Inspection on 02/11/05 for 22 St Peter`s Road

This inspection was carried out on 2nd November 2005.

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

Other inspections for this house

22 St Peter`s Road 28/01/09

22 St Peter`s Road 09/02/07

22 St Peter`s Road 04/05/05

22 St Peter`s Road 06/10/04

22 St Peter`s Road 22/04/04

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 22 St Peter`s Road St Leonards on Sea East Sussex TN37 6JG Lead Inspector Caroline Johnson Announced Inspection 2nd November 2005 09:30 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 22 St Peter`s Road Address St Leonards on Sea East Sussex TN37 6JG 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) 01424 447851 01424 Mr Dominic Paul Kennard Mrs Francesca Sarah Kennard Mr Robert John Ralph Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum service users to be accommodated is 4. To allow a specific service user who has a dual diagnosis to be admitted to the home. 4th May 2005 Date of last inspection Brief Description of the Service: 22 St Peters Road is situated in a residential area in St Leonards on Sea. The home is registered to accommodate four adults with autistic spectrum disorders. The property is a three storey building with bedrooms situated on the first and second floors. The home is close to shops and amenities and there is easy access to Hastings and St Leonards. 22 St Peters Road is one of three homes owned by the proprietors Mr and Mrs Kennard. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second in the year running from April 1 2005 to March 31 2006. The inspection lasted from 09.30am until 12.50pm. The registered manager was on duty on the day of inspection. During the inspection there was an opportunity to spend time with one resident in private and with another resident whilst there was a member of staff present. One member of staff was interviewed in private and there was an opportunity to meet with a member of senior staff to discuss some areas of the inspection. A number of records were examined including medication records, health and safety documentation, recruitment records, staff rotas, training records and minutes of staff meetings. A full tour of the building was not undertaken. However the lounge, dining room and bathroom were seen. What the service does well: What has improved since the last inspection? What they could do better: The home needs to continue to work towards having 50 of the staff team trained to National Vocational qualification (NVQ) level two or above. As required in previous inspections the home needs to develop a quality audit tool to check with residents and their relatives about their views on the quality of the care provided in the home. The proprietor or a representative on their 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 6 behalf visits the home monthly to monitor the conduct of the home. A report of the findings is copied to the Commission. These visits are carried out but it is essential that the visits are unannounced instead of announced. A recommendation was also made to consider encouraging residents to come up with a list of house rules. 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. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5 There is a detailed statement of purpose in place showing details of the home and the services provided. EVIDENCE: The statement of purpose has been amended and updated since the last inspection. There are still a few minor amendments to be made. The home has also produced a new service user guide and the residents participated in the process. The terms and conditions of residence have been updated to include the correct title for the Commission. As recommended at the last inspection the home now keeps a record of all documentation sent to the residents’ relatives and representatives. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 Residents are given regular opportunities to share their views on their home and the way it is run. Staff are getting better at recording information about how this is achieved. EVIDENCE: House meetings continue to be held weekly and these are an opportunity for residents to make choices and decisions about how they wish to spend their weekends. Particular emphasis is placed on deciding activities and menus but there is also an opportunity for discussion of house issues. At the last inspection of the home a recommendation was made to include in the records the details of the house issues discussed and the views expressed by the residents. Topics are now included but recordings of the views of the residents are limited. Discussion was held about the usefulness of encouraging the residents to come up with a list of house rules. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,14,17 Residents continue to lead very active and interesting lives. They are encouraged to be as independent as possible and to make positive choices about how they wish to spend their time. Menus provided are varied and the diet offered is well balanced. EVIDENCE: Each of the residents has a programme of the activities that they participate in. Three of the residents work on a voluntary basis one morning a week. Other activities arranged include gym, bowling, aromatherapy and piano lessons. Residents also enjoy regular trips to the cinema and theatre. One of the residents spoken with stated that she enjoys playing the keyboard in her spare time and that she also enjoys knitting. She was particularly proud of her recent participation in the home’s fire safety training and of the certificate she received. Another resident spoke very positively of her work experience, and stated that she enjoys the work. There is a four-week menu in place, which shows that the residents receive a varied and well balanced diet. The residents take it in turn to assist with 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 11 cooking and they all participate in menu planning, shopping for food and tidying up after meals. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 The home works hard to meet the physical and emotional needs of the residents and to be sensitive to needs of the residents. Where possible specialist advice is sought to assist in this process. EVIDENCE: Three of the residents receives specialist input from a psychiatrist. The medication cupboard was examined and was in order. Records are kept of the temperature of the cupboard. Records seen of medication administered to residents were also examined and were in order. All staff receive training on the medication in use in the home. The home will be making a referral to a nutritionalist for advice and support with one of the resident’s dietary needs. A discussion was held regarding the use of picture boards to enable the resident to choose combinations of foods. Another resident has indicated that they would like to loose weight and the home is trying to support the resident in this endeavour. A report has been sent to the Commission and to the resident’s social worker highlighting the actions they will take to assist in this process. Following discussion it was agreed that the home would try to come up with ideas for providing positive reinforcements for all weight lost. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 13 The home is continuing with their assessment of residents’ wishes in relation to dying and death. As part of this process a questionnaire was sent to the relatives of the residents about this subject. At the time of inspection only one response had been received and the manager advised that he would arrange to see each of the relatives individually to discuss the questionnaire, as it is a difficult and sensitive subject. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Since the last inspection the home has worked hard to clarify and simplify their policy and procedure in relation to the management of residents’ finances. In addition emphasis has also been placed on producing a detailed procedure on adult protection and prevention of abuse. EVIDENCE: There is a detailed complaint procedure in place. Records showed that there had been no complaints since the last inspection. The home has updated their policy and procedure on the management of residents’ finances. Record keeping was examined and was found to be in order. The homes procedure on adult protection and prevention of abuse has been updated since the last inspection. Half of the staff team have received training on the subject and arrangements are being made for the remainder of the team to receive training. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28, Overall the home is well maintained and furnishings and fittings are homely and domestic in design. The new carpets to be fitted in the lounge and hallway will enhance this further. The Recording of fire drills are good but the home needs to record how long it takes to evacuate the home. If it takes more than five minutes they may need to review their procedure. EVIDENCE: The arrangements in place in respect of fire safety were examined and record keeping showed that equipment was tested regularly in line with the home’s policy and procedures. Fire drills are held regularly and detailed records are kept of the outcome. However, the home also needs to record how long it takes to carry out drills. An external trainer has provided training to the staff team in relation to fire safety. The manager advised that the bath in the first floor bathroom is to be removed and refitted in January 2006 to try to resolve a problem with a recurrent leak. As recommended at the last inspection of the home the carpet in the lounge and hallway was cleaned. However, a decision has since been taken that the carpet needs to be replaced. On the day of inspection the carpet fitters visited to measure the area and arrange a time to fit the new carpet. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 The turnover in the staff team does not appear to have had too much of an impact for the residents. The home works hard to ensure that there is good communication and this assists in achieving consistency in approach. All staff are provided with good training opportunities and they feel well supported in their work. EVIDENCE: Since the last inspection the role of one of the staff members has been reviewed and they now work as a senior member of staff. Three members of care staff have left their employment since the last inspection. Three new staff have been recruited. At the time of inspection there were four care staff working through their induction. Records held in relation to the recruitment of two members of staff were seen during this inspection. Application forms were completed, references obtained and Criminal Records Bureau checks carried out. All new staff as part of their induction to the home receive training on first aid, basic food hygiene, fire safety, medication, health and safety and POVA (Protection of vulnerable adults). The company is also putting together a training calendar, which will include details of autism specific training that will be provided for all staff. One of the care staff has completed a NVQ (National Vocational Qualification at level three. On completion of their induction the 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 17 new care staff will be offered the opportunity to train for a NVQ. Staff spoken with stated that they receive monthly formal supervision sessions. Records seen in relation to the two new staff showed that they too receive regular supervision. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42,43 The home is well run and staff receive a clear sense of direction from the manager. Staff find the manager supportive and approachable. It is essential that the requirement made in relation to the production of a quality audit tool be met as this has been repeated in several inspection reports. There are good procedures in place to ensure the health and safety of the residents and the staff. EVIDENCE: The registered manager has completed NVQ level four in management and care. He has now commenced the Registered Managers Award (RMA). The manager has worked for a number of years with adults with autistic spectrum disorders and brings a wealth of experience to the home. A staff member spoken with stated that the manager is `helpful and approachable’. They stated that there is good teamwork and staff are encouraged to ask questions. Staff meetings are held regularly and minutes of meetings show that staff are encouraged to share their views on the running of the home. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 19 The manager advised that he is working on a quality assurance tool and that as part of this process a questionnaire will be distributed to the relatives of the residents prior to Christmas. As part of the inspection process comment cards were sent to the residents and their relatives to seek views on the quality of the care provided in the home. Two of the residents chose to respond. Overall the response was positive. However, one of the residents stated that they felt well cared for sometimes, and that sometimes they would like to be more involved in decision-making. The second resident stated that sometimes they liked living in St Peter’s Road and that their privacy was respected sometimes. Three responses were received from relatives. One was wholly positive. The second stated that in their opinion `the standard of care and the overall quality of the home and services provided are exceptionally high’. However they also stated that they are not always consulted about the care of their relative. The third respondent was not aware of the home’s complaint procedure and also thought that there was not always sufficient staff on duty. They were also not sure how to get access to inspection reports. Hot water temperatures tested on the day of inspection were within agreed safety limits. In relation to health and safety measures, records showed that the whole house had been rewired during the summer. A gas safety certificate was obtained in October 2005 and Portable Appliance Testing (PAT) was carried out in February 2005. The home’s checklist in respect to health and safety is carried out monthly, in line with the home’s policy. A manager from one of the other homes owned by the proprietors, visits 22 St Peter’s Road every month. The purpose of the visit is to check on the conduct of the home. A copy of the report is then sent to the proprietors and to the Commission. Monthly visits are currently announced rather than unannounced as is required. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 2 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 3 3 X X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 22 St Peter`s Road Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 3 2 X X 3 2 DS0000045882.V250609.R01.S.doc Version 5.0 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA24 YA32 Regulation 23(4)(e) Requirement Timescale for action 15/01/06 3 YA39 4 YA43 Records of fire drills must include a record how long it took to evacuate the home. 18(1)(a)(c) Arrangements must be made for 15/02/06 50 of the staff team to receive NVQ training to level two or above. 24(1a)(b) The home must develop a 15/02/06 quality audit tool to measure the quality of the care provided to residents. (This was a requirement of the previous four inspections last timescale give 30/7/05). As part of this process they must review the comments referred to in this report, in response to the Commission’s comment cards. 26(3) Monthly reports carried out in 30/12/05 relation to this Regulation must be following an unannounced visit to the home. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 22 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 YA8 Good Practice Recommendations The home should consider encouraging residents to come up with a list of house rules. 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 23 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 22 St Peter`s Road DS0000045882.V250609.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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