Inspection on 21/11/05 for 24 Surrenden Road

This inspection was carried out on 21st November 2005.

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

24 Surrenden Road 07/08/07

24 Surrenden Road 03/10/06

24 Surrenden Road 06/02/06

24 Surrenden Road 21/02/05

24 Surrenden Road 07/09/04

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 24 Surrenden Road 24 Surrenden Road Brighton East Sussex BN1 6PP Lead Inspector Glynis McLeod Announced Inspection 02:00 21 November 2005 st 24 Surrenden Road DS0000014123.V262992.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 24 Surrenden Road DS0000014123.V262992.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. 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 24 Surrenden Road Address 24 Surrenden Road Brighton East Sussex BN1 6PP 01273 504344 01273 552626 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) Hallcreed Limited Ms Alison Benwell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users must not exceed three (3). The service users will be aged between nineteen (19) and sixty-five (65) on admission. 21st February 2005 Date of last inspection Brief Description of the Service: 24 Surrenden Road is a small home situated in a pleasant residential area of Brighton, close to local parks, shops and pubs. The home is convenient for bus services into Brighton and other areas, and Preston Park train station is also nearby. The home is registered to accommodate up to three people with learning disabilities; it does not provide nursing care. The current residents have lived in the home for many years. The building is a two-storey house with accommodation on both floors; it is not suitable for people with mobility problems. There is a garden to the rear of the property and parking on the road outside. Residents have the use of the lounge and a large kitchen/diner and also the hydrotherapy pool located at one of the other properties owned by Hallcreed Limited. 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection, which was announced, took place over three hours and was one of two inspections required over the year. A tour of the premises took place and records relating to care, medication, staffing and maintenance were inspected. Two of the residents, one staff member and the owner were spoken to. Comment cards from relatives were received and were positive about the service. The inspector would like to thank the residents and staff for their hospitality and co-operation during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Care plans need to be presented in a way that residents can understand and they should be given a copy of their plan. Plans also need to include guidelines to help staff manage residents who have challenging behaviour so that neither residents nor staff are put at risk. Residents also need to have clear and understandable information about how to make complaints in the home. To make sure that residents are properly protected from harm, staff need to undertake special training, and documents in the home telling staff what they must do if they suspect a resident is being 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 6 harmed, need to be clearer and follow the local guidelines. Training must also be provided staff in how to care specifically for people with learning disabilities. The home currently does not have a manager available on a daily basis and, in her absence, care staff must receive proper supervision and support to make sure that the home is run well and that residents are kept safe and their needs are being properly met. 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. 24 Surrenden Road DS0000014123.V262992.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 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 The manager appropriately assesses prospective residents. Consultation with other professionals and families ensures that a clear picture of residents’ needs and wishes is available before admission. Prospective residents are given many opportunities to visit and meet with staff and other residents before moving in so that they become familiar with the home. EVIDENCE: The home has a long-term group of residents who have lived at the home since it opened. Residents move from the main home, Rogate, to the smaller units where they will have already met staff and become familiar with them. The owner described the assessment process, which includes talking to families and carers, and requesting written assessments from any previous placements and from the social worker. Risks and restrictions are discussed with families and other agencies and are included in the care plan. The moving-in process takes place over several months and includes day visits, and overnight and weekend stays at the home. A six-month settling-in period is offered to give the new resident and existing residents the opportunity to get to know each other and ensure that the placement meets both the needs of the individual and the group. 24 Surrenden Road DS0000014123.V262992.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): 6 Care plans are available but do not include guidelines on dealing with challenging behaviour, which can leave residents and staff at risk. Residents do not receive a plan of their care in a format they can understand, meaning that residents are not fully involved in the care planning process. EVIDENCE: Care plans were available with records of the six-monthly reviews, which the resident attends, on file. There were general risk assessments, but for residents who have challenging behaviour there were no guidelines for staff as to how to deal with incidents when they occurred. It was also noted that residents do not receive a copy of their care plan. Although not all the residents can read, it would be possible to supply them with information in a suitable picture format, similar to their contracts. A requirement was made that specific guidelines are drawn up detailing possible risks and advising staff on how to manage residents who have challenging behaviour, and that care plans are given to residents. Key workers are not allocated since only two members of staff work at the home. 24 Surrenden Road DS0000014123.V262992.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): 12, 13, 15 and 16 Residents are encouraged to continue their education and participate in social activities both within the home and in the community, thus providing both lifelong learning opportunities and stimulating and creative activities. The residents are fully integrated into the life of the community, and many local amenities and facilities are accessed providing opportunities for recreation and stimulation that enhance their lives. Residents are given daily opportunities to meet with different people and are encouraged to keep in contact with their friends and families. This enables them to develop life and social skills and to maintain important family relationships. EVIDENCE: All the residents attend day centres five days a week. One resident also attends the local college for courses in music and communication. A full programme is provided at the centres and there are opportunities for literacy and numeracy skills to be developed. Residents enjoy shopping trips and 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 11 outings to the cinema and pub. One resident said she liked the weekly shopping trip. All the residents are currently involved in making lanterns for the Brighton ‘Burning of the Clocks’ celebration. Comment cards received from relatives said they always felt welcomed at the home and were able to visit residents whenever they wished. Some residents also go home to visit their families or ring them up regularly. Residents spoken to said that staff were always kind to them and knocked on their doors before entering. One resident is unable to open their own mail, but staff ensure that mail is always opened when the resident is present. It was clear that residents had a good relationship with the staff member on duty and felt comfortable with her. 24 Surrenden Road DS0000014123.V262992.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): 20 Medication policies and procedures are clear and comprehensive, and regular monitoring of medication issues means that residents receive their prescribed medication correctly. EVIDENCE: None of the residents are assessed as being able to manage their own medication, and one service user said that they wanted staff to give it to them. Records were examined and were up-to-date and accurate, and staff had all been trained both in-house and by the local pharmacy in the storage, handling and administration of medication. Medication is ordered in by the main house, Rogate, and distributed to the units once it has been checked. 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 13 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 Residents’ concerns and wishes are listened to and staff make every attempt to meet their requests. The home’s complaints policy, however, is not produced in a format that residents can understand. Information on adult protection policies and procedures was in place but did not give clear guidelines for staff on the procedures to be followed in the case of an alert in order to ensure the safety and well-being of residents. EVIDENCE: The home’s complaints policy is clear and gives agency contact details and timescales for responding to complainants. However, as with the care plan, it was not in a suitable format for residents and a requirement was made that the policy must be appropriate to the needs of the residents. Staff were aware that they had to report any concerns to their manager, but it was not clear in the policy that all concerns must be reported immediately to social services as the lead authority. A requirement was made that all staff must attend adult protection training and that the policy is updated to reflect the multi-agency guidelines for the protection of adults. 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 14 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 and 30 The home is safe, well-maintained, clean and hygienic. Residents live in comfortable, well-decorated surroundings and have access to all parts of the building and the garden. EVIDENCE: Since the last inspection the home has treated the damp patch in the hallway and completed redecorated the whole area to a good standard. The home is located near to shops and other public amenities, and good transport links are close by. The owner advised that he had an annual plan for all the homes in the group, and that there were plans to replace the settees and refurbish the kitchen in the Surrenden Road property. Staff are responsible for keeping the home clean and the kitchen was fully equipped with washing machine and tumble drier. Staff have undertaken infection control training and the relevant policies and procedures were in place; staff were clear about how to wash soiled linen safely. 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 The home does not ensure that staff are appropriately trained for the work they have to do. Residents are therefore put at risk by staff who have not received specific training on how to deal with vulnerable and challenging people. In order to protect residents from unsuitable carers, the home carries out the necessary checks on staff before they begin working at the home. EVIDENCE: At the last inspection, a requirement was made that all staff must undertake foundation training. At this inspection, it was again found that not all staff in the home had undertaken such training. In addition, one member of staff who had been in the home for over a year, although they had received induction and other core training, had not received specific training in working with people with learning disabilities. Another member of staff had not attended any training for 16 months. The standard recommends that staff receive a minimum of five days training per year in order to ensure they have the necessary skills and knowledge to work with vulnerable people; this includes disability training and equal opportunities training. Core training skills must also be updated on a regular basis. The home is not providing the necessary training. 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 16 The owner advised that the organisation has employed a training officer who has completed a needs assessment of all staff. It is essential that the home makes a full review of the training needs of the staff and that appropriate training is put in place as soon as possible. Requirements were made that the home ensures all staff undertake foundation training and specific training linked to learning disability, and that all staff must receive suitable assistance to obtain further qualifications to enable them to care for residents properly and safely. Staff files showed that the home follows proper recruitment procedures and that all the necessary checks are carried out to ensure that only suitable staff are employed at the home. 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 17 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, 42 and 43 The home’s management structure is not robust and does not have clear lines of accountability to ensure the continued safety and well-being of residents. Portable electrical appliances have been checked and are considered safe to use. EVIDENCE: The registered manager, who has recently successfully completed her NVQ4, is currently on maternity leave and will not be returning to the home until March 2006. During her period of absence, a senior carer is providing cover with the support of the owner; a senior manager at one of the other homes who was providing support is currently unable to continue doing so. In the absence of the registered manager and the other senior manager, the home is not being effectively and competently managed and residents’ safety and well-being are being put at risk. The management structure is not clear and staff were unsure as to whom they were accountable to. A requirement was made that the home puts into place a strong management structure to 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 18 support and supervise staff during the absence of the manager, and to review the structure of all the homes in the group following the return of the two absent managers. Following on from a requirement made at the previous inspection, the home has now ensured that all portable electrical appliances have been tested. Other health and safety issues were not inspected again at this inspection. 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 2 x 3 2 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 24 Surrenden Road Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 1 DS0000014123.V262992.R01.S.doc Version 5.0 Page 20 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 YA6 Regulation 13(4c) 15(2a) 2 3 4 YA22 YA23 YA23 22(2) 13(6) 13(6) Requirement Care plans must include details of how to cope with challenging behaviour. Care plans must be made available to the service user. The complaints policy must be appropriate to the needs of the service user. All staff must attend adult protection training. Policies and procedures must be revised to be in line with multi-agency guidelines for adult protection. All staff must undertake foundation training. (Outstanding requirement from previous inspection.) Staff must undertake specific training linked to disability. All staff must receive appropriate training and assistance (ie time off) for the purpose of obtaining further qualifications. Timescale for action 31/12/05 31/12/05 31/03/06 31/12/05 5 YA32 18(1) 31/03/06 6 YA35 18(1) 22/11/05 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 21 7 YA43 8 YA43 18(1)(24)(38)(2) A robust management structure must be put into place to support and supervise care staff during the absence of the manager. 18(1)(24)(38)(2) The management structure of the organization must be reviewed and strengthened to ensure the proper management of all the homes. 12/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 22 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 24 Surrenden Road DS0000014123.V262992.R01.S.doc Version 5.0 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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