CARE HOME ADULTS 18-65
267 Old Shoreham Road 267 Old Shoreham Road Portslade East Sussex BN41 1XF Lead Inspector
Jenny Blackwell Announced Inspection 20th October 2005 09:00 267 Old Shoreham Road DS0000058271.V260301.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 267 Old Shoreham Road DS0000058271.V260301.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. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 267 Old Shoreham Road Address 267 Old Shoreham Road Portslade East Sussex BN41 1XF 01273 296400 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) Brighton & Hove City Council Mr Glen Scott Campbell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: The home is set in a residential area of Portslade, on a main road. The building is semi-detached and has three storeys, with the office and staff sleeping-in rooms on the top floor. The home is domestic in scale and is situated near local shops and amenities. Hard standing parking space is available at the front of the home. The home can accommodate up to 3 people with learning disabilities who are physically able. Each person has their own individually decorated bedroom and share communal space, a lounge, kitchen/dining room and bathroom facilities. The home was designed around the needs of the current 3 people and has specialist adaptations to provide a safe environment for the people. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. During this summary the people who live at the home will be referred to as people/person (except in the requirement section) and the people who work at the home as staff or by their job title. This was the second inspection of the home under the Care Standards Act and it was announced. At the first visit none on the people who live at the home were in and the staff team numbers were low due to them covering a persons holiday and some staff sickness. An announced follow-up visit took place on the 4/11/05. The people who live at the home, some of the staff team, deputy and managers were present during the two-day inspections. Some time was spent with two of the three people who live at the home, and the other person was seen briefly in-between trips out. The manager and deputy were spoken to individually and several staff was spoken to throughout the day. The day was arranged to fit around the activities organised for the people. The requirements that were made during the last inspection were checked to see if they had been met. Some had been met in the timescale, however one requirement was still outstanding from May 2005. The people who live at the home and the staff were helpful throughout the inspection and contributed to the report where possible. What the service does well:
The manager and staff team at the home regularly review the guidelines that are in place for each person and a formal review of each person’s care is conducted every six months. The care plans were of a good standard and contained information that described the person’s interest, likes, dislikes, family and friends connections, basic health and social care needs. The keyworkers and other staff contributed to the plans and were knowledgeable about the individuals support needs. The manager and staff arrange individual activities with each person, based around their interest and support needs. The staff view each person as individuals and the manager produces a staff rota that is built around leisure activities. Staff were seen to use objects of reference, Makaton and photos, which demonstrated a commitment to supporting each person to control their day as much as possible. The staff team were focused and helped people to deal with their levels of anxiety, focusing on supporting people to reduce certain behaviours. The staff worked well with other professionals and sought advice when they needed additional support. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 6 Staff were observed working in a relaxed manner with people, helping them to learn and develop skills. It was noted that particular emphasis was place on consistency of approach to the people, as this was important for the individuals to manage their levels of anxiety. What has improved since the last inspection? What they could do better:
This was the second inspection of the home since it opened at the beginning of 2004. The staff team have worked well with the people to help settle them to a new home and were committed to supporting the people, some with complex behaviours to be as independent as possible. However the registered provider, Brighton and Hove City Council have not ensured the suitability of the placements have been kept under review. The placing authority had not conducted the annual review of the people’s community care assessments. As raised during the previous inspection this was particularly concerning as this was a new home for the people and staff saw the move to the home as a challenging time for each person. Several actions have been taken to prevent conflict between the people at the home, and to reduce noise levels from one person. These actions restrict on the individuals freedom of movement. One person’s bedroom no longer meets the National Minimum Standard because of the changes made to reduce the noise levels. The compatibility of the current group of people living at the home and the suitability of the environment needs to be assessed. The home did not have a specific contract with the people at the home. The manager stated that the organisation was working with their registered managers to produce a clearer contract for the individuals. As previously noted some work had been carried out to one person’s bedroom. These alterations to her room needed to be included in her care plan and regularly reviewed. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 7 The manager had informed the Commission that on two occasions restraint was used against one person. It was noted with concern that on both the occasions a staff member operated outside of the home guidance. The manager had addressed the issue appropriately. The use of restrictive practices is currently being reviewed by the organisation - the outcome of this review will be monitored by the Commission to ensure practice within the home remains lawful. During the second visit it was noted, whilst looking at the home’s staffing rota, that the home had an increase in the number of hours covered by relief staff. It was required that the manager produces a recruitment plan to employ permanent staff to the vacant posts. 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. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 8 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 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 9 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): 2,3,4 and 5. Not all of the people had their placements and aspirations assessed. The current group of people were having their needs met by the home. Any new person would have an opportunity to visit the service before moving in. The current people did not have a contract with the home. EVIDENCE: Not all of the people’s placements had been reviewed annually. The manager and organisation ensure that they review each person’s support needs and goals regularly, including the person in the process. This happens according to the organisation’s policy and the staff demonstrated a commitment to this process. However the placing authorities had not conducted the annual review of the people’s community care assessments. As raised during the previous inspection, this was particularly concerning as this was a new home for the people and staff saw the move to the home as a challenging time for each person. Alterations had been made to one person’s bedroom to reduce noise levels in the home, that meant her room no longer met the National Minimum Standards. A lock was still being used on occasions on one person’s bedroom door to protect other service users and the staff. The manager stated that one person was being taken out more when another person was having incidents. He had noticed the noise levels were affecting her. These circumstances would indicate that the three people’s placements needed to be reviewed to ascertain if the home was suitable for their needs and the
267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 10 compatibility between the three people was working. Their placing authorities had not reviewed their placements since they moved in at the beginning of 2004. The use of the restrictive practices in the home needed to be part of the assessment to ascertain the suitability of the people living in a shared community home. A discussion took place between the manager and inspector about the expectation in the National Minimum Standards for the manager to ensure these assessment reviews take place. Although the manager could not guarantee the social workers from the placing authorities would conduct the reviews, he must provide evidence that he has requested the reviews take place annually. The staff have received specific training tailored to suit the needs of the current group of people. They have skills in supporting people with autism, behaviours that challenge and communication difficulties. Staff were observed in supporting people with specialist sign language, structured activities and supporting people with boundaries and routines. These interactions were conducted sensitively and professionally. The home had an admission policy. It includes providing prospective people opportunity to visit the home. The home did not have a specific contract with the people at the home. The manager stated that the organisation was working with their registered managers to produce a clearer contract for the individuals. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 11 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): 6,8 and 10 Care plans were in place for all three people, containing information that enabled staff to provide a consistent support to each person. The people are consulted on and participate in day-to-day decisions in their life. The information about people was stored appropriately in accordance with the organisation’s policies. EVIDENCE: The manager and staff team at the home regularly review the guidelines that are in place for each person and a formal review of each person’s care is conducted every six months. The care plans were looked at for each person. They contained information that described a person’s interest, likes, dislikes, family and friends connections, basic health and social care needs. The keyworkers and other staff contributed to the plans and care was taken in the use of language when describing the people’s support needs. One person had some major changes to her bedroom in response to a complaint about noise levels. These alterations to her room needed to be included in her care plan and regularly reviewed. The manager and team do not have a formal process of consulting the people who live at the home. The manager stated that the people’s concept levels
267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 12 meant that staff worked individually with people and used different communication methods to ascertain their preferences. Staff were seen to use objects of reference, Makaton and photos, which demonstrated a commitment to supporting each person to control their day as much as possible. One person was encouraged each morning to put up photos on a board of the places she was going that day. The personal information about the people is stored appropriately in the home. The manager ensured that records and files about the people were locked away and staff were seen to make sure the records were put back in a secure place after they had used them. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 13 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): 11-17 The manager and staff were commited to supporting each person with their daily interests. The home was concerned with the individual and did not group people together during activities for ease. People were supported to be part of the community. The manager and staff had fostered good relationships with family members who were involved in the home. Privacy was respected and staff freely engaged with the people at the home rather than restrict conversation amongst themselves. The rights of the individuals were understood and respected by the staff although restriction around the home encroached on each other’s freedom of movement. The menus appeared to offer nutritional and balanced meals. EVIDENCE: On the day of the second inspection all three people were engaged in different activities. One person attended a specialist day service that supported people to participate in different leisure activities. Another person was due to do some baking with the staff in the afternoon. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 14 A named member of staff always supported each person. The staff support the women to prepare their meals, participate in housework and encourage them to learn new skills. This was seen through observation of the team. Although everyone was busy during the morning it was well organised. On the first visit to the home, one person was away with staff on her holiday. The manager said the holiday was going well and staff had reported to him the person was relaxed and did not demonstrate the levels of challenging behaviour she had at home. Each person had contact with members of their family. The staff were able to talk about each persons family and the arrangements for visiting them. This demonstrated that the whole team took responsibility to keep good relationships with family members. The manager had been working with other managers and the team to ensure the people’s rights were supported. An example of this was the work that the team was doing about medical interventions. The staff team were currently supporting a person to be comfortable with giving blood samples for health checks under the guidance of “Best Interest” The inspector spoke with the manager, deputies and the behaviour support worker about ensuring a better understanding of the need to balance the duty of care to the individual and at the same time uphold their rights. Some practices in the home encroach on some people’s freedom of movement, for example a lock on one person’s bedroom door. The support staff prepared the meals. Each staff member attends a food hygiene course before they get involved in food preparation. The people who live at the home contribute to choosing the menu where possible. The staff make up the menus based on direct choice of the individuals and known preferences. The meals are balanced and appeared to be enjoyed by the people. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 15 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 and 21 The people received personal support from the staff in a way that was identified in their care plan. The people’s physical and emotional support needs are met by the staff and was supported by the organisation’s policies. The manager and staff ensured that the health needs of the people are monitored and supported. The medication was stored, administered and recorded appropriately. Staff training was organised regularly and staff are tested on their competency before administering medication. EVIDENCE: The people’s care plans describe the personal support that they required. Their preferences were recorded and some detailed information about the importance of maintaining routines was noted. A medication check was carried out. The medications were stored, administered and recorded appropriately. The staff spoken to were knowledgeable about the system and the medication regime the people were taking. The manager demonstrated a good understanding of the importance of monitoring and reviewing any medication that was prescribed to suppress behaviours or sedate people. The staff team had produced a good book to help people cope with bereavement. Recently the staff had undertaken training in loss and
267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 16 bereavement and were working with one person. The book was developed with skill and sensitivity and appeared to be helping the person. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 17 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 manager and staff were responsive to the concerns of the people living at the home. A formalised complaints procedure is in place for the home that adheres to the organisation’s policy. The organisation and manager emphasised the importance of protecting vulnerable adults, through policy, training and supervision. However two incident of restraint were used outside the guidance of the home’s policy. EVIDENCE: Since the previous inspection the manager had received a significant complaint about noise levels from the home. The manager had acted appropriately and professionally in addressing the complaint. The Commission had not received a complaint about the home. New staff to the home were instructed in Adult Protection during their induction period. The training plan was looked at and this showed regular and organised A.P training for staff. All staff were expected to attend Adult Protection training and this was monitored by the manager. He ensured that people attended refresher courses regularly. The manager had informed the Commission that on two occasions restraint was used against one person. Both of the occasions a staff members had locked a person in her room when she was displaying challenging behaviour. This procedure had been challenged during a previous inspection and it had been required that the home review the use of the lock. The guidelines provided had been improved to give clear detailed guidance on when, in exceptional circumstances, the use of the lock should be used; this was mainly to protect the other people at the home and the staff. It was noted with concern that on both the occasions a staff member operated outside of the
267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 18 home guidance. The manager stated that he had addressed the issues with the individual staff member and was confident that this would not happen again. The manager and the organisation must ensure that the procedures in the home are lawful. That people are not made vulnerable to abusive practices and appropriate action is taken if staff are failing to adhere to the home’s policies. The use of restrictive practices is currently being reviewed by the organisation - the outcome of this review will be monitored by the commission to ensure practice with the home remains lawful. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 19 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): 24-30 The home was generally homely, comfortable and safe. Two people’s bedrooms were adapted to suit their needs and effort had been made to personalise them. Toilet and bathroom facilities were private and had been designed to meet the needs of the individuals. The shared space complimented the bedroom space for the people. Some specialist equipment is provided to enable the people to be independent. The home was clean and hygienic in all areas. EVIDENCE: The home was generally homely in appearance and had been improved since the previous inspection. The staff team had made an effort to make on person’s bedroom more homely by removing the fixed material on the wall to prevent self-injurious behaviour. The staff had used the risk assessment process and reviewed the needs for the material regularly. They found the person had not exhibited the behaviours that put her at risk. They therefore responded to their findings and removed the materials. The staff had showed imagination when helping the people to personalise their rooms finding ways of reflecting the people’s personalities but also considering some people tolerances of certain objects in their rooms. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 20 As mentioned in the previous sections, one person’s bedroom had been re designed and part of the window had been boarded up. This was to reduce the noise levels. The manager had raised the difficulty of the noise levels at a multi-disciplinary meeting and a collective decision was taken to board up the windows. The person’s bedroom no longer meets the National Minimum Standards and has not been directly implemented from the assessed needs of the person. The action was taken to respond to a complaint. The effect this has on the individual needs to be part of the review of her placement assessment conducted by her placing authority. The flooring had been replaced in one person’s bedroom, as required from the previous inspection. The bathrooms had been specially designed around the needs of the three people and were spacious. The shared spaces in the house were kept in a reasonable order and generally had a homely feel. The kitchen and dining room were open plan and the people had unrestricted access to the kitchen facilities. The lounge was separate and had the facilities that are expected in a domestic home. The home was clean and well kept and the laundry facilities met the needs of the people. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 21 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): 31,32,34,35 and 36 Staff understood their roles and responsibilities and the limitation of the job roles. The staff team were competent to support the current group of people at the home. Staff received training although no staff had completed an N.V.Q qualification. The home’s recruitment procedures support and protected the people. The staff were well supported and received formal supervision. EVIDENCE: The staff team was structured with a clear line of management structure. The staff spoken to understood their roles. Time was spent with one relief member of staff who was working 1:1 with a person. She was able to describe her tasks for the day and demonstrated a good knowledge of the person and her support needs. It was not noticeable through the day which staff were relief or agency, they worked well with the individuals and used their own initiative. The staff were committed to improving the quality of the people’s lives. This was evidenced by the attention paid to working in a consistent way with people. By the detailed information in the people’s plans and through conversation with individual staff who where knowledgeable about the people’s interest and support needs. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 22 The organisation provided a rolling programme of training for the staff. The manager ensured that staff attended courses that would benefit the current group of people at the home. Training planned for the team included Neurological background to learning disabilities, Makaton sign language, I.T skills and Fire training. Two staff had started their N.V.Q level 2 training and one staff had started the level 3. On the first visit to he home the home was short of staff due to vacancies, sickness and a staff member being on holiday with one person. During the second visit it was noted whilst looking at the home’s staffing rota, that the home had an increase in the number of hours covered by relief staff. It was required that the manager produces a recruitment plan to employ permanent staff to the vacant posts. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 23 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): 37-43 The home was well run and the people who lived at the home benefited from the ethos and leadership of the management. The home did not have a clear quality assurance tool although audit checks such as health and safety were carried out. The people’s rights were protected by the home’s policies and procedures, which were reviewed regularly. The record keeping protected the people’s interest. The organisation and home were organised to protect the health and welfare of the people. The organisation monitors the financial viability of the home. EVIDENCE: The staff spoken to were asked about the support they received from the manager. They commented that they felt supported by the manager and that he was accessible to them. The organisation undertakes different audits in the home to check for the quality of service the home provides. It was not clear if the organisation and home has a quality audit tool to meet the standard. It was required that the
267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 24 manager provides a quality audit tool to demonstrate the organisation and the home monitors the quality of service provided. The list of the homes policies were forwarded as part of the pre inspection questionnaire. However review dates of the policies had not been included in the information. It is recommended that the manager supply the commission with a schedule of review for the organisation’s policies. The manager demonstrated knowledge of monitoring health and safety issues at the home. Staff are trained in first aid, moving and handling, and food hygiene. Responsibility for monitoring different areas of health and safety is delegated to the staff members. Staff members carry out these checks on a daily and weekly basis. They are recorded as part of the detailed handover sheet, which are checked off and signed on each shift. The organisation monitors the financial viability of the service. The manager is a budget holder. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 25 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 1 2 3 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 X 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 2 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
267 Old Shoreham Road Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 3 3 3 DS0000058271.V260301.R01.S.doc Version 5.0 Page 26 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 YA2 Regulation Requirement Timescale for action 04/11/05 2 YA5 3 YA6 4 YA23 4 YA33 5 YA39 14(1)(a)(2)(a)(b) The manager shall not provide accommodation to a person without a full assessment and that it is kept under review. (From previous inspection May 2005) 5(1)(c) It was required that the manager ensure each person has a contract with the home. 15(1) (2)(b) It was required that the manager ensure that the restrictive changes made to one person’s bedroom is recorded in the care plan and reviewed. 13(7)(8) It was required that the manager ensures that use of restraint in the home is in exceptional circumstances and adheres to guidelines. 18(1)(a) It was required that the manager produces a recruitment plan to employ permanent staff to the vacant posts. 24(1-3) It was required that the manager provides a quality
DS0000058271.V260301.R01.S.doc 31/01/06 04/11/05 04/11/05 31/12/05 31/01/06 267 Old Shoreham Road Version 5.0 Page 27 audit tool to demonstrate that the organisation and home monitors the quality of service provide. 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. 2. Refer to Standard YA16 YA40 Good Practice Recommendations The organisation forwards the report into restrictive practices to the Commission. The manager forwards the review schedule for the homes policies and procedures. 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 28 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 267 Old Shoreham Road DS0000058271.V260301.R01.S.doc Version 5.0 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
