CARE HOME ADULTS 18-65
13 Wilbury Gardens Hove East Sussex BN3 6HQ Lead Inspector
Merle Blakeley Announced Inspection 6th December 2005 10:30 13 Wilbury Gardens DS0000014115.V260354.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 13 Wilbury Gardens DS0000014115.V260354.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. 13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 13 Wilbury Gardens Address Hove East Sussex BN3 6HQ 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) 01273 205044 01273 771871 Royal National Institute for Deaf People Susan Ann Arnold Care Home 8 Category(ies) of Sensory impairment (8) registration, with number of places 13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is eight (8) Service users must be aged between forty five years (45) and sixty five (65) years on admission Service users with sensory impairments only to be accommodated To admit one named service user who is aged forty-one (41) years of age on admission Date of last inspection Brief Description of the Service: 13 Wilbury Gardens is registered to provide care, accommodation and support for up to eight adults aged 45 years and over with hearing impairments and physical disability. The home is run by the RNID (Royal National Institute for Deaf People). Another RNID home is located close by at 32 Ferndale Road, Hove which caters for younger adults with hearing impairments. The service is located in a three-storey detached house in a quiet residential area of Hove. The home is in close proximity to local transport, shops and other amenities. Accommodation is provided in single rooms, none of which have en suite facilities. There is a lift to all floors. There is a large garden and conservatory to the rear of the building, which residents enjoy during the warmer months. The home is well maintained and has a very welcoming atmosphere. 13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Announced Inspection took place over a period of five hours on 6th December 2005. The inspection process included the completion of a preinspection questionnaire, the return of four service users comment cards and one relative/visitors comment card, informal chats with six of the residents with the assistance of a sign language interpreter, document reading, tour of the premises and informal discussions with the manager and staff on duty. Not all residents chose to take part in completing the comment cards. What the service does well: What has improved since the last inspection? What they could do better:
The RNID still need to provide each resident with a formal contract. This has been an outstanding requirement for approximately two years. It is hoped that these documents will be available in 2006. The home must ensure that all PRN
13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 6 medication is accounted for. A running total of these medications must be maintained at all times. 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. 13 Wilbury Gardens DS0000014115.V260354.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 13 Wilbury Gardens DS0000014115.V260354.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, 4 & 5 Thorough assessments are carried out on all new residents. Prospective residents are able to visit the home prior to moving in. The RNIB continue not to be able to provide contracts for residents. EVIDENCE: The home carries out assessments on all prospective residents. A resident recently moved into the home in August this year and his assessment record was viewed. The manager and a staff member visited the resident and carried out an assessment to ensure that the home could meet his needs. He has settled in well and his communication skills have improved. Prospective residents are offered visits to the home prior to moving in with meals and weekend stays being offered. Residents are able to make as many visits as they wish before making a decision to move in. Contracts are still not being provided for residents and this has been an ongoing issue with the RNIB at a national level for over two years. It is hoped that in 2006 they can finally provide each resident with a suitable contract. 13 Wilbury Gardens DS0000014115.V260354.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 & 10 Residents are supported to take responsible risks. Confidential information is stored securely within the home. EVIDENCE: Residents are encouraged and supported to make informed choices and risks with assistance from staff. Risk assessments are carried out. The manager stated that staff do try to promote residents independence and enable them to have as much freedom as possible. Where risks are identified staff will accompany a resident. Some residents have been supported to go on holiday and to visit friends who live out of the area. Care plans and other confidential information are stored within the office. As residents care plans are kept on an open shelf the home must ensure that this area is secure at all times. 13 Wilbury Gardens DS0000014115.V260354.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): 13, 14 & 16 Most of the residents are out and about in the community and encouraged to participate in leisure activities. Flexible daily routines are offered. EVIDENCE: Currently three of the residents go out into the community on their own and are confident to use public transport. The other four residents go out with the assistance of staff. Residents use local shops and amenities that are available. Residents are encouraged to take up hobbies and leisure activities where possible. Three residents and three staff members recently went on a day trip to France, which they all enjoyed. A holiday in Egypt was also enjoyed this year by several of the residents. An activity rota is displayed on a board and describes activities that residents like to participate in. The home tries to ensure that daily routines remain reasonably flexible. Two of the residents prefer to eat together in the sunroom, whilst the others sit together in the dining room. Residents are able to make drinks and snacks when they wish. Residents can choose when they wish to be alone or in the company of others. There are no restrictions to freedom of movement within the home.
13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 11 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 & 20 Most residents do not require personal care from staff. All PRN medication must be accounted for. EVIDENCE: The vast majority of residents are independent enough to carry out their own personal care; therefore, staff do not carry out any personal care duties. Some resident’s just require assistance from staff to help run a bath. Medication records were checked during the inspection and all charts were seen to be up to date and correct. As discussed with the manager, there are some drugs in bottles that are labelled to be given on a PRN basis. The amount of each drug is not recorded anywhere so the home does not know how many of these drugs should be remaining. These drugs must be accounted for by recording each individual amount in a separate book and when they are administered a running total can be maintained. A local pharmacy provides staff with updated medication training each year. One resident self medicates and a risk assessment has been carried out. The home must ensure that this risk assessment is reviewed on a regular basis. 13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 12 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 The home has a complaints policy and procedure. EVIDENCE: The home has produced a complaints policy and procedure, which is also available in widget format. A few minor complaints have been made internally and the manager stated that these have been successfully resolved. Resident’s monies were checked and were found to be in order. 13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 13 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, 27 & 30 Residents live in a safe and comfortable environment. The home provides adequate bathing and toilet facilities. The home was found to be clean and tidy. EVIDENCE: 13 Wilbury Gardens provides residents with a homely and caring environment. The home is maintained to a good standard. The basement area, which, leads off from the dining room, has been cleared out and a new fire door is to be fitted shortly. The patio doors in the sunroom are also due to be repaired. The home has sufficient bathing and toilet facilities on each floor. Resident’s rooms appear comfortable and personalised. One bedroom was recently redecorated and the resident was able to choose his own furnishings and décor. Another bedroom was also refurbished with a new bed and curtains. On the day of inspection the home was found to be very clean and tidy with no offensive odours. 13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 14 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): 31 & 34 Staff are provided with job descriptions. Staff recruitment files now include proof of identity documents. EVIDENCE: Staff receive job descriptions and understand their role within the home. The staff team appear to work well together and generally maintain good working relationships with residents. The current staff team has remained relatively stable. Two agency staff are working in the home at the moment and they are both familiar with all the residents, therefore continuity of care is being maintained. The majority of staff are able to communicate with residents in sign language. All new staff are provided with induction training which includes learning sign language. During the last inspection the home was required to provide proof of identity documents for each staff member. This is now being carried out. 13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 15 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, 38, 39, 41 & 42 An experienced registered manager runs the home. The home provides a positive and caring environment. Resident’s surveys are being carried out more frequently. Records are being correctly maintained. There were no health & safety concerns found on the day. EVIDENCE: The registered manager has several years experience of working with people who have sensory impairments. The registered manager has obtained the NVQ Level 4 in Care and Management and is due to complete the Registered Managers Award in February 2006. Other recent training she has attended includes first aid, food hygiene and manual handling. She is also able to communicate proficiently in BSL sign language. The home is run in a friendly, open and inclusive manner. Residents who were spoken to stated that they felt they could approach the manager with any issues or concerns that they may have. Staff also said that they felt well supported by the manager. The home has produced a resident’s satisfaction feedback sheet in picture form and this survey is now being carried out twice a year. Feedback forms were
13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 16 also sent out to relatives/friends/visiting professionals. The manager stated that the response from these forms was quite disappointing, however the home will persevere with obtaining feedback from family members where possible, as this is part of the Quality Assurance System. Several records were viewed and were found to be up to date and correct. There were no health & safety concerns identified during this inspection. Overall the home appeared safe and well maintained. 13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 17 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 3 1 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
13 Wilbury Gardens Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 3 3 X DS0000014115.V260354.R01.S.doc Version 5.0 Page 18 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 YA5 Regulation 5C Requirement That the RNID provide each service user with a standard form of contract. PREVIOUS REQUIREMENT FROM THE LAST THREE INSPECTIONS. That the home ensures that all PRN medication is accounted for. Timescale for action 31/01/06 2. YA20 13(2) 06/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 13 Wilbury Gardens DS0000014115.V260354.R01.S.doc Version 5.0 Page 19 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
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