Inspection on 04/01/06 for 123 Segensworth Road

This inspection was carried out on 4th January 2006.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

123 Segensworth Road 16/07/08

123 Segensworth Road 09/01/07

123 Segensworth Road 08/06/05

123 Segensworth Road 03/11/04

123 Segensworth Road 04/05/04

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

CARE HOME ADULTS 18-65 123 Segensworth Road Titchfield Fareham Hampshire PO15 5EL Lead Inspector Kathryn Kirk Unannounced Inspection 4th January 2006 10:00 123 Segensworth Road DS0000012329.V269552.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 123 Segensworth Road DS0000012329.V269552.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. 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 123 Segensworth Road Address Titchfield Fareham Hampshire PO15 5EL 01329 843934 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) Community Integrated Care Miss Julia Rogerson Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users may be admitted between the ages of 20 and 55 years. Service users who have physical disabilities must also have learning disabilities. 8th June 2005 Date of last inspection Brief Description of the Service: 123 Segensworth Road is a detached property located in a residential area between Fareham and Titchfield. The home is registered to provide care and accommodation for up to three adults with a learning disability and physical disabilities. Community Integrated Care is the registered provider. Knightstone Housing Association manages the property. All three bedrooms are on the ground floor and all are single. Service users share the use of bathroom, kitchen, dining room and lounge. There is a small enclosed rear garden. 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to take place in the year April 2005-March 2006. It lasted for four hours. The needs of current service users are such that they are unable to contribute verbally to the inspection process, however, time was spent with them and two staff members spoke of their experience of working within the home. The manager has completed a written pre inspection questionnaire, which provides further information about the service. One letter from a regular visitor was received, which praised the care provided. Not all key standards were assessed on this occasion. As such to gain a detailed overview this inspection report should be read in conjunction with the one dated 8/ 7/05. What the service does well: What has improved since the last inspection? Statements of terms and conditions have been agreed and signed by representatives on service users. Risk assessments have been updated 123 Segensworth Road DS0000012329.V269552.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. 123 Segensworth Road DS0000012329.V269552.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 123 Segensworth Road DS0000012329.V269552.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 and 5 There is evidence that prospective users needs are considered fully prior to moving into the home. Statements of terms and conditions are more meaningful because they have been agreed by service users representatives. EVIDENCE: The file of the most recent service user to be admitted has been viewed during a previous inspection. It contained a care management assessment of need, and an assessment completed by staff at the home. A statement of terms of conditions was seen and this had been signed on behalf of the service user. Staff confirmed that all such documents are now witnessed. 123 Segensworth Road DS0000012329.V269552.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): 9 Risk assessments have been updated, but one needs to be followed through to ensure safety of service users. EVIDENCE: Staff said that risk assessments have been updated since the last inspection and those seen had been reviewed in November 2005. It was discussed at the previous inspection that one risk assessment states that service users must not be left unattended at any time in a vehicle. Staff said that this still happens very occasionally when one service user is escorted in to a day service session. Staff undertook to review this practice to ensure that it no longer occurs. 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 15 16 and 17 Staff are committed to supporting service users to enable them to maintain fulfilling lifestyles inside and outside the home. EVIDENCE: Staff on duty said that all service users attend specialist day services for some sessions during the week. An examination of the rota and discussion with staff indicated that there was a slight improvement in staff/service user ratios. Staff demonstrated that they had a good understanding of the daytime needs of service users and that they were committed to ensuring as far as possible that these are met. Service users have use of an unmarked tailgate minibus. Staff said that two service users also travel on trains with staff support. Staff said that service users attend a variety of events and facilities in line with their indicated interests. These include visits to the theatre, swimming and having pub lunches. The rota indicates that there is no significant difference in staffing levels at the weekend. Important relationships are documented in care plans. The home has a policy about visitors, who may visit at any time convenient to the service users. The 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 11 home does not have a separate visitors lounge. Service users receive friends and relatives either in the communal lounge or in their bedrooms. Service users bedroom doors and the bathroom doors are fitted with appropriate locks and staff were seen to knock and wait before entering a service users bedroom. Staff were observed to talk and interact with service users and not exclusively with each other. It was noted that the front door is kept locked, but this situation has been risk assessed and reviewed. The menu and records of meals indicated that the service users receive a varied, balanced and nutritious diet. Staff provided appropriate assistance. Some of the service users are on controlled diets. Staff spoke knowledgably about service users nutritional needs and there was evidence that a dietician had been consulted for further advice and support. Adequate supplies of fresh, dried, frozen and tinned foods were seen to be available. 123 Segensworth Road DS0000012329.V269552.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 and 20 Personal support is provided in a sensitive and flexible way. Policies and procedures relating to medication are appropriate. EVIDENCE: Staff confirmed that personal support is provided in private. They said that service users had no obvious preferences about whether their personal care needs are attended to be a male or female staff member. Staff said that times for getting up are flexible although planned activities particularly during the week entail that a routine is generally adhered to. Staff said that service users do not choose their own clothing but that staff are aware of what style of clothing is preferred, by observation and evaluation of service users needs, for example one service user has a preference for loose fitting clothing. Records showed that all staff are trained in moving and handling and that a senior carer is a facilitator in this area. Appropriate aids and equipment were seen to be present in the home. Staff confirmed that service users have additional specialist support and advice as needed from, for example, occupational therapists. 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 13 There is a medication policy in place. No service users self-administer medication. All staff asked said that they had received training in medication issues. Medication is stored in a lockable cabinet that appeared clean and in order at the time of the visit. Records checked reflected stocks held. Separate procedures and guidelines were seen for the use of ‘as required’ medication. These had been updated in May 2005. Records show that staff have signed to confirm that they have read the guidelines. 123 Segensworth Road DS0000012329.V269552.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): No standards were assessed on this occasion. EVIDENCE: 123 Segensworth Road DS0000012329.V269552.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): 24 Some alterations and upgrading needs to be undertaken to make the environment as safe as possible. EVIDENCE: At the last inspection the following issues were identified: 1. A requirement was made that the fire service must be consulted regarding fire safety arrangements. Records show that a fire officer visited in September 2005 and proposed changes to increase safety. At the time of this inspection the fire officer was awaiting feedback about how these changes would be implemented 2. There was an outstanding requirement regarding the refurbishment of the kitchen. Letters seen from Knightstone Housing dated April 2005 and June 2005 stated that Knightstone was tendering for this work. Staff said that they understood that the tendering process had been completed but that a date has not yet been given for this work to commence. 3. There was an outstanding requirement regarding the resurfacing of the front driveway. 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 16 Staff said that they had been told that this work would start in January 2006. As requirements regarding the kitchen and driveway were first issued in 4/5/04 and 31/3/05 respectively further requirements will be issued in which it will state that work must commence by 31/3/06. 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 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 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): 32, 33, 34 and 35 The staff team is committed to providing a good quality of service. Recruitment procedures are thorough. Policies regarding where information is held for bank staff members need to be developed. Training opportunities are generally good Staff would benefit from training in issues around the management of epilepsy as this is particularly relevant to meet needs of current service users. EVIDENCE: Staff on duty were approachable and were observed to be comfortable with service users. Through discussion they demonstrated that they were motivated and committed to providing a good service. A letter commending the staff team has been received by CSCI. Records show that of the seven care staff employed, five either have or are studying for their NVQ level 2 or above. It was discussed at the last inspection that at times, some difficulties arise when two staff are on duty in terms of meeting the disparate needs of service users. It was a requirement that staffing levels should be reviewed to ensure that the number of staff on duty can meet assessed need. Staff said that when possible an additional staff member works a mid shift during the day. Examination of the rota indicated that this occurs about 50 of the time. Recruitment records were checked for one staff member. They were found to contain all relevant information and documents. This included proof of identity, 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 18 two written references, health declaration and evidence that a satisfactory CRB check had been completed. One bank staff member is currently regularly employed at the home. Some records were held regarding them at the home although these were not complete either in terms of evidence of identity or training records. Staff said that they believed that these might be held centrally. Staff agreed that they would seek clarification regarding this and ensure both that all documentation that should be held at the home is present at the home and that training is relevant and up to date. Training records showed that all regular staff have up to date training in moving and handling, first aid, fire safety, medication food hygiene and CPI Crisis Prevention and Intervention. Staff said that none had undertaken any training in the management of epilepsy. It was agreed that training in this area would be useful because of the needs of current service users. Staff confirmed that new staff receive induction training. 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 19 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, 39 and 42 The registered manager is experienced. Appropriate quality monitoring systems are in place. Some outstanding environmental issues need to be resolved to ensure health and safety is promoted within the home. EVIDENCE: The registered manager is Ms Julia Rogerson. She has been working for Community Integrated Care since 1996 and is currently studying for a Registered Managers Award. Evidence was seen that she undertakes regular training to maintain and update her knowledge. Records show that relatives and relevant professionals can contribute their views about the service, for example during care planning meetings. Community Integrated Care conducts national surveys regarding the quality of care provided and staff said that all home managers regularly complete an audit of the home, which is sent to senior managers. A senior manager undertakes a monthly visit to the home to review the standard of care provided. A copy of the written report completed following these visits is received by CSCI. 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 20 As discussed, action has not in all cases been undertaken within agreed timescales to implement requirements identified in CSCI inspection reports. The following records were viewed with regard to safe working practices: Gas safety check had been completed 10/10/05 An accident report that had been completed satisfactorily Evidence that PATT testing had been undertaken. Staff said that paper towels are in the process of being supplied for the upstairs bathroom and confirmed that plastic gloves and aprons are always available. Health and safety issues that have been discussed in the environment section of this report still need to be addressed. 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 21 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 3 X X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 123 Segensworth Road Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000012329.V269552.R01.S.doc Version 5.0 Page 22 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 YA24 Regulation 23 Requirement The refurbishment of the kitchen must be undertaken. This is an outstanding requirement from 04/05/04 and 31/03/05. The resurfacing of the front driveway must be undertaken. This is an outstanding requirement from 31/03/05 Adequate precautions against the risk of fire must be undertaken in consultation with the fire authority. Timescale for action 31/03/06 2. YA24 23 31/03/06 3. YA24 23 31/03/06 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 Refer to Standard YA35 YA35 Good Practice Recommendations That staff are offered training in the management of epilepsy. That a policy and procedure is developed to ensure that all appropriate records relating to bank staff are available for inspection. 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 123 Segensworth Road DS0000012329.V269552.R01.S.doc Version 5.0 Page 24 - 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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