Inspection on 28/04/05 for 12 Shenfield Way

This inspection was carried out on 28th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

12 Shenfield Way 18/01/07

12 Shenfield Way 27/10/05

12 Shenfield Way 19/01/05

12 Shenfield Way 20/07/04

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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 12 Shenfield Way Brighton East Sussex BN1 7EX Lead Inspector Jenny Blackwell Unannounced 28 April 2005 10:00 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. 12 Shenfield Way Version 1.10 Page 3 SERVICE INFORMATION Name of service 12 Shenfield Way Address 12 Shenfield Way Brighton East Sussex BN1 7EX 01273 296364 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) Brighton & Hove City Council Ms Elizabeth Bateman Care Home 3 Category(ies) of Learning Disability (LD) registration, with number 3 of places 12 Shenfield Way Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is 3. 2. Service users should be aged between 18 and 65 years on admission. 3. Only adults with a Learning Disability who have been assessed as requiring residential care are to be accommodated. Date of last inspection 19th January 2005 Brief Description of the Service: 12 Shenfield Way is part of the South Downs Health NHS Trust and Brighton and Hove City Council joint provision of services. Kelsey Housing Association manages the building. The home provides residence and care to up to three younger adults with a learning disability. Currently the two people who have lived at the home for some time have recently been joined by a new person. The home is a detached two-storey building, situated in Brighton. The location of the home offers access to local amenities, including a food shops, pubs and cafe. Each person has their own individually decorated bedroom. Communal areas comprise of a lounge/dining room and kitchen. The people who live at the home attend local day services, and also have one to one activities during the day. 12 Shenfield Way Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this summary the people who live at the home will be referred to as people/person, and the people who work at the home as staff or by their job title. The people who live at the home, some of the staff team, deputy and manager were present during the inspection. Time was spent with all of the three people who live at the home. The manager and deputy were spoken to individually and four staff were spoken to throughout the day. The day was arranged to fit around the activities organised for the day. The requirements that were made during the last inspection were checked to see if they had been met. Some had been met in the timescale however three requirements were still outstanding from July 2004. The people who live at the home and the staff were helpful throughout the inspection and contributed to the report where possible. What the service does well: The staff and people who live at the home have had a difficult time over the last few weeks getting used to a new person moving to the home. During this time the staff have endeavoured to make the settling in period for the person go as smoothly as possible. One of the existing people at the home has found the new person coming to the home difficult. However the staff had worked with the person, manager, health care professionals and the other people at the home, in a professional and dedicated manner. Some staff were asked about their views on how the persons move went. They stated that although the initial move was difficult the staff team had worked well together and supported each other throughout. The staff had been developing different communication aids to help the people communicate with the staff. These included using objects of reference photo’s and Makaton sign language. 12 Shenfield Way Version 1.10 Page 6 Daily activities were planned and arranged around the peoples likes and dislike and were tailor made for each person. During the day all the people went out, and staff organised their shifts around their wishes. The care plans are well written with comprehensive information about individuals preferred routines during the day. This enables the staff team to be consistent in their approach to each person. What has improved since the last inspection? What they could do better: Two of the three people who live at the home still do not have community care assessments that are essential for arranging appropriate support for people. A requirement was made in July 2004 to ensure that the two people concerned had assessments in place and that they were reviewed. This has not been achieved to date and the action plan from the previous inspection report, stated the assessments would not be in place until 2006. This time scale does not meet the requirement. The manager stated pressure had been applied from some senior managers to have the new person move into the home quickly. Although social work assessments were in place for the new person, little information was seen as to the compatibility between the new person and existing people living at the home. The process was rushed and appears to have contributed to the staffs difficulty in initially supporting the person and the other people at the home. The manager and responsible individual need to ensure they adhere to the 12 Shenfield Way Version 1.10 Page 7 National Minimum Standards and Regulations when admitting new people to the home. Although the manager and team had created better access around the home for the people further work needs to continue to open access to other areas. The manager had been unable to meet the requirement to identify the budget holders for redecorations and maintenance tasks. The is due to on going discussion between Kelsey Housing Association who own the building and the Commissioners at Brighton and Hove City Council. The responsibilities of the organisations have yet to be agreed leaving the requirement unmet from July 2004. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 12 Shenfield Way Version 1.10 Page 8 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 12 Shenfield Way Version 1.10 Page 9 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) 2 and 4 The manager and staff have access to policies and procedures for new people moving to the home. However these were not followed for the recent person moving to the home. Assessments are not in place for two of the three people living at the home. New people are able to visit the home before moving in. EVIDENCE: A person had recently moved to the home. His care plan was looked at and particular attention was paid to the assessment of his needs and the process of supporting him to move to the home. The assessment was detailed highlighting the person’s history and current support and health needs. However there was limited information about the wishes of the person or their representatives. In addition the impact of the move on the people who lived at the home did not appear to be assessed. The manager related that the process had been rushed due to external pressures and that she had not completed a compatibility study with the other people at the home. She said her line manager had been supportive during the move and training days had been arranged prior to the person moving in. Several staff described the moving in of the new person as a difficult time but had felt the team had supported each other. 12 Shenfield Way Version 1.10 Page 10 Both the original people at the home do not have a full assessment conducted by Brighton and Hove Social Services. This has been required at previous inspections and has not been met. This will be carried forward to this report with an urgent timescale for completion, as the proposed date of 2006 is unacceptable. 12 Shenfield Way Version 1.10 Page 11 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 and 9. Care plans were in place for all three people, containing information that enabled staff to provide a consistant support to each person. The manager and staff worked sensitively with individual’s to engage them in the decision making process through the day. The risk assessment process was improving which enabled each person to move towards a more independent lifestyle. EVIDENCE: The care plans were looked at for each person. They contained information that described a persons interest, likes, dislikes, family and friends connections, basic health and social care needs. Activity timetables were in the plans and were tailored to each person’s interest. The plans were drawn up from a variety of resources such as lifting and handling assessments, reviews and day centre information. Morning and afternoon routines were detailed helping the staff to have a consisitant approach. The keyworkers and other staff contributed to the plans and care was taken in the use of language when describing the peoples support needs. Communication aids used by the home such as objects of reference, Makaton and photos, demonstrated a commitment to supporting the each person to control their day as much as possible. 12 Shenfield Way Version 1.10 Page 12 Since the previous inspection the home had removed some of the environmental restrictions around the home. During the day the stairgate was left open and staff encouraged the people to access the kitchen and participate in making meals and drinks. The manager and staff undertake comprehensive environmental and task risk assessments. The inspector and manager discussed the need to continue to support the people to take responsible risks both within the home and elsewhere to ensure the people are not overly restricted in their daily lives. 12 Shenfield Way Version 1.10 Page 13 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) 12,13,15 and 16 The manager and staff were commited to supporting each person with their daily interest. The home was concerned with the individual and does not group people together during activities for ease. People were supported to be part of the community. The manager and staff have fostered good relationships with family members who were actively involved in the home. Privacy was respected and staff freely engaged with the people at the home rather than restrict conversation amoungst themselves. EVIDENCE: During the day all three people were out in the community participating in a variety of activities. One person was at his day services in Lewes for the day. Another person had been to a doctor’s appointment in the morning and then been for a walk with staff. The other person went swimming to a pool, which the staff had newly discovered in Burgess Hill. They said the public pool had good facilities for people with disabilities, and that the people from the home were enjoying the swimming very much. They believed this was due to the good facilities at the 12 Shenfield Way Version 1.10 Page 14 pool, which enabled the staff to be more relaxed when supporting the people to get ready. Two people had regular contact with family members and the staff team ensured that visits to the families are supported when necessary. The staff support one person to attend church. During the inspection some staff were asked about supporting people to religious services. They commented that they did not have difficulties in supporting people with their religious beliefs and would seek guidance on religious observance if they needed to. Later in the afternoon one person was seen to make himself a cup of tea in the kitchen with support from staff. This participation should continue to be encouraged to help people with self-confidence and developing skills. 12 Shenfield Way Version 1.10 Page 15 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) 20. The homes administration, recording and storage of medications were generally run well and monitored correctly. However it was noted the home did not operate to the organisation’s policy of two staff signing for the administration of medication. 12 Shenfield Way Version 1.10 Page 16 EVIDENCE: The medication system was checked with the manager present. Overall the procedures worked well. However during the past two inspections it was noted the organisation medication procedure states that two people should be witnessing the administration of medication. The manager stated this was not always possible due to the staff numbers in the house and the needs of the people living at the home. A requirement to address this conflict between policy and practice was first made in April 2004. To date this requirement has not been met. In addition some topical creams in the medication cabinet were out of date. It was required the creams are disposed of. Those staff spoken to were able to describe the people’s current health concerns and were knowledgeable about medications they were taken and for which condition. 12 Shenfield Way Version 1.10 Page 17 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 and 23 The manager and staff were responsive to the concerns of the people living at the home. A formalised complaint procedure is in place for the home that adheres to the organisations policy. The organisation and manager emphasised the importance of protecting vulnerable adults, through policy, training and supervision. EVIDENCE: The home had comprehensive information for staff on reporting Adult Protection alerts and during the inspection staff were able to talk about the vulnerability of the people living at the home. New staff to the home were instructed in Adult Protection during their induction period. All staff were expected to attend Adult Protection training, this was monitored by the manager. She ensured that people attend refresher courses regularly. The course run by the organisations training department covers definition of abuse signs and symptoms and process for reporting suspected abuse. The complaints log was examined during the inspection. No formal complaints had been received since the last inspection, however one member of staff reported that a neighbour had made a verbal complaint to the home but did not wish to make it formal. 12 Shenfield Way Version 1.10 Page 18 It was recommended the home record all complaints or concerns in the home’s log for monitoring purposes. In addition it was recommended the complaints policy included contact details of C.S.C.I. 12 Shenfield Way Version 1.10 Page 19 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 and 30. The house had minor adaptions in place to support people with disabilities. The house maintainence was undertaken by Kelsey Housing Association. Due to a dispute in contractural arrangements the manager was unable to identfy the budget holder for decoration of the home. A requirement to address this has not been met from July ’04. Each person had their own bedrooms which were decorated to their individuals tastes. The bathroom facilities were adequate and the home was clean and well kept. EVIDENCE: During a tour of the building it was noted the house was in a reasonable state of repair although some parts were in need of decoration. The shared spaces in the house were kept in a reasonable order and generally had a homely feel. The kitchen had a locked hatch and bars running from wall to wall. This was to prevent the people who live at the home gaining unsupported access to the kitchen. The office, sleep in room and laundry had keypad’s fitted. These are the exceptions to the homely feel of the house. 12 Shenfield Way Version 1.10 Page 20 It was noted that a fire extinguisher in the laundry was not easy to remove from the wall. It was required that the extinguisher be resited to enable access to it. Each person’s bedroom was individually decorated and contained personal items such as family photographs, TV’s and stereos. One person briefly invited the inspector to his room to help him put some music on. All three of the people were seen to use their bedrooms freely although two people appeared to prefer being in the lounge. Since the previous inspection improvements had been made around the home. The fireboard had been boxed in making it safer and more visually acceptable. Previously the fireboard jutted out at head height causing a risk of injury and was unsightly. Staff are still able to view and access the fireboard. As previously stated the manager and staff now left the stairgate open and supported the people to have freer movement around their home. It was required the manager and organisation address the issue of identifying who is responsible for the decoration of the home as this has been outstanding since July ’04. 12 Shenfield Way Version 1.10 Page 21 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) 35 and 36. The staff were observed through out the inspection and asked about their induction to the home and training. Staff demonstrated competence when supporting the people at the home and in particular had adapted well to the support needs of the new person and the reaction of the exsisting people. The organisations training plan meant the peoples needs were met by appropriately trained staff. EVIDENCE: A person who had lived at the home for a few years had found the new person moving in particularly difficult. During the inspection it was noted staff were supporting the person to be active during the day and the staff were making good use of engaging the person in outdoor activities to reduce his time with the new person. The two staff were asked about their experience of the new person moving to the home. Both believed the processes had not been managed well by the organisation and had led to frustration amongst the staff team. However they felt the manager and staff had coped well and everyone had “pulled together”. In addition one person stated he believed the staff were positive about the change, as the new person had brought a different dynamic to the house. 12 Shenfield Way Version 1.10 Page 22 A new member of staff was asked about his thoughts about joining the team. He felt welcomed by the team and was glad to be joining the organisation. Minutes were seen from the staff meeting held on the 24/4/05. Six staff attended and a review of the new persons admission to the home was conducted along with current issues of the other people. A plan of supervision dates for all staff was seen. In addition a training plan for all the staff team was displayed on the office wall. Each person had a record of the course they attended including, first aid, lifting and handling, autism and active support training. 12 Shenfield Way Version 1.10 Page 23 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 and 42. The people living at the home benefit from a well run home with clear leadership and consisitant approach. The manager demonstrated knowledge of monitoring health and safety issues at the home. Staff are trained in First aid, moving and handling and food hygiene. The home had appropriate fire protection procedures. The home was generally a safe enviorment for the people who live and work in the home. EVIDENCE: The manager and deputy had established support systems in the home for staff. These include regular 1:1 supervisions, staff meetings and appraisals. Staff were seen to be given a level of autonomy to decide with the people at the home what would happen that day. One staff member felt the manager had run the home well when the difficulties with the new person’s move arose. Another felt supported by the management team and was confident to approach them if he had any difficulties. 12 Shenfield Way Version 1.10 Page 24 Contractors appointed by the organisation carried out health and safety checks. They visited the home to undertake checks on the fire system, water temperatures and general repair issues. The staff carry out weekly water temperature checks and weekly and monthly fire system checks. The inspector discussed with the manager the need for the registered person to be accountable for the monitoring of the checks in the house. She demonstrated that she was aware of when checks where due and what work was undertaken. It is recommended that the manager and staff establish some in house checks such as the water temperatures and that of the fire alarm systems. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 1 x 3 x Standard No 22 23 ENVIRONMENT Score 2 3 Standard No 24 Score 2 12 Shenfield Way Version 1.10 Page 25 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score 25 26 27 28 29 30 STAFFING 3 3 3 x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 3 x 12 Shenfield Way Version 1.10 Page 26 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. Standard 20 Regulation Requirement Timescale for action 28/04/05 2. 2 3. 20 4. 20 5. 24 6. 24 14(1a&b,2 It is required that the manager ) ensures a suitable qualified person assesses and reviews the placements at least annually. (Not met from 20/7/04) 14(1a&c) The manager shall not provide acommodation to any person without a full and comprehensive assessment. 13(2) It is required that the manager develops a medication policy that is consistant with the needs of the people living at home. (not met from 20/7/04). 13(2) It is required that the manager ensures all out of date medication be returned to the pharmacist. 23(2b) It is required that the manager identify the budget holder for the home and produce a redecoration programme. (Not met from 20/7/04) 23(4c) It is required that the manager ensures the fire extenguisher in the laundry is accessable. 28/04/05 28/04/05 28/04/05 28/04/05 28/04/05 12 Shenfield Way Version 1.10 Page 27 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. Refer to Standard 22 22 42 Good Practice Recommendations It is recommended that all concerns or informal complaints are recorded in the homes complaints log. It is recommended that the manager adds the address of C.S.C.I in the complaints policy. It is recommended that the manager establish some in house checks of water temperatures and fire equipment. 12 Shenfield Way Version 1.10 Page 28 Commission for Social Care Inspection 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 12 Shenfield Way Version 1.10 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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