Inspection on 20/04/06 for 19 Leicester Villas

This inspection was carried out on 20th April 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

19 Leicester Villas 26/04/07

19 Leicester Villas 24/11/05

19 Leicester Villas 26/05/05

19 Leicester Villas 26/01/05

19 Leicester Villas 31/08/04

19 Leicester Villas 03/03/03

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 19 Leicester Villas Hove East Sussex BN3 5SP Lead Inspector Jenny Blackwell Key Unannounced Inspection 20th April 2006 10:00 19 Leicester Villas DS0000031913.V288708.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 19 Leicester Villas DS0000031913.V288708.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. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 19 Leicester Villas Address Hove East Sussex BN3 5SP 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 295840 Brighton & Hove City Council Ms Dee Holborn Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That no more than five (5) service users are to be accommodated at any one time. 24th November 2005 Date of last inspection Brief Description of the Service: 19 Leicester Villas is a semi-detached property in a quiet, residential road in Hove. It is possible to walk to the shops, and public transport systems are within close proximity. The service is for up to five adults with learning disabilities. At the present time there are four service users who are supported 24-hours a day. Single bedroom accommodation is provided on the ground and first floor. There is one assisted bathroom on the ground floor and a none assisted bathroom upstairs and toilets are located on both floors of the home. Meals are prepared by the staff with the people being supported to participate in the preparation. The home is domestic in scale and consists of lounge with a dining area and a kitchen. A large, rear garden provides a safe and pleasant area for residents to spend time in. The fee information for 19 Leicester Villas is yet to be passed to the Commission. As the home is run by Brighton and Hove City Council specific set fee amount had not been calculated. This information will be required for the next published report. More detailed information about the services provided at 19 Leicester Villas can be found in the home’s Statement of Purpose and Service User Guide – copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are kept in the homes office. Two of the relatives spoken to said they were not aware the report was available to them in the home. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Leicester Villas have are referred to as “people” or “person”. People working at the home will be referred to as “staff” or by their job title. This report reflects a key inspection based on the collation of information received since the last inspection, feedback from representatives and visiting professionals and an unannounced and follow up announced site visits which lasted a total of nine hours on Thursday 20th April and Saturday 22nd April. The site visits included a tour of the premises and an examination of medication, care and staffing records. The Inspector joined residents for their lunchtime and evening meals. Throughout the inspection process, the Inspector spent time with all of the four people, one person individually and observed the way the people were supported in communal areas. Time was spent with one relative at the home and telephone conversations were held with one representative and three professionals. Written feedback was received from one relative. The Deputy Manager is currently overseeing the home and the registered managers position is vacant. The deputy manager was met with during the site visit. The line manager for the home was met with after site visits to gain further information about the running of the home. In addition, two staff were interviewed individually and two others together. What the service does well: The inspection process has identified the home as operating adequately in some areas and good in others. The relatives and staff spoken to collectively acknowledged the home had been going through some difficult times in the last year with management and staff changes. However those spoken to were looking forward to having a new manager appointed to complete the team and having a more settled time. Evidence was seen through observation and feedback from the relatives that the staff were concerned with providing good outcomes for the people who lived at the home. This was observed during the 1:1 working with people during the site visit. Staff were seen to be focused on the choices of the individual and encouraging them to be involved with their daily routines. Staff had adjusted their working patterns to improve the quality of the individuals “home day” from their day services. This has meant that the people 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 6 can be out on day trips for longer without needing to come home early to fit in with the staff shift changes. The health and wellbeing of the people is closely monitored by the staff and they had good links with healthcare professionals. Any changes in the individuals needs are acted on and adjustments to their care and support is put in place. What has improved since the last inspection? What they could do better: The relatives and staff raised their concerns about the unsettled period the home had been in since the registered manager had left, particularly about not knowing when a new manager would be in place. This was raised with the line manager of the home who had acknowledged that had been a difficult period as the replacement for the manager had been a lengthy process. She said this concern had been passed to senior managers in the organisation. Requirements from this inspection primarily focus on the home completing the out standing requirements in particular ensuring a fire risk assessment is in place, refurbishment of the kitchen, adult protection training and ensuring the home has a quality assurance system in place. Please contact the provider for advice of actions taken in response to this 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 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 the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person’s needs and aspiration was assessed by those providing care and day services to them. EVIDENCE: Since the previous inspection no new person has been admitted to the home. The temporary manager who worked in the home up until February 2006 and the line manager for the home had written to the placing authorities (Brighton and Hove) requesting a review of each person’s placements. This evidenced that the management in the home had attempted to have the people’s initials community care assessment kept under review by the placing authorities. The deputy manager was aware of the need to keep the people placements and initial community care assessment under review to ensure the home could continue to meet each persons needs. He and the keyworking staff arrange for in house six monthly reviews. Each person, their relatives and representatives from the day services are present at the reviews. Minutes of the latest reviews were seen in the peoples care plans. A keyworker spoke about a review that had been set up for one person for the 24/4/06. A social worker form the Brighton and Hove team was not attending. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 10 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 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 the following standard(s): 6,7,and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the people needs are covered in their plans some further work is needed to ensure all information is up to date and signed. People were seen to make choices throughout the inspection. The staff supported their decision-making. EVIDENCE: The staff at the home have been using the care planning system for many years. The staff spoken to on the visits had a good understanding of the plans with one staff member explaining how the care plans improve the continuity of support provided to the people from the staff team. All of the care plans were looked at during the inspection. The contents of the plans should enable all staff to be able to provide support to each person in ways that they preferred. Information about preferred routines likes and dislikes and family connections were recorded. Comprehensive information about personal safety, specific disabilities, and healthcare support were noted. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 12 The plans were not all put together in the same order using the same index. This made it a little difficult to get to particular information. One persons needs had changed recently and some information had not been updated. A staff member was asked about this and she said it had been difficult to get the time to ensure the written information was up to date. Staff had met at team meetings and agreed working with the person in different ways but not all of this information had been written up in her plan. Two other staff were asked about the persons new support needs and were able to describe the changes that were implemented. Some information in another persons plan was handwritten and not dated. The information was guidance on how to support the person in particular circumstances. It was required that all information in the care plans are dated and signed. Each person had risk assessments in their plans. They covered the environment, activities outside of the home and equipment. One assessment was noted that still referred to bolting the kitchen door, which did not match with the improved practice in the home. It was required that the risk assessment was updated. The staff team had improved the opportunity for each person to take measured risks. Previously the kitchen had been a restricted area to the people living at the home due to concerns over safety. The staff team had worked with each individual to support them to have safe access to the kitchen to participate in making drinks and meals. This was seen on both visits to the home, different people used the kitchen often. It was noted that the atmosphere was more relaxed and the staff appeared confident in supporting the individuals to take measured risks around the home. As at the last inspection the staff continue to improve the opportunity for each person to make choices in their lives. The staff use more pictorial and photo prompts to help the people make choices about places they want to go food the wished to eat and also to give them information such as which staff was on duty. However on the day of the unannounced inspection it was noted that the pictorial menu board was not used. Through out the inspection on both days staff were observed to offer choices to each person using a combination of methods such as speech, physical prompting and objects of reference. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 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 the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff ensured that the people took part in meaningful appropriate activities both at home and in their local community. The people were able to continue their family relationships although information about friendships with others outside of the home was not evident. The rights of the people were respected and the home and provider organisation were developing their understanding of protecting the people rights. EVIDENCE: The staff team supported each person to engage in activities within and out side of the home. The care plans had information about activities each person like to take part in. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 14 At the six monthly review meetings current activities and the opportunity to take up new activities are explored. A relative who was spoken to said that the staff endeavoured to think of new opportunities with her relative and were keen to help her pursue her interests. Although she felt in recent months that due to staff changes and vacancies some regular planned activities had not been achieved. During the inspection visits to the home each person was engaged in some kind of activity. Each person attended organised day services run by the Local authority. The staff team had arranged with each person to have one “home day” where they would have one to one time with a staff member. A staff member spoken to said that the managers and staff team had extended the time staff work with each person on their home day. She said this meant that the people had the opportunity to be out for the day and not rush back for staff change over. One person was at home on the first visit to the home and was supported by one member of staff. The staff member had arranged the day with the person and he was seen to be engaged in all aspects of the activities. He was supported to make a pizza for lunch, which involved him cooking the pizza from scratch. The staff member was observed to encourage the person to lead in the activity and to make decisions about the preparation of the food. Representatives from the day centres that people attend were spoken to. They said they worked closely with the homes staff to encourage the individuals to be engaged in meaningful activities whilst at the centres. They run each person’s six monthly review jointly with the home, where the person, their relatives and the staff attend. The review minutes were seen in each persons care plan. The monthly monitoring visits to the home conducted by a representative of the provider (Brighton and Hove City Council) look at the variety and regularity of activities offered to the people. In the reports the Care Standards Officer records the type of activity the people are engaged in and highlights areas that could be improved. In the report for February 06 the staff were prompted to remember seasonal festivals that the people may be interested in and be part of their culture, the example given was Shove Tuesday. This evidenced that the provider of the service had good in house monitoring of the quality of the activities provided and the relevance to each personals cultural needs. Through discussions with the staff and some of the relatives it was evident that the people were able to continue to maintain their family relationships. Time was spent with one relative and her son during the first day of the visit. She said she had regular contact with her son and was always welcomed to the home. Information about people’s relatives was recorded in their plans. A staff 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 15 member spoke about a holiday that had been arranged for one person so he could visit his relatives that lived some distance away. Since the previous inspection the home and the provider organisation have worked on supporting people rights and responsibilities. At previous visits to the home access to some parts of the home was restricted. The staff were seen to be much more relaxed in enabling the people to spend time in the kitchen helping to prepare meals and drinks. The provider organisation had undertaken some work to look at restrictive practices across their homes and to encourage these practices to be reduced. The deputy manager had also been aware that a recent monitoring process used to observe the movements of one person was restrictive practice and could impinge on the persons rights. He contacted the Commission to raise his concerns and look for a solution to the difficulty. The staff prepare and cook the meals at the home. During the lunch period of the visit the person was actively engaged in preparing the meal. At the evening meal the staff took the lead in preparing the meal and although they chatted with the people during the preparation none of the people present were encouraged to take part in the preparation. It was also noted that the photo menu board did not relate to the meal the people were having. Staff were not observed to tell the people what they were having for dinner. The staff team had spent time in developing pictorial communication methods to encourage the individuals to be involved in decision making in the home. It would be necessary for the staff team to commit to using these tools every day to ensure that all the people benefited from having them in place. The evening meal was presented nicely and the mealtime was relaxed. The food was a cottage pie and fresh vegetables. The staff supported people respectfully when they needed assistance with their meal and ensured they responded to the individual’s preferences. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 16 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): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff had ensured that the people’s preferred methods of personal support were recorded and adhered to. Each person’s physical and emotional health needs were met by accessing community health care professionals. The staff team monitors this appropriately. The staff understood their roles in administering medication and the policies and procedures protect the people when dealing with their medications. EVIDENCE: Each person’s preferences about how they liked to receive personal support were recorded in their plans. Daily morning and evening routines were recorded for each person. This was checked with a staff member who was able to talk about the individual’s preferences. During the visits to the home staff were seen to react sensitively to the personal support needs of the people and were discreet when supporting them. Health care checks were viewed in people’s care plans. Each person is registered with a G.P and attends community-based appointments for dentists and opticians. Health care monitoring for each person is recorded in the daily 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 17 records and is looked at formally in the six monthly review process. One family member said that she was informed by the staff if her son was unwell. A staff member said the staff had good links with community healthcare professionals who provided support with managing epilepsy, medication, and speech and language development. Information from these visiting professionals was seen in people’s files. A check of the medication was carried out on the first visit to the home. A staff member was asked to go through the medication procedure and discuss any change in medication for any of the people. The staff member demonstrated good knowledge of the current medication regime for each person and was able to describe why people were taking certain medications. The procedures were in line with the provider organisations policy and recorded correctly. The medication was stored, recorded and administered correctly. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 18 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at the home relied on others to raise complaints on their behalf, the complaints system is suitable to support their complaints and concerns. The people are protected from abuse in part. Staff have not been suitable trained in detecting and reporting abuse. EVIDENCE: The organisation has a complaints leaflet that has been designed to be more accessible to some people by using pictorial information. The current group of people living at the home would need support to make a complaint. The complaints leaflets were in the homes hallway. The deputy manager said that the home would rely on relative’s staff or other people to raise a complaint on behalf of the people who live at the home. The deputy manager said he would be aware of his responsibilities to look into complaints and would seek support form his line managers if he needed to. The Care Standards Officer checks complaints during the monthly visits. The commission has not received any complaints about the home since the previous inspection. The home had a requirement from December ’05 for all staff to attend adult protection training. After checking the training records and speaking to each staff member present during the visits it was evident this requirement had not 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 19 been met. One staff member was supplied to the home by an employment agency. She had not received adult protection training by either the agency or the home. The deputy manager said that one staff member had attended the training. In order to protect the people from abuse staff must be suitable trained in detecting suspected abuse and the appropriate reporting procedures. Evidence was seen that the staff work to procedures that protect people from abuse. Each shift change over check the peoples money and record the balance. Any discrepancies are noted and reported to the managers. In each person plan “body map” forms are available to be filled in if bruising or marks are noted on a person. These are recorded and reported to the managers. It is required that all staff working with vulnerable adults are trained in protecting them from abuse. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 20 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment was homely except for the kitchen. The kitchen floor has not been deemed as safe and response to the requirement to refurbish the kitchen had been poor. The staff provided a clean and hygienic surrounding for the people to live in. EVIDENCE: The home is continued to be let down by the condition of the kitchen. A requirement to refurbish the kitchen has been outstanding since May ’05. It was noted that the movement in the floor had worsened since the last inspection and needs to be investigated for safety reasons. The deputy manager reported that discussion were being held between the Estates Officer of the South Downs Health NHS Trust who are responsible for the building and Brighton and Hove City Council who provided the care support at the home. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 21 The requirement will be continued for this report and confirmation will be sort directly from the provider organisation as to when the refurbishment will commence. The rest of the home is presented in a homely way. The staff had ensured that each person’s bedroom reflects their interest and hobbies. On person showed the inspector around his room and indicated “yes” when he was asked if he liked his room and had all the things he needed. The living room and dining room are small; the people were encouraged to make use of the garden on both days of the visit, as the weather was fine. It was noted during observation over the two days that the people and staff need to walk through the lounge to get to the dining table, kitchen and garden As the lounge is fairly narrow it would be difficult for people to watch T.V or sit quietly if people are moving around the house. The people present did not appear to react negatively with this situation. It was noted that one person did not spend much time in the lounge or other communal spaces. The home was clean and presented well. The deputy manager reported that all the staff had undertaken infection control training as required from the last inspection. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team had worked with vacancies that had some impact on the effectiveness of the team. Although the recruitments procedures were robust some gaps in record keeping could effect protection of the people. The people are supported by a team of staff who are committed to meeting their needs. Generally the training provided ensured staff were effective in their roles. EVIDENCE: As noted in the previous report the registered manager for the home had not been working in the home since July ‘05 and has now retired form the post. The organisation had placed temporary managers in the home for short periods of time to provide managerial support. Two members of staff had said this period of time had been difficult as they were not aware of when a new manager would be appointed. This concern was also identified in a monthly monitoring visit to the home in April ’06. However they talked positively about the future of the home and were looking forward to getting some stability in the home. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 23 Two relatives were spoken to as part of the inspection process. Both had concerns about what was happening about the home getting a permanent manager. They were happy with the day-to-day support of their relatives but did express some anxiety about the staffing at the service. As in addition to a managers absence, some longer serving staff members were away from the home due to secondment or illness. They were concerned about the effect this would have on the remaining staff. Both relatives said they thought the staff had managed well during the time of uncertainty. Representatives from two of the day services the people attended were asked about the absence of a manager at the home. They reported that they had continued good links with the home and the deputy manager and the line manager for the home were in regular contact with them. The deputy manager was able to confirm that recruitment of a new manager had taken place and was expecting to hear of an appointment to the post. The recruitment records where viewed for three members of staff. Each file had sections for the documents received during the recruitment process. Most of the information was complete in the files however some gaps were noted. One staff file did not have any references. The deputy manager stated that he would follow up with the organisation Human Resource department about the references. It was required that all the documents be in place prior to staff working at the home. The deputy manager was asked to talk about the homes and organisation recruitment procedures. He was able to describe the application and interview process and the documents required to ensure the home was appointing suitable and competent staff. Information about the staffs training was recorded in their files. The three files inspected had a training list with the dates of attendance, these included first aid, food hygiene and Epilepsy training. As previously stated no evidence was seen of the staff undertaken adult protection training recently. One member of staff had attended training two years ago. The staff spoken to said they looked at individual training in supervision and their annual appraisals. From there training needs were set and courses applied for. A Speech and Language therapist was spoken to about her involvement with the home. She had arranged training with the staff team at the beginning of July that focuses on developing the communication of the people who live at the home. She said she found that she was always welcomed to the home by the staff. She found the deputy manager and the keyworker of the person she was working with enthusiastic about improving the interaction between the staff and the people. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 24 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 25 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has been run reasonable well in the absence of a manager. The home does not have a quality assurance system that meets the standard currently in place. The home generally promotes the health safety and welfare of the people. EVIDENCE: At the time of the visits the deputy manager was running the home with support from his line manager. He said he had received good support form his manager and was looking forward to having a permanent manager in post. Feedback from some relatives and the staff had raised concerns over the uncertainty of the manager’s post. There concern’s were raised with the line manager of the home by the inspector during the inspection process. She confirmed that the organisation had recruited a new manager who they were hoping to start at the home shortly. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 26 At the previous inspection a requirement was made for the home to develop a quality assurance monitoring tool. The organisation conduct’s monthly monitoring visits to the home and produce a report after each visit. The deputy manager said that feedback is sort from relatives about their views of how the home was running. A discussion was had with the line manager to the home who confirmed that Brighton and Hove City Council are developing a quality assurance tool for all the services. The work has currently focused around health and safety monitoring. It is recommended the tool be expanded to include people who live in the service views, their relatives and staff. The inclusion of these views should ensure the quality monitoring meets the standard. The home has yet to develop its fire risks assessment as required from the fire brigade safety office visit. This requirement is outstanding from January ’05 and needs to be addressed as a matter of urgency. The organisation have developed a good pro forma for the home that sets out the procedures the manager and staff follow for fire safety. It includes details of weekly fire systems checks, who is responsible for conducting the checks and were the evidence of the checks should be recorded. The organisation expects the home to run fire drills every six months some of which should be unannounced. The staff checks the water temperature weekly and food storage temperatures are also monitored. The staff are trained in food hygiene and have undertaken training in different aspects of health and safety. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 27 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 2 X X 2 X 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 28 Are there any outstanding requirements from the last inspection? YES 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 5(1)(b) Requirement It is required that the manager ensures that terms and conditions of living at the home are in place for each service user. (From previous inspection 26/01/05) It is required that information in the care plans are dated and handwritten information is clear and up to date. It was required that risk assessments be updated. It was required that all members of staff receive training in protecting vulnerable adults. Timescale for action 30/09/06 2. YA6 15(1) 31/07/06 3. 4. YA9 YA23 4(c) 13(1)(6) 31/07/06 31/07/06 5. YA24 23(2)(a)(d) That the manager ensures the kitchen is refurbished to suit the needs of the people. (From previous inspection 26/05/05) 19(1)(b) It was required that all recruitment records be in place prior to staff working at the home. It is required that the manager provides a quality audit tool to DS0000031913.V288708.R01.S.doc 30/09/06 6. YA34 22/04/06 7. YA39 24(1-3) 31/07/06 19 Leicester Villas Version 5.1 Page 29 demonstrate that the organisation and home monitors the quality of service provide. 9. YA42 23(4)(a-c) That the manager implements a fire risk assessment for the home. (From previous inspection 26/01/05) 31/07/06 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. Refer to Standard YA39 Good Practice Recommendations It is recommended the quality assurance tool be expanded to include people who live in the service views, their relatives and staff. 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 19 Leicester Villas DS0000031913.V288708.R01.S.doc Version 5.1 Page 31 - 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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