Inspection on 06/02/06 for 24 Surrenden Road

This inspection was carried out on 6th February 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 5 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 21/11/05

24 Surrenden Road 21/02/05

24 Surrenden Road 07/09/04

Similar services:

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Southfields

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 24 Surrenden Road 24 Surrenden Road Brighton East Sussex BN1 6PP Lead Inspector James Houston Unannounced Inspection 6th February 2006 08:30 24 Surrenden Road DS0000014123.V270258.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.V270258.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.V270258.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.V270258.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is three (3). Service users will be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection 21st November 2005 Brief Description of the Service: 24 Surrenden Rd 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 close to Preston Park station. The home is registered to care for up to three people with learning disabilities. The home 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 mobility problems. There is a garden to the rear of the property on the road outside. Residents have the use of the lounge and a large kitchen/diner and also the hydrotherapy pool located in one of the other properties owned by Hallcreed Limited. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection, which was unannounced, took place over four hours during the early morning and afternoon of the sixth of February 2006,and was one of the two inspections required over the year. The inspector met with the care manager of the provider, two staff and the home’s residents. A tour of the premises was made and a range of records, including the care plans, and a selection of policies and procedures were read. Three residents were living in the home on the day of the inspection. What the service does well: What has improved since the last inspection? 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. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 6 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.V270258.R01.S.doc Version 5.0 Page 7 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): 3 and 4. The home meets the needs of the existing resident group. Prospective residents and their representatives would be given every assistance to help them in their decision about whether or not to move into the home. EVIDENCE: The home has a long-term group of residents who have lived in the home since it opened. Staff individually and collectively have the skills and experience to met the needs of the existing resident group. The home does not have a vacancy at present, but the care manager said that in the event of a vacancy, for any prospective resident that there would be a moving process over several months, including day overnight and weekend visits. A six month settling or trial period is offered. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 8 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 and 10. Care plans are available. One needs some attention. Confidentiality is respected. EVIDENCE: Care plans were available with details of six-monthly reviews. One resident’s review was due the next day and the resident confirmed that they would be attending. There are general risk assessments, but for one resident with challenging behaviour guidelines for staff on how to deal with incidents when they occur were not to hand. Residents have access to their care plans. The home has a suitable confidentiality policy that was inspected, and of which staff said that they are aware. Staff were alert to the limits of confidentiality i.e. when they might need to might need to share information, given to them in confidence, with their manager or others. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 9 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): 11,14 and 17. Residents have opportunities for personal development and appropriate leisure activities. Meals and mealtimes promote the well being of residents. EVIDENCE: Residents attend day centres and one resident attends college, giving opportunities for maintaining and developing emotional and communication skills. The care manager said that at present no residents have individual complex needs requiring specialist interventions. There are no identified spiritual needs, but residents enjoy festivals. Staff said that residents are encouraged and free to choose from a range of appropriate leisure pursuits. The home has access to suitable transport. Residents said that they have at least one annual holiday, and one resident said that holidays have been taken both in England and abroad. Residents said that they like the food served in the home. Menus of food served were available for inspection, and staff said that they keep a record of any alternatives given. Residents are involved in the purchasing and preparing of food. The care manager said that discreet assistance is given as needed at mealtimes. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 10 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): 19 and 21. Thorough arrangements are made to meet the healthcare needs of residents. Suitable systems exist for the provision of good care for ill or dying residents. EVIDENCE: Records inspected showed that careful arrangements are made for the provision of healthcare to residents. Detailed plans had been made for a resident following a recent accident. A resident said that they see the doctor when they need to. Staff said that residents are accompanied on visits to the surgery. The home has suitable policies on the care of dying residents and staff said that they are familiar with them. The care manager said that the home provides 24-hour cover where residents are not well, linking with community health care staff as needed. Care plans contain details of arrangements to be made in the event of the death of a resident, to ensure that the wishes of the resident and their family in respect of arrangements to be made after the death of a resident are carried out. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 11 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. The home has a suitable complaints system. The home’s adult protection systems protect residents in the event of abuse or allegations of abuse. Training is needed for a staff member. EVIDENCE: The home’s complaints policy is clear and gives the requisite agency contact details and timescales for responding to complainants. There is now also a suitable format appropriate to the needs of residents. The home has a log in which to record any complaints made. This was inspected. The home has received no complaints since the last inspection and the Commission for Social Care Inspection has received none concerning the running of the home. The home has a suitable adult protection policy. A minor amendment was made during the inspection. Staff are aware of it and the home’s whistleblowing policy. One staff member needs to attend adult protection refresher training. The home has a suitable policy on staff not receiving gifts from residents. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 12 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): 24,26 and 28. The home gives residents comfortable surroundings on a domestic scale. EVIDENCE: The home provides accommodation on two floors. Due to an accident one resident has been unable to access his room on the first floor for the time being and suitable temporary arrangements have been made. The home’s washing machine had just broken down, and during the inspection a replacement was fitted. Staff said that matters needing repair are addressed quickly. The home is well decorated and furnished throughout. There are plans to replace the settees in the lounge and the units in the kitchen. Residents said that they like their rooms and that they had been able to choose the décor in them. They are able to have their own items and records inspected showed that an inventory of these items is kept. Residents said that they did not choose to lock their doors. The care manager said that residents could have a lockable box in their rooms. The home’s communal areas provide ample space for residents. There is a garden at the rear of the house that is available to residents. The facilities in the house for staff are good, including a large sleeping in room/office. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 13 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): 31,32,33 and 35. The home has a competent staff group. Qualification levels and some training need review. EVIDENCE: Staff have suitable job descriptions and a sample of these was made available for inspection. Staff confirmed that they have contracts of employment and that they are familiar with the General Social Care Council’s code of conduct, and a copy was available in the home. Since the last inspection foundation training has not been provided for the home’s staff and the care manager said that this would be done. Some training in some aspects of working with people with disabilities is needed. The care manager said that the staff have been offered NVQ training in care (Level 2). Neither has as yet attained the qualification. Two full time staff and the manager normally staff the home. Cover comes from the group’s main home and such staff were on duty during the inspection in the absence of the home’s regular staff members. The home is not normally covered from 10am to 3 pm weekdays, as all residents attend day-care/college on a full time basis. There were enough staff on duty during this unannounced inspection to meet residents’ needs. The home also employers a gardener and maintenance staff. Separate cooking and cleaning staff are not employed. Staff were seen to have effective relationships with residents. Agency/bank staff are not used. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 14 Staff should receive appropriate training and assistance (i.e. time off) for the purpose of obtaining further qualifications. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 15 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): 38,40,41 and 43. The home’s atmosphere is good. Policies and procedures are well drawn up. Records need some attention. The home has suitable management processes. EVIDENCE: The home has regular staff meetings but these are not minuted. It is recommended that this be considered. Residents meet staff regularly. The atmosphere in the home was warm and friendly. The home’s policies and procedures were sampled and were found to be well drawn up. They were seen to be regularly reviewed. Staff said that they have easy access to them. A range of records was sampled and was found to be well kept and up to date. However the care manager said that no monthly visits to the home by a representative of the provider had been made for three months. She will ensure that these recommence. The record of monies kept on behalf of residents showed small discrepancies and this should be looked into. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 16 The registered manager will be absent from the home for the next few weeks, and the group’s care manager has a responsibility for the home in her absence. Staff on duty in the home knew who is responsible, and the care manager gave an assurance that she or the group’s owners are available on call to staff at all times. The home has suitable insurance. Administrative support is given by staff at the main home in the group. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 17 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 X 3 3 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X 3 X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 3 X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 24 Surrenden Road Score X 3 X 3 Standard No 37 38 39 40 41 42 43 Score X 3 X 3 2 X 3 DS0000014123.V270258.R01.S.doc Version 5.0 Page 18 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 3 4 Standard YA6 YA23 YA32 YA35 Regulation 13(4)(c) 13(6) 18(1) 18(1) Requirement A care plan must include detail of how to cope with challenging behaviour. A staff member must refresher attend adult protection training. All staff must undertake foundation training and specific training linked to disability All staff must receive appropriate training and assistance (i.e. time off) for the purpose of obtaining further qualifications. Keep in the home available for inspection all required records. Timescale for action 31/03/06 31/05/06 31/03/06 31/05/06 5 YA41 17 Sch 4 4 and 9 28/02/06 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 YA32 Good Practice Recommendations 50 of care staff gain NVQ level 2 in care. 24 Surrenden Road DS0000014123.V270258.R01.S.doc Version 5.0 Page 19 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.V270258.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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