CARE HOME ADULTS 18-65
34/36 Shaftesbury Road Southsea Portsmouth Hampshire PO5 3JR Lead Inspector
Lorraine Parton Unannounced Inspection 1st November 2005 01:00 34/36 Shaftesbury Road DS0000011832.V270148.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 34/36 Shaftesbury Road DS0000011832.V270148.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. 34/36 Shaftesbury Road DS0000011832.V270148.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 34/36 Shaftesbury Road Address Southsea Portsmouth Hampshire PO5 3JR 023 9229 4414 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 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places 34/36 Shaftesbury Road DS0000011832.V270148.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users may be accommodated between 18 - 60 years of age One service user over 65 may be accommodated until 1st December 2003 29th June 2005 Date of last inspection Brief Description of the Service: 34-36 Shaftesbury Avenue is a care home registered for thirteen service users within the category of mental health. One service user who has lived at the home for many years is over the age of 60. The home is managed by Southern Focus Trust and currently the home does not have a registered manager. The home provides single room accommodation and on the ground floors are kitchens, two lounges, and staff facilities. To the front of the property is car parking facilities and to the rear is a well maintained garden accessible from the ground floor. 34/36 Shaftesbury Road DS0000011832.V270148.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 3.0 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 14 standards and reassessed 5 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 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. Several of the service users since the last inspection, have become more stabilised and are now participating around their home and in activities of their choice in the community. These 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 excellent and that they are treated with respect. Service users confirmed that they are able to make their own decisions and that staff are available to discuss any concerns they may have. On auditing the home, this appears to be due to a more consistent approach to care planning and permanent staffing in the home. Staff advised the inspector that the home is more settled and issues raised are being addressed appropriately. All service users are supported in their chosen lifestyles and service users wishing to participate are given guidance on how to access their chosen 34/36 Shaftesbury Road DS0000011832.V270148.R01.S.doc Version 5.0 Page 6 activities if necessary. Staff support service users if they wish to access these service and say that its good when they go out with them, although this is dependent on staffing levels. 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. Service users confirmed that they like living in the home and that they are happy with the communal areas of the home and their bedrooms as they are able to have them has they wish. Several service users have brought their personal possessions into the lounge and advised the inspector that they are proud of their work on display. 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 remains 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. 34/36 Shaftesbury Road DS0000011832.V270148.R01.S.doc Version 5.0 Page 7 A requirement was made at the last inspection for Southern Focus Trust to submit an application for a registered manager and this remains outstanding. 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. 34/36 Shaftesbury Road DS0000011832.V270148.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 34/36 Shaftesbury Road DS0000011832.V270148.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 admission since the last inspection. The inspector was able to see the assessment that had been carried out by the homes staff, which had been incorporated into a initial care plan. The home had also undertaken risk assessments for the assessed needs, which 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. 34/36 Shaftesbury Road DS0000011832.V270148.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. 34/36 Shaftesbury Road DS0000011832.V270148.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 an 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. 34/36 Shaftesbury Road DS0000011832.V270148.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): 18,19 All service users are able to manage their own personal care themselves and with support of the homes staff. The health needs of the service users are being met, in consultation with other health care professions. 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 obtain their personal care when they wish and that the homes staff will support them if they require any assistance. One service user is currently experiencing difficulties due to illness and the homes staff support them in their personal care and lifestyle. The home has referred the service user to the older persons team and it is envisaged that alternative accommodation will be sought in the future in order to meet their changing needs. All personal care needs are documented in the service user plans. All staff spoken to were aware of service users choices of the preferred staff to support with personal care.
34/36 Shaftesbury Road DS0000011832.V270148.R01.S.doc Version 5.0 Page 13 All service users are registered with a general practitioner and therefore can access a wide range of healthcare professions when necessary, including mental health teams, consultants and dentists. 34/36 Shaftesbury Road DS0000011832.V270148.R01.S.doc Version 5.0 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): None EVIDENCE: Previous inspections indicate these standards have been met and therefore were not reassessed during the inspection. 34/36 Shaftesbury Road DS0000011832.V270148.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: Some areas of the home have been redecorated and refurnished since the last inspection. Service users and staff confirmed that service users had been involved in the selection of the furniture and colours of the new decoration. 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 them has 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
34/36 Shaftesbury Road DS0000011832.V270148.R01.S.doc Version 5.0 Page 16 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 review its staffing arrangements in accordance with service user needs and maintenance of the home. The inspector did not identify any issues with 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. 34/36 Shaftesbury Road DS0000011832.V270148.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): 32, 34, 35 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. The home had implemented recruitment practices that ensure nobody working at the home poses an obvious risk to service users. Service users are supported by staff who are aware of their roles and responsibilities and work has part of an effective team, however, at times the home does not have enough staff to support service users has they wish. EVIDENCE: The inspector had the opportunity to speak to three members of staff who all stated that they were aware of their roles and responsibilities. Staff advised the inspector that the homes acting manager supports their ideas and encourages their development in areas relating to the service they provide. The inspector found the staff to be motivated in their work and knowledgeable on service user needs. Service users described the staff as helpful and approachable. Staffing rota’s indicate that the home only has five full time and one part time member of staff covering 24 hours of care. The homes staff advised the
34/36 Shaftesbury Road DS0000011832.V270148.R01.S.doc Version 5.0 Page 18 inspector that they use agency staff to cover shortfalls in staffing levels. At the time of the inspection the home was being covered by two members of staff and an agency employee. The home covers the night time by a sleep in member of staff that is accessible to service users should they need support. 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 has they wish. This includes activities and for one service user who is being reintroduced back into his home. This is unacceptable. The requirement for the review of staff was made at the last inspection and this remains outstanding. A further requirement has been made. The inspector audited three staff files, which were found to contain all relevant information required. This included CRB and POVA, two references, identification and details of application and interviews. This had been a previous legal requirement. All staff files also 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 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. 34/36 Shaftesbury Road DS0000011832.V270148.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 provides a safe environment for service users to live, and this is supported by documentation. Service users live in a well run home that promotes independence and encourages self expression. 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 had not provided evidence of the financial management of the service. EVIDENCE: The home has undertaken a range of risk assessments and implemented suitable controls for any identified risks. The inspector audited all the homes certificates and insurances which were up to date and satisfactory. 34/36 Shaftesbury Road DS0000011832.V270148.R01.S.doc Version 5.0 Page 20 Service users confirmed that they are able to express their views openly and trust the staff to act on their concerns. Service users confirmed that they like living at the home and that they feel totally involved in the running of the home. The home holds monthly meeting with service users to discuss any difficulties they may be experiencing. These meetings are documented and did not display any major issues. At the last inspection the home has 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. 34/36 Shaftesbury Road DS0000011832.V270148.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 3 3 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 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
34/36 Shaftesbury Road Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 3 2 DS0000011832.V270148.R01.S.doc Version 5.0 Page 22 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 YA37 Regulation 8 Requirement Timescale for action 31/12/05 2 YA43 25(2) 3 YA33 18 4 YA39 35 Submit an application for a suitable registered manager. This remains outstanding from the last inspection. 31/12/05 Provide the CSCI with a copy of the companys accounts. This remains outstanding from the last inspection. 31/12/05 Review staffing levels in accordance with service user needs. This must include during the night and cleaning of the home. This remains outstanding from the last inspection. Ensure the views of service users 31/12/05 regarding the service being provided are addressed and incorporated into the management of the home. This remains outstanding from the last inspection. 34/36 Shaftesbury Road DS0000011832.V270148.R01.S.doc 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 34/36 Shaftesbury Road DS0000011832.V270148.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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