Inspection on 10/01/06 for 17 Shakespeare Road

This inspection was carried out on 10th January 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

17 Shakespeare Road 23/09/08

17 Shakespeare Road 22/08/06

17 Shakespeare Road 05/09/05

17 Shakespeare Road 13/12/04

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Insight - Eastchurch

Southfields

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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 17 Shakespeare Road Worthing West Sussex BN11 4AR Lead Inspector Ms B Tye Unannounced Inspection 10th January 2006 12:30 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 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 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 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. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 17 Shakespeare Road Address Worthing West Sussex BN11 4AR 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) 07903 234457 Sutton Court Associates Ltd Mr Paul James Sullivan Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 6 male and/or female service users in the category of learning disability may be accommodated. Only persons between the ages of 18-65 years of age may be admitted/accommodated. 5th September 2005 Date of last inspection Brief Description of the Service: 17 Shakespeare Road is a care home registered for up to six service users in the category LD (Learning Disabilities 18-65 years). The establishment is a converted premises situated close to Worthing town centre. Public transport services are easily accessible. Accommodation is provided over two floors and all rooms are single occupancy with en-suite facilities. The service is privately owned and the registered provider is Sutton Court Nursing Associates. Mr N Ramdin is the Responsible Individual on behalf of the organisation. Mr P Sullivan is the Registered Manager in charge of the day to day running of the home. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on the 10th January 2006. Prior to the inspection, information held on file was examined including the last two inspection reports and any official documentation relating to the home. During the inspection a tour of the home was undertaken and records relating to the residents care and health needs were examined. The inspector spoke to the manager and interviewed a new staff member. Staff files and health and safety records were reviewed. In addition, the inspector had the opportunity to speak to some of the residents about their experience of the home. For standards previously assessed and where there is no change, the text in this report will remain the same as the previous inspection report. What the service does well: What has improved since the last inspection? All requirements and recommendations made at the last inspection have now been met. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 6 Records showed supervision for staff is up to date. A new monitoring system has been implemented by the management, to ensure staff are supervised on a regular basis. All staff have now undertaken training in the ‘Protection of Vulnerable Adults’ which will enable them to act appropriately should an incident arise. Outstanding CRBs for two staff members have been obtained. Recruitment files are all up to date with the required checks and paperwork in good order. This will reduce risk and actively promote protection of vulnerable residents. A copy of the homes Death and Dying policy is now on file to ensure staff are aware of proper procedures. 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. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 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 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 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): 1, 4 & 5 Prospective residents are provided with all the information needed to make an informed decision, prior to admission of the home. Each potential resident is given the opportunity to visit and have a trial stay if required. Terms and Conditions for each resident is provided and kept on individual files at the home. EVIDENCE: A Statement of Purpose and Service User Guide was made available to the inspector. It was noted each document is provided in a format suitable for the occupants so each resident is aware of the service provided prior to admission. Each resident has the opportunity to visit the home prior to admission, as many times as they need to. This helps them to develop a sense of ownership. A contract of Terms and Conditions are provided to each resident on admission. A key worker assists individuals to understand its content prior to signing. Each contract is available in signs and symbols to assist new arrivals in understanding exactly what the home has to offer them. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 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): 6, 9 & 10 Residents are involved in producing detailed care plans which reflect their changing needs. They are consulted on aspects of daily living and are able to participate in regular reviews and meetings at the home. The home holds regular meetings for residents to discuss issues as a group. Personal information is kept on file in a locked office. EVIDENCE: The inspector reviewed care plans at the home. Each plan is generated from pre admission assessments, which relate to all aspects of the individuals health, personal and social care needs. All plans seen were detailed and easy to follow which means care staff can transfer the information into daily practice. In addition management guidelines provide staff with detailed instruction relating to individual care such as; medication, home management, relationships and general living skills. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 10 It was evident from the information seen on file and discussions with the manager that regular reviews occur to evaluate residents care and update changing needs as appropriate. All changes were dated and signed by the manger and resident, confirming the home includes residents in decisions about the care they receive. Each plan contained detailed risk assessments and risk management for each resident and their home environment. This gives staff detailed information about how to deal with behaviours correctly and allows informed choices to be made in supporting individuals to achieve independent living. All information is kept in a locked staff office to ensure confidentiality. The home also has policies and procedures, which promote good practice in this area. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 11 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): 14, 16 & 17 The outcome for resident’s personal development and activities provided was good. Residents spoken to, confirmed the home offered a good range of activities, which is appropriate to their assessed needs and interests. Residents confirmed they are offered a healthy diet and enjoy the meals provided at the home. EVIDENCE: It is clear residents are provided with opportunities to develop their personal lives through activities and regular contact with family and friends. Goals have been set out in individual care plans to support this and there was evidence these are reviewed on a regular basis according to the individuals changing needs. The structured activities programme incorporates college attendance, with a range of outings, sports and leisure opportunities. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 12 Residents are encouraged to pursue individual interests in the wider community such as shopping, dog walking, visits to local pubs and restaurants, bowling, horse riding and regular attendance at day centres. The inspector observed a relaxed and friendly rapport between staff and residents. Demonstrating an awareness of how to communicate according to the individuals needs and behaviours. The kitchen area was very clean and tidy. Food is stored appropriately and it was noted there was fresh fruit and vegetables, to ensure residents benefit from a healthy balanced diet. Menus are drawn up on a four weekly basis and records are kept of what is cooked each day. Staff confirmed they will adapt the menus to suit the residents preference. Special diets are catered for, and where appropriate nutritional intake is monitored and recorded. Staff confirmed residents assist with cooking and food preparation where possible, to encourage independence and help develop life skills. One resident is able to do her own shopping and cooking within the home, reflecting that the service promotes independence where appropriate according to individual capabilities. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 13 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): 20 & 21 The inspector concluded all medication was dispensed, stored and recorded in line with the homes policies and procedures. A policy in relation to death and dying was available at the home to ensure residents wishes were respected. EVIDENCE: Policies and procedures relating to all aspects of healthcare and medication are in place and up to date. The inspector examined all medication charts and found they were up to date and in good order. The manager is responsible for ordering and monitoring all records relating to medication. Records showed that staff have undertaken relevant training to dispense medication safely to the residents. Medication is stored appropriately at the home. One resident continues to manage her own medication. Records demonstrated that this had been risk assessed by staff and a disclaimer had been signed. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 14 The inspector concluded the home had promoted her independence appropriately whilst considering and minimising potential risk. The home has a policy in place for Death and Dying. It specifies residents wishes are paramount when providing care to them at this time. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 15 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 The inspector concluded the home protects its residents from abuse and neglect and staff are able to respond appropriately should an incident occur. Residents feedback to the inspector that they felt listened to and would complain if they needed to. EVIDENCE: The home has a complete and full policy on complaints. Detailed risk assessments for daily living enable staff to respond appropriately to challenging behaviour and health needs, therefore reducing risk to individuals. All staff have completed Vulnerable Adult training since the last inspection. This will build upon information staff have gained at induction and promote good practice should an incident of suspected abuse arise. The home has a detailed Complaints procedure and policy, which is included in the Statement of Purpose and Service Users Guide. This provides residents with clear information about how to complain. The complaints log was examined and the inspector found five recorded incidents since the last inspection. All were minor and the manager had resolved them appropriately, so no further action had been taken. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 - 30 The home overall offered a comfortable and clean living space and the standards were met, therefore providing a good outcome for residents. EVIDENCE: There is a large modern lounge with TV and stereo equipment for use by all residents. The dining room is adjacent to a light, brightly decorated kitchen, which residents have access to for cooking (with assistance) and drink making facilities. Residents rooms were a good size and furnished in their individual styles with personal possessions and pictures. One resident’s room is sparsely furnished. This was due to repeated damage and the need to keep the resident safe. Details were recorded on his individual care plan and had been agreed with the Social Worker. Another resident has been provided with a specialist bed base, as she continually bounces on her bed and has been at risk of injury. The inspector found these details were recorded appropriately on her care plan. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 17 Residents are responsible for cleaning their own rooms with assistance from staff. Some residents participate in cleaning the communal parts of the home under staff supervision to promote daily living skills and provide a sense of ownership. Each bedroom has en-suite facilities. There are sufficient toilets throughout the building. All bedrooms have locks on the door and lockable cabinets for residents to store items of value. The home has a large, mature garden, which has a patio and lawned area for residents to make use of, in the warmer weather. A small shed in the garden is used for storage of residents bikes. One resident pointed out that the shed door needed to be replaced in order to protect the bikes from damp weather. The inspector fed this back to the manager who stated he was aware of the issue and it would be resolved in the near future. A laundry room provides a large washing machine with sluice facilities and tumble dryer. Infection control training is provided to staff and policies and procedures were evidenced. This reduces the risk of infection spreading throughout the home. A fire alarm and emergency lighting system is in place. Records showed these are checked and serviced on a regular basis to ensure the safety of staff and residents. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 18 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, 34 & 36 The staff employed to work at Shakespeare Road have all been recruited and trained to meet the assessed needs of the residents. Residents benefit from a well supported and supervised staff team. EVIDENCE: The home provides an induction and training programme for staff members, including specialist training relevant to individuals assessed needs. Training records for staff indicated all staff have attended training since the last inspection and records were up to date. The home has achieved the national minimum guideline for National Vocational Qualification Level 2 or above with 60 completion by staff. Recruitment procedures are in place and records indicated all staff checks were fully up to date. Records seen on file were in good order. New staff had appropriate checks and references in place. A new staff member confirmed she had undertaken a detailed induction, evidence of this was held on file. The inspector concluded, following discussion with her that she was clear about her role and responsibilities within the home. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 19 The home currently has a full staff compliment and does not use agency workers. This provides consistency of care to residents. Since the last inspection the manager has set up a supervision programme which ensures staff receive regular supervision and support. Details of each session are recorded on file, these were found to be up to date and in good order. A staff supervision chart provides the manager with an effective monitoring system to ensure no sessions are missed. Feedback from residents, staff interviews and observations led the inspector to conclude that the staff functioned effectively as a team and were supported by the management in doing so. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 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): 37, 40 & 42 Good practice in the home was evident. This was supported by efficient administrative systems, which promote the health, safety and welfare of the residents. EVIDENCE: The inspector examined all safety records and concluded they were up to date and in good order. The records seen, showed that the home promoted the welfare and safety of its residents. The home has up to date policies and procedures in line with current legislation to safe guard the rights and interests of the staff and residents. Efficient administrative systems are in place to support staff in their daily care provision and ensure accountability in relation to work practices. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 21 Discussions and observations on the day of inspection, confirmed staff are given clear direction in their roles and good working practices are promoted through staff support, supervision and training. Hazard Reports and had been completed on all areas of the homes environment to minimise risk to staff and residents. All care records were kept in a locked cabinet to maintain confidentiality. The inspector concluded that the care provision at the home continues to be of a good standard and the overall conduct and management of the home served the best interests of the residents. 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 X 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 3 X X 3 X 3 x 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 17 Shakespeare Road DS0000061335.V277950.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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