at a local pub. On their return, they spoke positively about the experience and what they had chosen to eat. Service users access a range of community facilities, including swimming, bowling and cinema trips. Six of the seven service users also access a wide range of college courses. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 13 The home has arranged for all service users to go on holiday. Three service users went to Belgium, two to Devon and the other two are due to go to Camber Sands in the near future. On the day of the inspection, it was observed that the routines of the home were reflective of the individual needs of the service. It was evident that service users are enabled to choose where to spend their time and make informed choices about their daily lives. 111 Eastbourne Road has a positive approach to enabling residents to maintain contact and relationships with families and friends. There was evidence in the care plans that residents have regular family contact and staff support service users to meet with and receive visits from their families. Relatives are invited to attend all service user reviews and throughout the inspection, it was noted that the home keep relatives informed of any issues. Meals are generally prepared according to a six-week rotating menu. Staff on duty stated that the menu was currently in the process of being revised to incorporate a wider variety of fresh fruit and vegetables. One service user informed the Inspector that she had recently chosen to undertake a healthy eating diet and was proud of the results she had achieved. Staff have made efforts to support this service user, including on some occasions, preparing a separate meal just for her. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 14 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): 19 & 20 Staff demonstrate a real commitment to ensuring healthcare needs are fully met. Service users would be further protected if specialist needs were identified and relevant referrals made prior to admission. Service users benefit from medication being handled appropriately, but people trained to do so. EVIDENCE: Staff support service users to ensure their health needs are met. Care plans contain a record of any visits or contact with healthcare professionals. There was evidence of current involvement from General Practitioner, Chiropodist, Dentist and Optician. Recent referrals have been made for psychology and speech and language input for two service users. It is required that in future, the home approach the Community Learning Disability Team to ensure resources are available to meet specialist needs, prior to admission. Medication is stored, dispensed and administered appropriately. Staff confirmed that only staff who had received relevant training were permitted to administer medication. It is recommended, that the home devise a procedure 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 15 for the role of the second person in administering medication, to ensure that staff are fully aware that the dispensing, administering and recording of medication is one process. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 16 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 Service users and their opinions are valued by both staff and management. Service users would be better protected from abuse, if all staff had undertaken training in this area. EVIDENCE: The complaints policy and procedure is now on display on the service users’ notice board. Neither the home, nor the Commission for Social care Inspection has received any complaints about the service since it opened in September 2004. Service users’ views are sought and whilst some have limited verbal communication, it was observed that residents were able to air their views in other ways. Various systems are in place to protect clients from abuse. The three recruitment files inspected showed that new staff are employed subject to the required checks by the Criminal Records Bureau and two written references. The home has triggered several adult protection alerts in the last six months and a major contributory factor to this was identified as the service having admitted two service users whose needs could not be fully met. The CSCI have met with The Regard Partnership to discuss these concerns, which now appear to have been rectified. With the exception of one person, staff have not undertaken training in the protection of vulnerable adults and it is required that this be arranged as a matter of priority. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 17 There is also a requirement outstanding from the last inspection that employment and disciplinary policies be updated to reflect the correct procedures to be followed in the event of an adult protection allegation being made against a staff member. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 18 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 & 30 Service users benefit from a clean, comfortable and well maintained home EVIDENCE: 111 Eastbourne Road is a two storey, detached property which is situated just off the main road between Eastbourne and Polegate. The home is well maintained and provides residents with sufficient private and communal space to meet their needs. Service user accommodation is provided in nine single bedrooms, with ensuite facilities. Bedrooms have been decorated and furnished to reflect the individual. Communal space comprises of a large lounge and separate dining room. There is an additional games/activity room on the first floor. A large and well-maintained garden is situated to the rear of the property. At the time of this unannounced inspection, the home was found to be clean and tidy throughout. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 19 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 , 34 & 35 Service users are supported by a dedicated team of staff who are committed to meeting their needs. The home would benefit from an active programme of training for all staff. EVIDENCE: The rota showed that minimum staffing levels provide a minimum of four staff on duty throughout the waking day. At night, the home is covered by one waking and one sleep-in person. The atmosphere in the home was observed to be calm and relaxed on the day of the inspection and there were sufficient staff on duty to meet the needs of the residents. The recruitment files for three new staff were viewed and whilst the majority of the required information was found to be in place, it was identified that not all staff had supplied a full employment history, containing a written statement to account for any gaps. Staff training was identified as an area which required attention. The Acting Deputy Manager has undertaken an audit of training needed and this now needs a commitment from the Organisation to ensure these requests are actioned. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 20 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 & 42 Service users benefit from a committed team of staff who have worked hard to ensure the disruption in management arrangements have not affected the way service users are supported. The home is safely maintained, although service users would be better protected if the identified issues of fire safety were addressed. EVIDENCE: The Registered Manager has been away from the service since August 2005 and the Deputy Manager has recently transferred to another home within the Organisation. A senior member of staff has been acting up and over recent weeks has been effectively managing the service. The entire staff team are to be commended for the way in which they have continued to run the service through a difficult period and for ensuring these disruptions to management have not negatively impacted on the service users who live in the home. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 21 Various systems are in place to ensure the Health and Safety of the home are maintained. Several safety audits were viewed and found to be accurately maintained. It was however identified that fire training is be provided at least every six months for all staff. An Immediate Requirement Notice was also issued in respect of those fire doors found propped open. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 22 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 2 2 3 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 2 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 111 Eastbourne Road Score X 2 2 X Standard No 37 38 39 40 41 42 43 Score X 3 X X X 2 X DS0000061489.V256621.R01.S.doc Version 5.0 Page 23 YES 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 Standard YA2 YA6 Regulation 14 15 Requirement The home to ensure that all assessment information is documented. That the homes care planning system provides comprehensive support guidelines which outline how care and support should be given. Risk assessments are developed to include all activities and how the controls in place manage the risk. The risk identified during the inspection process to be immediately assessed. Goals are identified that fit into service users’ long term aims. The home identify specialist needs and request the necessary professional input prior to accepting placement. The home review the medication procedure to ensure that it reflects the correct practice within the home. All staff to undertake training in the protection of vulnerable adults. Policies and Procedures to reflect DS0000061489.V256621.R01.S.doc Timescale for action 01/12/05 01/02/06 3 YA9 13(4) 01/01/06 4 5 6 YA9 YA11 YA19 13(4) 12 13(1)(b) 08/11/05 01/02/06 01/12/05 7 YA20 13(2) 01/12/05 8 9 YA23 YA23 13(6) 13(6) 01/02/06 01/12/05 Page 24 111 Eastbourne Road Version 5.0 10 11 YA35 YA42 18(1) 23(4) current guidance on the Protection of Vulnerable Adults. (Previous timescale of 01 April 2005 not met) The home ensure that staff receive training relevant to the work they perform. The practice of propping fire doors open with wedges or other items, cease immediately. 20/12/05 08/11/05 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 YA4 Good Practice Recommendations The home to record the details of when prospective service users visit the home, which can then form part of the initial care plan. 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 25 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 111 Eastbourne Road DS0000061489.V256621.R01.S.doc Version 5.0 Page 26 - 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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