Inspection on 13/01/06 for 32 Kentish Road

This inspection was carried out on 13th January 2006.

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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

32 Kentish Road 08/05/07

32 Kentish Road 30/01/07

32 Kentish Road 29/09/05

32 Kentish Road 28/02/05

32 Kentish Road 03/01/05

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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 32 Kentish Road Freemantle Southampton Hampshire SO15 3GX Lead Inspector Christine Hemmens Unannounced Inspection 13th January 2006 2:00 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 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 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 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. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 32 Kentish Road Address Freemantle Southampton Hampshire SO15 3GX 023 80 701227 023 80 772007 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) Southampton City Council Mrs Nicola Jane Ward Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th September 2005 Brief Description of the Service: 32 Kentish Road is a Local Authority Home provided by Southampton City Council. The home offers respite care to seven younger adults who have learning disabilities and associated physical disabilities. The home recently opened following a major refurbishment. Improvements have been made to the environment and two rooms situated on the ground floor now provide on suite facilities to accommodate service users with physical disabilities associated with their learning disability. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to be undertaken within a twelvemonth period. The purpose of the visit was to review the four requirements issued following the last visit in September 2005 and to review the standards in relation to service users opportunities to make choices, form relationships, their daily routine whilst staying at the service, medication, staffing, quality assurance and health and safety. Two senior practitioners assisted the inspector, both were very helpful and appeared knowledgeable of the systems and ethos of the service. Unfortunately the inspector did not have an opportunity to seek the views of service users due to the complex communication needs of the service user in accommodated at the time of the visit. What the service does well: What has improved since the last inspection? What they could do better: The home has been issued with six requirements following this visit to the home these reflect mainly the poor practice in appropriate documentation and recording of important information. The inspector spoke with senior staff at 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 6 length and they were able to confirm and provide information to demonstrate they understood the importance of appropriate recording. The staff were aware of the importance of undertaking risk assessments, however had failed to record all risks associated with some service users and to regularly review the information. The staff were aware of the importance of appropriately signing for medication administered, however there was evidence to suggest that this did not always happen. The staff must also receive specific training on administering eye drops and be provided with information that will assist them to make a decision when “as required medications” must be given. From discussion the staff appeared aware of the importance of undertaking regular checks on the home fire fighting equipment and fire alarms however evidence suggested that regular checks had not been consistently undertaken for a number of months. The service provides a clean environment for service users to stay, however the staff must seek advice on how to correctly clean up blood spillages to prevent the risk of cross infection. The staff are aware of the importance of seeking the views of the service users and their families to continue to improve the quality of the service, however the service fails to adopt a systematic approach in order to monitor standards. 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. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 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 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 – 5 were not viewed on this occasion, please refer to inspection report dated 29th September 2005 to establish the outcome for services users under key standard 2, “prospective service users’ individual aspirations and needs are assessed”. EVIDENCE: 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 The service does well to support the service users to make decisions about their lives and provide assistance where required. The service does well to identify individual risks to service users, however associated risks must be included and all risk assessments must be regularly reviewed. EVIDENCE: The two senior care practitioners demonstrated good values and understanding of the rights of the services users. They spoke of the importance of ensuring the service users are provided with the right support to make choices, promote and maintain their independence and undertake activities of their choice. This was further demonstrated through care plans and observation made by the inspector of staff interacting and providing support to a service user at the time of the visit. The inspector viewed three service users’ plans in respect of risk assessments, the inspector observed that the home has adopted good documentation in identifying, recording and advising staff how they can minimise the risk to the service users, however the home must ensure where there are further 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 10 identified risks such as the risk of falls associated to a specific disability then the home must provide guidance for staff on how they can minimise those risks as well. The inspector was informed that where there are specific identified risks associated to service users’ behaviour, illness, and learning disability the home will work with the family and health care professionals. However to ensure the service users are kept safe as far as feasibly possible at all times the service must undertake regular recorded reviews of their risk assessments. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 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): 16 The service supports service users to maintain and develop relationships. The service does well to respect service users as individuals with the right to take responsibilities and make choices about their daily lives. EVIDENCE: The inspectors spoke at length with the senior care practitioners regarding relationships between service users, staff and relatives. The service at all times needs to consider the compatibility and associated risks of the service users, their wishes and those of their relatives when providing them with respite care. The senior carers informed the inspector that they are aware of who gets on with whom, who could cause a potential risk to another and books their stays accordingly. The inspector talked at length with the senior carers regarding their views on service users building sexual relationships. They both agreed that this was a very sensitive area and would have to be sure it was a consenting relationship and seek advise from specialist health care teams regarding keeping them safe. Both carers showed a sensitive cautious approach to the subject, however were aware of the rights of the service users but the potential risk of conflict this could cause with others. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 12 The senior carers also demonstrated a good understanding of the value of respect and providing service users with the appropriate support to express their individualism. Care plans describe how the service user wishes to spend their day and a weekly activity plan is available to inform staff of the specific activities the service users are involved in whilst they stay at Kentish Road. The members of staff informed the inspector that the weekly plan was a guide and if the service user did not wish to undertake the specific activity scheduled for that day they would be offered an alternative activity. The inspector was informed that care staff will ring in advance of the service user coming to stay to establish if they have anything planned for the days or weeks they will be staying. The service offers a range of activities for the service users such as the cinema, pub lunch, drives in the forest and in house activities such as pool or relaxing in front of the television watching DVD’s or listening to music. Service users can bring in their own activities if they wish. Service users are encouraged to do as much for themselves as they can and the carers will support them to maintain daily living skills such as cleaning, cooking, making their bed etc, however this is not enforced if the service users chooses not to. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The service demonstrates good practice in some areas of its policies and procedures in administration of medication, however steps must be taken to safe guard service users from the potential risk of harm. EVIDENCE: The service does not hold stock medication as each service users brings in their own medication on arrival to the home. The home undertakes a robust procedure in checking the medication, ensuring that it is the right medication, has clear directions on the packaging and the correct number of tablets have been supplied for the service users stay. The inspector was informed that this is undertaken by two members of staff or the primary carer. This is seen as good practice. However a number of discrepancies were found such as medication not being signed for or a reason for omission. The service does not have care plans in place for “as required medications” PRN, including topical lotions and creams and training has not been undertaken in the administration of eye drops. The manager must ensure all staff receive training in the administration of eye drops, that staff record at all times when medications have been administered or provide a reason why it has been omitted and each service user has clear guidelines in place in order to provide guidance for staff when an “As required medication “ is needed. The home is advised to work in conjunction with the specialist health care team when drawing up PRN guidance in respect of anticonvulsant and antipsychotic medications. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 14 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): Standards 22 and 23 were not viewed on this occasion, please refer to inspection report dated 29th September 2005 to establish the outcome for services users under key standard 2, “prospective service users’ individual aspirations and needs are assessed”. EVIDENCE: 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 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): 27, 30 The service provides adequate facilities to provide options for service users to choose where and how they wish to bathe. The service provides a clean and welcoming environment for service users to stay, however measures must be taken to minimise the risk of cross infection. EVIDENCE: The service has adequate bathing and showering facilities to provide service users with options to choose if they wish to bathe or shower. Each bedroom has a wash hand basin and two bedrooms have en suite facilities for service user who require support with their physical and personal needs. The requirement to replace the shower basin in the first floor bathroom remains unmet, however the inspector was informed that the shower was currently out of action and waiting repair, the inspector was informed that this does not prevent service users from meeting their personal hygiene needs. The requirement to replace the shower basin remains and will be reviewed during the next visit to the home. The inspector was informed that support services staff are responsible for cleaning the home, however arrangements have been made to employ a part time cleaner. The senior carers informed the inspector that they thoroughly clean all bathrooms, toilets and the rooms occupied following use. Service 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 16 users are encouraged to assist to clean and keep their rooms tidy during their stay, however this is not enforced if they choose not to. On the day of the visit all communal areas were found to be clean and tidy. However the laundry room was in need of tidying and cleaning. The home has adequate facilities for laundering clothing and linen including soiled laundry. The service takes advice from the service users’ primary carers regarding the washing of their personal clothing. The service is advised to speak with the appropriate authority on blood spillage kits in order to deal with blood spillages quickly and efficiently. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 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 The service ensures the service users are supported by an effective staff team. EVIDENCE: The service continues to run with a small number of staff vacancies, however the manager deploys her staff to ensure that there are adequate numbers and skilled members of staff to support the service users in day-to-day activities. Staff are deployed at times when they are mostly needed and the rota is adjusted to meet the needs of the service users such as support with personal needs, mobility or complex needs that challenge staffs understanding and resources. The inspector was informed that the manager was to undertake interviews for three staff at the end of January 2006 and the part time cleaner was due to start very soon. The services staffing levels will be routinely reviewed during the next visit to the home. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 18 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): 39 and 42 The service has documentation to seek the views of the service users and their relatives, however a more systematic approach is required to ensure views and comments are acted upon. The service attempts to as far as feasibly possible protect service users and staff from risk of harm. However the service must ensure regular checks are made on the home’s fire systems to safe guard service users and staff from the risk of harm from fire. EVIDENCE: The inspector regularly receives a regulation 26 notice from the responsible individual for Kentish Road. It is a report that is sent to the Commission for Social Care Inspection detailing the outcome of the standard of care at the time of the visit with actions detailing what the manager must do to improve the service. The report includes the views and comments made by service users and staff. This is good evidence that the service takes seriously its obligations to ensure a good standard of care and support is provided and 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 19 demonstrates that it is attempting to improve standards. The home had good documentation for the service users, known as, “How did your stay go”, this has been produced in an accessible format. The senior carers informed the inspector that they did not offer them to the service users on every visit as many of them stay regularly. However there was no evidence of how the service monitors how often the questionnaires are completed and action taken to address any views or concerns made by the service user. Therefore the home is required to adopt a system where by a systematic approach to seeking the views of the service users is undertaken and recorded and an annual report is sent to the Commission for Social Care Inspection detailing any actions to further develop and improve standards. The service is regularly maintained and inspected by Southampton City Council’s maintenance department. The inspector was informed that the workmen undertake regular checks on the buildings utilities including fire systems and appliances. However at the time of the visit the inspector could not check records, as they were locked away in the boiler house. The senior staff informed the inspector that the manager had being trying to obtain a key in order that records could be available at all times for inspection. However the inspected did view records of fire equipment checks undertaken by the staff. The inspector found records to be incomplete and demonstrate that regular checks were not being undertaken. The manager must ensure that designated members of staff are aware of the risks of not undertaken regular checks. The inspector viewed evidence of regular training and designated members of staff taking annual fire marshal training with the Local Fire and Rescue Service. The requirement issued following the last visit to seek advice on appropriate door closures for bedrooms has been undertaken, however the home is currently waiting for notification when the door closures will be installed. This will be reviewed during the next visit to the home. A senior member of staff informed the inspector that she was responsible for the homes health and safety. The staff member keeps very good records on all COSHH substances used in the service and makes sure they are securely locked away. The member of staff informed the inspector that routine maintenance and hazards are quickly responded to by maintenance staff. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 20 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 2 X X 1 X 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 YA9 Regulation Requirement Timescale for action 28/02/06 13(4)(a)(b)(c) The registered manager must ensure all identified risks including associated risk are recorded and regularly reviewed. This requirement has been in part repeated. A further failure to comply will result in further action being taken. 2 YA20 13(2) The registered manager must ensure all staff responsible for administering medication are trained in the safe administration of eye drops. The registered manager must ensure all service users receiving “As required” medications have care plans in place detailing how and when to administer. The registered manager must ensure staff sign when medication has been given or indicate the reason for omission. DS0000039603.V253257.R01.S.doc 31/03/06 3 YA20 13(2) 28/02/06 4 YA20 13(2) 31/01/06 32 Kentish Road Version 5.1 Page 22 2. YA27 23(2)(j) The registered manager must replace the shower basin situated in the upstairs bathroom. The registered manager must seek advice from the appropriate authority on how to minimise the risk of cross infection from blood spillages. The registered manager must adopt a recorded systematic approach to seeking the views of the service users. The registered manager must send a copy of the outcome of the quality audit to the Commission for Social Care Inspection. The registered manager must ensure regular recorded checks are undertaken on the services fire detectors and fire fighting equipment. A visual check of the detectors and equipment must be undertaken by the given date. The registered manager must have access to all records held in respect of the homes maintenance and servicing. 31/03/06 3. YA30 23(5) 16(2)(j) 31/01/06 4. YA39 24(1)(a)(b) 24(3) 01/04/06 5. YA31 24(2) 30/04/06 6 YA42 23(4)(c)(i) (v) 06/02/06 7 YA42 17 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA30 Good Practice Recommendations The registered manager is advised to put together a blood DS0000039603.V253257.R01.S.doc Version 5.1 Page 23 32 Kentish Road spillage kit after seeking advice form the appropriate authority on what is required. 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 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 © 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 32 Kentish Road DS0000039603.V253257.R01.S.doc Version 5.1 Page 25 - 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!