Inspection on 09/10/07 for 26 Penkridge Road

This inspection was carried out on 9th October 2007.

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

Other inspections for this house

26 Penkridge Road 07/10/08

26 Penkridge Road 11/05/06

26 Penkridge Road 23/01/06

26 Penkridge Road 27/09/05

26 Penkridge Road 23/02/05

26 Penkridge Road 07/09/04

26 Penkridge Road 21/01/04

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Fairways

Treloar College

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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 26 Penkridge Road Bedhampton Hampshire PO9 3LU Lead Inspector Craig Willis Unannounced Inspection 9th October 2007 1:45pm 26 Penkridge Road DS0000011977.V347574.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 26 Penkridge Road DS0000011977.V347574.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. 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 26 Penkridge Road Address Bedhampton Hampshire PO9 3LU 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) 023 9247 5911 www.c-i-c.co.uk. Community Integrated Care Post vacant Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2006 Brief Description of the Service: 26 Penkridge Road is a detached house with four bedrooms. It is registered to accommodate two adults with a learning disability. The registered providers are Community Integrated Care (CIC). Knightstone Housing Association manages the property. One person currently lives at 26 Penkridge Road. The house is on a hill overlooking Portsmouth and the sea. It is in a residential area. The service has a car to access local shops and other amenities. At the time of the report CSCI were still waiting for information about the fee level, which was requested during the visit. 26 Penkridge Road DS0000011977.V347574.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) since the last visit. This information included an annual quality assurance assessment completed by an acting manager, incident reports sent to CSCI and comment cards from two members of staff. A site visit to the home was made on 9 October 2007. During the site visit the inspector met the person who lives in the home, although did not have a conversation due to their communication needs. The interactions between the resident and staff were observed. The inspector also spoke with members of staff on duty. A permanent manager started work in the home two weeks before the inspection, but was not present during the visit. We spoke with the manager by phone on the following day. All the communal areas of the building were viewed and documents relating to the running of the home were inspected during the visit. What the service does well: There are good systems to assess people’s needs before they move into the home. This helps to assure people that their needs can be met. People’s needs are set out in clear care plans. This helps to make sure people receive the support they need. The home provides good support for people to take part in activities they enjoy. There are good systems to keep people safe from abuse. The home is well maintained and provides a comfortable and clean environment for people. Staff are thoroughly checked before they work in the home and are well trained. This helps to ensure people are protected and staff have the right skills to meet people’s needs. 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. 26 Penkridge Road DS0000011977.V347574.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 26 Penkridge Road DS0000011977.V347574.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 people before they move into the home, which helps to assure people their needs can be met. EVIDENCE: There is currently one person who lives in the home, although they are in the process of moving to another home. The personal file of this person was viewed during the visit and contained details of a needs assessment that was completed before they moved in. This information was used to develop care and support plans. Community Integrated Care (CIC) has procedures in place for assessing the needs of people who may want to move into the home. The manager reported that they were currently assessing the needs of a person who has been referred to the home. Following this assessment process it will be decided whether they can offer the person a place. 26 Penkridge Road DS0000011977.V347574.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 good. This judgement has been made using available evidence including a visit to this service. There is a good care planning and risk assessment system, which helps to ensure people receive the support they need and are supported to make decisions about their lives. EVIDENCE: The personal files of the person who lives in the home were inspected during the visit. A requirement was made at the last inspection that the care plan must contain up to date information, including how staff support them and how risks are managed. These files contained a set of care plans and risk assessments that had been developed from the person’s needs assessment. The risk assessments contain action that is required to minimise the identified risks. There was clear information about how staff should provide support to meet the person’s needs. An acting manager completed the annual quality assurance assessment for CSCI and said the care plans need to be developed into a more accessible format for the person. The manager reported that this is work that will be done for the new people who move into the home. Staff 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 10 spoken with demonstrated a good understanding of the person’s needs and how they should meet them. During the visit, staff were observed responding to the person’s requests and supporting them to make decisions about the activities they took part in. This support was provided in friendly and respectful manner and was reassuring to the person when they became distressed. The person has a communication board, which they use to make decisions about the days activities. Work is taking place with staff from the person’s new home to ensure the move goes smoothly. There is a transition plan in place, although staff spoken with did not know how the person was going to be supported to move to their new home. The manager said she would ensure all staff are aware of the plans so that there is a consistent approach from staff. 26 Penkridge Road DS0000011977.V347574.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 people to take part in activities they enjoy and meet their lifestyle choices. EVIDENCE: The person who lives in the home is supported to take part in various social and educational activities. Until recently the person attended a local day service. This has now been stopped because the person is moving out of the area. In the time before the person moves, staff have been providing additional support during the day to do activities the person chooses. These have included trips out in the home’s car and walks. The manager reported there are very few community activities used due to the person’s needs. However, there is a current programme to support the person to go to a local supermarket at quiet times to do some personal shopping. There are clear guidelines and risk assessments in place, setting out the support staff should provide. There are opportunities for the person to take part in activities in the 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 12 home, including watching television and DVDs, listening to music and doing jigsaw puzzles. Staff reported that the person has regular contact with family members, with visits to the home and involvement in planning meetings. Staff also reported that the person chooses meals on a daily basis. There is a well-stocked freezer and food store for the person to choose from. A record is kept of food that is prepared. 26 Penkridge Road DS0000011977.V347574.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 adequate. This judgement has been made using available evidence including a visit to this service. The physical and emotional needs of people are well met, however, shortfalls in the medication records and storage do not demonstrate safe practice. EVIDENCE: Discussions with staff indicated they provide sensitive and flexible personal support to maximise the person’s privacy, dignity, independence and control over their lives. Information is provided in care plans on how support should be provided, and staff demonstrated a good understanding of the person’s needs. Records are maintained of appointments with a range of health professionals and include any advice given by the practitioner. There was no record that the person had been supported to visit a dentist. The manager said she would ensure this information was passed on to the person’s new service, so arrangements could be made. A requirement was made at the last inspection that there must be a medication procedure in place and staff must follow it. There was a medication policy 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 14 available in the office. The person living in the home does not currently administer their own medication. Most medication is stored in a locked cabinet in a cupboard next to the office. A record of medication administered is kept. All staff administering medication have completed assessed training in safe administration of medication and have to complete a re-assessment every six months. During the visit it was noted that staff placed some of the person’s medication in a separate container to take when they went out of the home. This was medication that was prescribed to be taken when required. The home’s medication policy states that medication must only be administered from the package it was dispensed in. Placing medication into a separate container is classed as secondary dispensing and is not a safe practice. During the visit it was also noted that a staff member had left this medication in their bag on return to the home. This meant that the medication was not locked in the home and staff were not able to immediately locate it when the person living in the home needed the medication. The medication cabinet had a container with several tablets that needed to be returned to the pharmacist to be destroyed. Staff reported that there was no system for recording and returning medication. The requirement made at the last inspection has not been complied with and is restated in this report. A letter was sent to the responsible individual on the day following this inspection requiring them to take urgent action to resolve the problems with the home’s medication systems. 26 Penkridge Road DS0000011977.V347574.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 good. This judgement has been made using available evidence including a visit to this service. The home has good systems for dealing with complaints and keeping people safe from abuse. This gives people confidence any complaints will be taken seriously. EVIDENCE: The home has a complaints procedure, although an acting manager reported in the annual quality assurance assessment for CSCI that this has not been supplied to the person who lives in the home in a format they can understand. The manager reported that the complaints procedure would be provided to the new people to move into the home in a format that is accessible to them. No complaints have been received by the home or CSCI since the last inspection. The home has safeguarding adults procedures in place. Staff have received training in these procedures and demonstrated a good understanding of types of abuse and action they should take if abuse is witnessed, reported or suspected. No allegations have been referred to adult social services for investigation under the safeguarding adults procedures in the last year. 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a comfortable and clean environment for people. EVIDENCE: All of the communal areas of the home were inspected during the visit. The home was clean throughout and was well maintained. Staff spoken with said CIC have a maintenance person who completes work quickly when requested. The home is owned by a housing association and there is a maintenance contract in place for areas they are responsible for. There has recently been a problem with the home’s heating system. This has now been fixed and temporary heaters were used while it was out of action. There is a bathroom on the first floor close to bedrooms. There is a domestic kitchen that is accessible to people who live in the home. The lounge has recently been decorated and staff reported there are plans to decorate the bedrooms. 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 17 The home has a separate laundry room with domestic machines and staff reported that all equipment was working effectively. Protective clothing is available for staff. 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 18 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, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good staffing arrangements, which helps to ensure people are protected and their needs are met. EVIDENCE: The acting manager reported in the annual quality assurance assessment for CSCI that two of the six staff have achieved the National Vocational Qualification (NVQ) in care at level 3. The acting manager reported in the annual quality assurance assessment for CSCI that they obtain Criminal Records Bureau (CRB) checks and references for all staff before they start working in the home. The files of four staff were inspected during the visit and confirmed that checks had been undertaken before people started work. The manager reported that they were in the process of recruiting additional staff. The home has a training programme and staff spoken with said they felt the training provided was good and helped them to meet people’s needs. Courses staff have completed include principles of care, first aid, food hygiene, person centred planning, fire safety, moving and handling, adult protection, autism 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 19 awareness, epilepsy, non-violent crisis intervention and safe administration of medication. 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 20 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, 41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of a permanent manager and ineffective quality assurance systems has meant the service has not improved and confidentiality is not maintained. People are protected by some of the home’s systems, however, people’s safety in the event of a fire would be better protected by regular checks of equipment. EVIDENCE: The home has had a series of acting managers, however, a permanent manager started work in the home two weeks before the visit. The manager said she was in the process of submitting an application for registration to CSCI. Staff spoken with said there had been difficulties in the home due to the lack of a permanent manager, but felt they had been well supported. The 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 21 manager expressed a commitment to rectify the shortfalls in the home’s performance. A senior manager from CIC visits to home each month to assess the quality of the service provided. Reports are made of these visits and sent to the manager, with any actions that are needed. Three of the four requirements made at the last inspection have not been fully complied with, despite confirmation from the responsible individual following the last inspection that action would be taken. The manager reported that there were no other quality assurance systems being used at present, but she was planning to introduce them so that improvements can be made to the service in a planned way. A requirement was made at the last inspection that individual records and the home records must be kept securely. During this visit personal staff records were kept in an unlocked cupboard in an open office and the records of the person living in the home were kept on an open shelf in the unlocked office. The manager reported that she planned to move the office upstairs and ensure all confidential information was kept secure. A requirement was made at the last inspection that fire safety standards must be maintained. Advice has been sought from the fire service, although recommended action to connect the home’s smoke and heat detectors has not been actioned. A fire door from the kitchen to the back hallway and office was propped open. The annual quality assurance assessment reported that weekly checks were being completed on the fire detection and fighting equipment. The records were not in the home to verify this during the visit as the manager had removed them to make changes to the format of the checks. The manager reported that the last recorded check was over two weeks before the visit. Checks have been carried out on the home’s gas system and portable electrical appliances. Hazardous chemicals were stored in a locked cupboard. 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 22 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 2 X 2 X 2 X 2 2 X 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 23 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 YA20 Regulation 13(2) Requirement The registered person must ensure staff follow the home’s medication procedure. • Medication must be kept in a locked cabinet in the home. • Medication must only be administered from the packaging it was dispensed in. • Spoilt or unused medication must be returned to the pharmacist for disposal. A record of medication disposed of must be maintained. This requirement was made at the last inspection and the time-scale of 11/07/06 was not complied with. 2. YA41 17 The registered person must ensure individual records and the home records are kept securely. This requirement was made at the last inspection and the time-scale of 12/06/06 was 26 Penkridge Road DS0000011977.V347574.R01.S.doc Version 5.2 Page 24 Timescale for action 31/10/07 31/10/07 not complied with. 3. YA42 23(4) The registered person must ensure fire safety standards are maintained. The smoke detectors must be tested weekly and the advice of the fire safety officer must be sought regarding which internal doors can be propped open. This requirement was made at the last inspection and the time-scale of 11/07/06 was not complied with. 30/11/07 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 26 Penkridge Road DS0000011977.V347574.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 26 Penkridge Road DS0000011977.V347574.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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