CARE HOME ADULTS 18-65
29 Shaftesbury Road Southsea Portsmouth Hampshire PO5 3JP Lead Inspector
Lorraine Parton Unannounced Inspection 1st November 2005 09:00 29 Shaftesbury Road DS0000011831.V270147.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 29 Shaftesbury Road DS0000011831.V270147.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. 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 29 Shaftesbury Road Address Southsea Portsmouth Hampshire PO5 3JP 02392 754771 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) Southern Focus Trust Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to be admitted between 18-55 years Date of last inspection 29th June 2005 Brief Description of the Service: 29 Shaftesbury provides accommodation for eight service users within the category of mental health. The home is managed by Southern Focus Trust and currently the home does not have a registered manager. The home provides staff during the day and in the event of an emergency can access the staff at 34 Shaftesbury Road out of these hours. Service users living at the home need minimum of supervision and support. The home provides accommodation in single bedrooms situated over three floors and the home has two lounges, a kitchen and dining room. To the front of the property is car parking facilities and to the rear is a small courtyard garden that is maintained by the service users. The home is situated close to local facilities and is a short journey away from the city of Portsmouth. 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The second inspection of the inspection year took place over 2.5 hours and the purpose was to ensure compliance with the legal requirements brought to the homes attention at the first inspection in June 05 and to complete the inspection process for the year. The inspector audited 12 standards and reassessed 4 standards, in which the inspector had raised requirements at the last inspection. All key standards have now been assessed throughout the year. The inspector recommends that the reader also looks at the previous inspection report to ensure that they get a total overview of the home. The inspection involved a walk around the home and an audit of some of the homes documentation. The inspector was assisted by the homes staff and the service users living at the home. The majority of the inspection was spent talking to the service users who confirmed that they liked living in the home and that the homes staff are generally supportive of their needs. Several service users advised the inspector of their involvement in the home and their participation in a range of activities of their choice. What the service does well:
Several service users advised the inspector of the range of activities that they are participating in and their development towards an independent lifestyle. Service users spoke very positively about the service they receive and the support given by the homes staff. On observation of the interactions between the homes staff and the service users these were seen to be positive and with total equality. Service users confirmed that the staff are very good and that they are treated with respect. All service users are supported in their chosen lifestyles and service users wishing to participate are given guidance on how to access their chosen activities if necessary. Staff support service users if they wish to access these services. Service users advised the inspector that they are able to go out when they wish and to venues of their choice. Staff at the home are extensively trained in areas specific to the identified needs of the service users and Southern Focus Trust are committed to ensuring the homes staff are offered training and development. The home is currently supporting one service user who is ill, which was documented. The home has involved all relevant health care professionals to assist and support the service user with their management of their illness.
29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
Several of the requirements brought to the homes attention in the inspection in June 05 remain outstanding and this includes acting on the views of the service users and other stakeholders of the business, reviewing staffing arrangements in the home, and providing the inspector with a copy of the companies accounts. Currently the home does not have a registered manager and has not had one since January 05. The area manager has been overseeing the home, however, they have now left the service. The inspector was advised that a new manager had been highlighted and is due to start overseeing the home in the near future. A requirement was made at the last inspection for Southern Focus Trust to submit an application for a registered manager and this remains outstanding. Service users raised two concerns during the inspection, which included hot water and issues relating to living in the home. The service users advised the inspector that the hot water is too hot and that they were unable to have a shower and wash their hands. The home is required to undertake risk assessments for this risk of scalding and implement suitable controls to prevent the risk of service users scalding themselves whilst having a shower or washing their hands. One service user advised the inspector that whilst they liked living in their home they wanted to leave because they do not feel able to enjoy their home due the dynamics of another service user living in the home. On speaking to staff the inspector was advised that other service users have commented to staff on the same issues raised with the inspector. The home is to review and act upon the issues raised by service users. 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 7 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. 29 Shaftesbury Road DS0000011831.V270147.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 29 Shaftesbury Road DS0000011831.V270147.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 Prospective service users aspirations and needs are assessed by the home. EVIDENCE: The home has had one new transfer admission since the last inspection. The inspector was able to see the initial assessment that had been carried out by the homes staff, which had been incorporated into the care plan. The home had also undertaken risk assessments for the assessed needs, and both the care plan and risk assessments had been done in agreement with the service user. Staff advised the inspector that the prospective service user had visited the home on several occasions prior to agreeing to move in. 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 10 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): None EVIDENCE: Previous inspections indicate these standards have been met and therefore were not reassessed during the inspection. 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The home supports service users to maintain a healthy diet. EVIDENCE: Several service users manage their own money for food and as such shop, prepare and cook their own meals. Some service users are unable to manage this and the homes staff support service users in this. Staff prepare and cook meals which is usually done with the assistance of the service users if they wish on the day. Staff advised the inspector that they encourage service users where possible to look at health diets. The home has systems in place to monitor service users they are concerned about and will implement suitable care plans if necessary. Several service users advised the inspector that they choose what they want to eat and that the home supports them when necessary. Previous inspections indicate the remaining standards have been met and therefore were not reassessed during the inspection. 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 All service users are able to manage their own personal care themselves and with support of the homes staff. EVIDENCE: All service users are able to manage their own personal care themselves and this is clearly documented in the service user plans. Service users confirmed that they are able to carry out their personal care when they wish. One service user is currently experiencing difficulties due to a serious illness and the homes staff support them in their personal care and lifestyle. The home has referred the service user to the appropriate health care teams. The service user is receiving all relevant support and this was clearly documented including the service users wishes. 29 Shaftesbury Road DS0000011831.V270147.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): None EVIDENCE: Previous inspections indicate these standards have been met and therefore were not reassessed during the inspection. Two concerns/complaints were raised by the service users during the inspection. One of these complaints raised was that the hot water system had not been addressed despite service users requesting that the hot water is controlled so that they can have a shower and wash their hands without the risk of being scalded. Service users raised this concern with the home and with the inspector prior to the inspection. The home had been contacted and assurances had been made that this would be dealt with. On inspection service users advised the inspector that this had been looked at but not acted upon. The inspector contacted Southern Focus Trust who acted upon the immediate requirement being made. Thermostatic valves were later fitted and this was confirmed in writing. On speaking to service users one service user raised concerns that they were unable to enjoy their home due to the interference of another service user. The service user advised the inspector that they wanted to leave despite the fact that they liked living in the home. On speaking to the staff present during the inspection they confirmed that other service users also had raised the same concerns. This was discussed with the acting manager and the area manager, who advised the inspector that the situation would be reviewed. A requirement has been made.
29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 14 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 30 The home was clean, homely and provides a safe environment, which is supported by documentation. Service user bedrooms are decorated and furnished to reflect individual needs and choices. EVIDENCE: The home is homely in appearance and service users advised the inspector that they like their home and the way that they have chosen to have their rooms. Two service users showed the inspector their rooms, which the service users advised the inspector they furnished as they choose. Rooms were found to include personal possessions that reflected their chosen lifestyles, interests and hobbies. The home was found to be clean and free from odours. Staff advised the inspector that they only have a cleaner for two days per week and the rest of the time they undertake the cleaning role with service users if they wish to. Staff advised the inspector that usually service users do not wish to be involved and therefore the cleaning usually relies on them. The home is to
29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 16 review its staffing arrangements in accordance to service user needs and maintenance of the service. Service users raised concerns about the hot water in the home and stated that they did not have a shower because the water is too hot and that when they wash their hands this also at times is too hot. The home is required to undertake risk assessments and implement suitable controls. An immediate requirement was made. No further issues were identified in the environment that would pose a risk to service users. The home has completed a range of risk assessments, which covered all identified risks and has implemented suitable controls for the identified risks. The inspector audited the homes certificates and found these to be satisfactory. 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 17 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): 33, 35 The home does not have adequate staff on duty to meet the assessed needs of service users. All staff have received training and new staff have undergone a thorough induction programme based on the identified needs of the service users living at the home. EVIDENCE: The inspector had the opportunity to speak to two members of staff. The inspector was advised that staffing levels are at times short and that much of the time is spent cleaning and due to low numbers cannot always support service users as they wish. The requirement for the review of staff was made at the last inspection and this remains outstanding. A further requirement has been made. All staff files contained the training the staff had undertaken. Some staff have completed the NVQ 2 training and several staff are booked on the NVQ training this year. Southern Focus Trust are committed to staff training and as such provide a wide range of training courses for staff to attend. This includes moving and handling, COSHH, basic food hygiene, health and safety, first aid both the one day and four day course, medication, fire, adult protection and
29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 18 epilepsy, which have all been carried out this year. All new staff employed have received an in depth induction programme based on TOPSS and attend a one day company induction day. 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 19 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, 39, 42, 43 The home generally provides a safe environment for service users to live, and this is supported by documentation. The home has no controls for the risk of preventing scalding from hot water. Service users live in a home that promotes independence and encourages self expression, though there remains no registered manager in place. The home has sought the views of service users and other stake holders of the home about the service it provides, however, as of yet have not acted on their views. The home has not provided evidence of the financial management of the service. EVIDENCE: 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 20 The home has undertaken a range of risk assessments and implemented suitable controls for any identified risks, except for hot water controls. A requirement has been made. The inspector audited all the homes certificates and insurances, which were up to date and satisfactory. Service users confirmed that they are able to express their views openly. One service user raised concerns about another service user who affected his enjoyment of his home. On speaking to staff it was confirmed that several service users had raised the same concerns. On discussions with the homes staff and acting manager it appeared these concerns had not been acted upon. At the last inspection the home had sought the views of the service users and stakeholders of the business, which identified that some of the views were negative about the service. The inspector was informed that these issues raised would be discussed at the next staff meeting and that Southern Focus Trust training and development unit is looking at staff training needs and a way forward for the home to act on the concerns raised. On auditing the requirement made by the inspector at the last inspection it appeared that the home had not undertaken this and had not acted on the views of the service users or other stakeholders of the business. This remains outstanding and a further requirement has been made. At the last inspection the inspector required a copy of their company accounts. This remains outstanding and a further legal requirement has been made. 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 21 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 X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
29 Shaftesbury Road Score 3 X X X Standard No 37 38 39 40 41 42 43 Score 2 X 1 X X 2 2 DS0000011831.V270147.R01.S.doc Version 5.0 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA33 Regulation 18 Requirement Review staffing levels. Cleaning hours must be additional to care hours. This remains outstanding from the last inspection. Ensure the views of service users regarding the service being provided are addressed and incorporated into the management of the home. This remains outstanding from the last inspection. Provide the CSCI with a copy of the companys accounts. This remains outstanding from the last inspection. Submit an application for a suitable registered manager. This remains outstanding from the last inspection. Undertake risk assessments and implement suitable controls for the risk of scalding in the home. Review the concerns of service users raised during the inspection relating to other service users affecting their enjoyment of their home, and take appropriate action to address their concerns.
DS0000011831.V270147.R01.S.doc Timescale for action 31/01/06 2. YA39 35 31/01/06 3. YA43 25(2) 31/01/06 4. YA37 8 31/01/06 5 6 YA42 YA39 13 35 31/12/05 31/01/06 29 Shaftesbury Road Version 5.0 Page 23 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 29 Shaftesbury Road DS0000011831.V270147.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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