Inspection on 07/11/06 for 2 West Road

This inspection was carried out on 7th November 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 West Road 09/08/07

2 West Road 09/11/05

2 West Road 08/02/05

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 2 West Road 2 West Road Hedge End Southampton Hampshire SO30 4BD Lead Inspector Craig Willis Unannounced Inspection 7th November 2006 09:30 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 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 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 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. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 West Road Address 2 West Road Hedge End Southampton Hampshire SO30 4BD 01420 544118 01420 544140 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) ILIACE Limited To Be Confirmed Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2005 Brief Description of the Service: 2 West Road is registered to provide care and accommodation for four adults with learning disabilities between the ages of 18 and 65. The service is provided by Iliace Limited, which also provides a number of similar services in the area. The home is situated in a cul-de-sac in Hedge End and has a large enclosed rear garden that is accessible for service users. Each service user has a single bedroom and there is a large communal lounge, dining / activity area and kitchen / diner. A car is provided at the home, which service users can access when there is a registered driver working. The manager reported in the pre-inspection questionnaire on 16th October 2006 that the average fee for the home is £1738.46 per week. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report was gained from a review of the information the provider sent to the Commission for Social Care Inspection (CSCI) and a site visit to the home on 7th November 2006. During the site visit the inspector spoke with two service users, care staff on duty and the manager. CSCI surveys were received from four service users and three relatives. A tour of the building was made and documents relating to the running of the home were inspected during the visit. What the service does well: What has improved since the last inspection? New carpets have been fitted in the communal areas and the lounge has been decorated. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 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 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems to assess the needs of service users before they move into the home. EVIDENCE: The files of two service users were inspected during the visit. Each contained an assessment of their needs that was completed before they moved into the home. This assessment covers the individual needs of service users, including communication and personal care needs. No new service users have moved into the home since the last inspection. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. The home has care planning and risk assessment systems, however, failure to ensure the risk assessments are followed may result in the needs of service users not being fully met. Good support is provided to help service users make decisions about their lives. EVIDENCE: The personal files of two service users were inspected during the visit. Each service user had a care plan that was developed from their initial needs assessment, which had been reviewed every two months and amended where necessary. Service users spoken with said that staff know what support they need and staff were observed providing appropriate support to service users. Care plans contain details of how service users should be supported to make decisions. Staff were observed supporting service users to make decisions about activities they took part in during the visit through Makaton sign language. This support was provided in a sensitive and friendly manner. The 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 10 staff also use objects of reference to support service users to make decisions about activities. Risk assessments were in place for both service users whose files were inspected. These documents set out the assessed hazards to service users and action to minimise the risk of harm. The risk assessment for the support one service user requires when going out into the community stated “two to one support would minimise the risk further”. However the manager reported that one to one support was provided for some trips, depending on how busy the location of the visit was. It was not clear from the documents when the additional support should be provided. One other risk assessment required all staff to have completed “SCIP-r” training to enable them to support service users who may be physically aggressive. The agency member of staff working on the day of the visit had not completed this training. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 home provides good support for service users to take part in suitable activities and to maintain relationships with family and friends. Good support is provided for service users to choose a balanced diet. EVIDENCE: Service users are supported to take part in a range of educational and leisure activities. One service user spoken with said he likes to go to a local college and enjoys using the computer. Service users’ files contained details of activities they had taken part in, including attending an outdoor activity centre, college courses, swimming, horticulture, cooking and rambling. On the day of the visit one service user was supported to go to a local activity centre. Service users are supported to keep in touch with family and friends, with one service user being supported to e-mail his parents during the visit. Service users spoken with said that staff maintain their privacy and treat them well. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 12 Details of the support service users need to complete household jobs, such as cleaning and cooking, are detailed in their care plans. The home has a planned menu that takes into account the likes and dislikes of service users and provides a varied and balanced diet. Service users spoken with said the food was good and they could always have something different if they wanted to. Mealtimes are flexible to fit in with service users’ activities. The kitchen was well stocked with a variety of good quality food. The menus are provided in pictorial format to aid understanding and one service user was being supported to make a choice about the evening meal. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 home provides good support to meet the personal care and health needs of service users. The medication systems in the home are good and protect service users. EVIDENCE: Details of the personal care support service users need are set out in their care plans. Service users spoken with said that staff provided support in the way they wanted it and treated them well. All of the four service users said in a CSCI comment card that staff treated them well and they felt well cared for. Records are maintained of service users’ visits to health services, including GP, dentist, optician, occupational therapist, psychiatrist and speech and language therapist. The records kept included details of any advice given by the practitioner. All of the four service users said in a CSCI comment card that they were able to see their doctor and dentist. Medication was stored in a locked cabinet in the office. The home uses a monitored dosage system for regular medication and all administration records were fully completed. Records were available of medication coming into and 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 14 out of the home and those returned to the pharmacist to be destroyed. All staff had completed medication training, which included an assessment of their knowledge. The manager reported that all staff had completed training in the administration of rectal diazepam, although could not find the records during the visit. Staff spoken with confirmed that they had completed this training. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are confident their complaints will be taken seriously and acted upon. The home has good adult protection systems, which help to keep service users safe, although this would be enhanced by tighter controls on service users’ money held by the home. EVIDENCE: The home has a complaints procedure available, which sets out who will deal with a complaint and how long the provider will take to respond to a complaint. The procedure has been supplied to all service users in an accessible pictorial format. Service users spoken with said they know what to do if they want to make a complaint and were confident that it would be taken seriously. All four service users said in a CSCI comment card that they felt safe living in the home and three said they know who to tell if they are unhappy. All three of the relatives who completed a CSCI comment card said they were aware of the home’s complaints procedure. Five complaints have been received since the last inspection. Two were from a neighbour concerning damage to property and items being thrown over a fence. The home has responded by repairing the damaged property and fitting a higher trellis. Guidelines are also in place regarding support for service users whilst in the garden. Three complaints were from staff and were dealt with through supervision meetings. The home has an adult protection policy and a copy of the local authority adult protection procedures. Staff have undertaken adult protection training and 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 16 those spoken with demonstrated a good understanding of abuse and action to take if abuse was reported or suspected. The money held on behalf of two service users was inspected during the visit. The records contained details of expenditure, which matched receipts and the balance held matched the records. There was one occasion when £20 of a service user’s money was lent to the home as staff had run out of petty cash. This money was repaid three days later. The manager was not aware that this was unacceptable, although did provide assurances that it would not happen again. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained and provides a safe, homely environment for service users, however, action is needed to ensure the bathroom is suitably equipped to meet the needs of service users. EVIDENCE: A tour of the communal areas of the home was made during the visit. The home is generally well maintained and decorated throughout. Furnishings were domestic and of good quality. The home has an enclosed rear garden, which service users are able to access. Since the last inspection a trellis has been fitted to the top of the fence with the neighbours garden to prevent items being thrown over. The lounge has recently been decorated and new carpets have been fitted in all of the communal areas. The manager reported that they were planning to develop a sensory area in part of the quiet lounge. The home has a domestic washing machine and dryer in the laundry room. Laundry does not need to be taken through the kitchen to access the laundry room. The upstairs bathroom did not have any toilet paper or soap. The 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 18 manager reported that this was due to the particular needs of one service user and that service users are provided with toilet paper and soap, which they keep in their rooms. Toilet paper and soap are available in the office for staff and visitors to use. The manager reported that he was looking at ways of solving this problem, but had not yet found a solution. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 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 home has good recruitment and training systems for their own staff, however action is needed to ensure agency staff used in the home are also thoroughly checked and have the training and skills necessary to meet service users’ needs. A review of staff deployment will ensure that staff are being used in the best way to meet service users’ needs. EVIDENCE: The manager reported that one of the eight staff employed have achieved the National Vocational Qualification (NVQ) at level two or above, and three have started the qualification. During the visit, staff were observed interacting with service users in a friendly and respectful manner. One relative who completed a CSCI comment card said they were very satisfied with “the tremendous commitment and dedication of the staff.” The manager reported that since the last inspection five members of staff have left and one has started. Another staff member was recruited but had not yet started work due to ill health. Two of the three comment cards received form relatives said there were always sufficient staff on duty, with one respondent not completing the question. Staff spoken with said the staffing levels were 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 20 generally sufficient to meet the needs of service users, although concern was expressed that this was more difficult when working with some members of agency staff. The manager said that the staffing levels were generally sufficient, although only having two members of staff available did cause some problems in accessing the community. The manager agreed to review the home’s staffing levels to ensure they are sufficient to meet service users’ needs. The manager reported that one new member of staff has been employed since the last inspection in November 2005. The recruitment records for this member of staff were inspected and did not contain written references. They did contain an enhanced disclosure from the Criminal Records Bureau. The manager said that he thought the references were being held at head office. The manager confirmed by e-mail on 10th November 2006 that the references had been located and copies requested so it could be held in the home. The records of one other staff member were also inspected and found to contain all of the required information. The home requests information regarding recruitment checks for agency staff employed in the home, although they were not available for the agency staff working on the day of the visit. This information was faxed through to the home during the visit. Staff spoken with said that they received good training, which helped them to meet the needs of service users. A record is kept of all training that staff have undertaken. Training staff have completed includes an induction, first aid, medication administration, food hygiene, fire safety, health and safety, infection control, adult protection, autism, challenging behaviour and crisis intervention and prevention. The risk assessment for one service users stated that all staff must have completed SCIP-r (crisis intervention and prevention) training, however, the member of agency staff working during the visit had not completed this course. The manager said he would look at the training all agency staff had completed to ensure that they had the skills necessary to meet the needs of service users. The member of agency staff working on the day of the visit said he received a good induction and was given key information on the needs of service users. This induction had not been recorded and the manager said he would put a system in place to ensure staff record the information they provide to agency staff. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 manager promotes the health, safety and welfare of service users and staff, however, action is needed to ensure that all of the supporting documentation is in place and that issues are identified in the provider’s monthly visits to the home. The implementation of the home’s quality assurance audit will help to ensure that the service improves. EVIDENCE: The manager has enrolled to complete the Registered Manager’s Award and has been in post since April 2006. The manager said he receives good support from the senior management staff and is able to speak with them whenever he needs to and has regular supervision meetings with the area manager. The manager said he is waiting for the return of an additional Criminal Records Bureau disclosure before submitting an application for registration to CSCI. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 22 The home conducts a survey of relatives, which is used to help develop the home’s objectives for the year. The manager said Iliace were in the process of introducing a new quality assurance system, which will be done through the head office rather than the home. Senior managers from Iliace visit the home each month to review the service quality. Reports of these visits contain actions that are required to improve the service, however, they did not contain details of actions in risk assessments that are not being followed, gaps in recruitment and training checks for agency staff or action to ensure the bathroom is suitably equipped. The home has a fire risk assessment and regular checks are made of the fire warning system and the equipment. The gas system is serviced annually and annual tests of portable electrical appliances are completed. Assessments are completed for chemicals used in the home, which are stored in a locked cupboard. The temperatures of the fridge and freezer are taken daily and recorded. Accidents and incidents to service users and staff are recorded and reported where necessary. 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 23 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 24 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. 1 2 Standard YA9 YA24 Regulation 13(4) 23(2) Requirement The registered person must ensure actions identified in risk assessments are complied with. The registered person must ensure that the bathroom is suitably equipped to meet the needs of service users. The registered person must ensure that agency staff used in the home have received suitable training to meet the needs of service users. Timescale for action 31/12/06 31/12/06 3 YA35 18(1) 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 2 West Road DS0000061632.V315782.R01.S.doc Version 5.2 Page 26 - 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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