Inspection on 20/04/07 for 34 and 36 Shaftesbury Road

This inspection was carried out on 20th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

34 and 36 Shaftesbury Road 06/11/06

34 and 36 Shaftesbury Road 01/11/05

34 and 36 Shaftesbury Road 29/06/05

34 and 36 Shaftesbury Road 16/12/04

34 and 36 Shaftesbury Road 15/06/04

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 34/36 Shaftesbury Road Southsea Hampshire PO5 3JR Lead Inspector Nick Morrison Unannounced Inspection 20th April 2007 10:00 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 34/36 Shaftesbury Road Address Southsea Hampshire PO5 3JR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 023 9229 4414 Southern Focus Trust Silvana David Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users may be accommodated between 18 - 60 years of age Date of last inspection 6th November 2006 Brief Description of the Service: 34-36 Shaftesbury Avenue is a care home registered for thirteen service users within the category of mental health. Southern Focus Trust owns the home and the manager is registered with the Commission. The home provides single room accommodation and on the ground and lower ground floors are kitchens, two lounges, and staff facilities, with bedrooms on the upper floors. To the front of the property is car parking space and to the rear is a garden accessible from the lower ground floor. The current fee scale is £57.66 per day with no additional charges except for a contribution of £10 per year towards the television licence. The building is only accessible by steps from the road and does not have a lift; access to all of the floors is via stairs. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report represents a review of all the evidence and information gathered about the service since the previous inspection. This included a site visit that occurred on 20th April 2007 and lasted six hours. During this time the Inspector toured the premises, looked at six service users’ files and met with three of those people. All records and relevant documentation referred to in the report was seen on the day of inspection. The Inspector spoke with the Deputy Manager, three members of staff and four service users. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 6 be made available in other formats on request. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having their needs assessed prior to moving into the home. EVIDENCE: There had been a recommendation from the previous report that the Service User Guide be updated and that copies are available for service users. The guide had been updated and copies were available to all service users on admission. There was a requirement from the previous inspection that people must not be admitted to the home until a full assessment had been completed and the manager was confident that the home could meet the person’s needs. This has now been met. Files for new service users were seen and each contained full assessments and clear decisions were made about whether or not the home could meet the identified needs. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from having clear individual plans and risk assessments in place, which are kept under regular review, and from support to take decisions and risks appropriate to their development. EVIDENCE: There had been a requirement from the previous inspection that care plans must record the needs, wishes and aspirations of service users. Examination of care plans showed that this requirement has now been met. There had also been a requirement from the previous inspection that care plans must show how individual risks are being managed. Files showed that there were now risk assessments in place that detailed risks and control measures and that they were kept under regular review. This requirement has now been met. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 10 Some service users’ files were difficult to read because there was a lot of old information in them and it was possible that some staff might read an old care plan thinking that it was the current one. It is recommended that service users’ files are re-organised and that old care plans are archived. All service users spoken with said they felt that they were able to make their own decisions and that staff supported them to do this rather than make decisions for them. Staff spoken with and observed during the inspection were clear about service users’ right to make their own decisions and were skilled in assisting them to focus on the decisions they needed to make on a day to day basis. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from support to take part in activities and to be part of the community. They have their rights recognised and are supported to maintain contact with their families and friends. They also benefit from having a healthy diet. EVIDENCE: There had been a requirement from the previous inspection that the home must demonstrate that the use of alcohol is regularly monitored and does not pose a potential risk to service users. The home has now put measures in place to monitor alcohol use as far as possible, in consultation with people who live in the home. This requirement has been met. Service user spoken to during the course of the inspection visit said they felt they had sufficient stimulation while living at the home. Some activities were 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 12 organised by staff, but most service users preferred to make their own arrangements. Staff did support service users in using the community and used the opportunity to go out on a one-to-one basis with people to discuss any particular needs they might have at that time. Service users were also supported to pursuer their own hobbies within the home such as painting and playing the guitar. Service users were supported to maintain contact with their families and staff made a point of keeping families informed about service users where they had requested this. There was a visiting policy in place which encouraged visitors between 10.00 am and 10.00 pm. Service users said they felt there were no unreasonable restrictions on them seeing families and friends. Service users said the food in the home was of good quality and they were able to contribute ideas for the menu on a regular basis. They said food was plentiful and that staff would always ensure they had enough to eat and were able to eat at times that were convenient to them. Regular monitoring checks were made on individual service users’ nutritional needs and special diets were catered for. Good records were kept of the food in the home. Service users were encouraged and supported to be involved in meal preparation if they wanted. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from receiving personal care in the way they prefer and from having their physical, emotional and medication needs met. EVIDENCE: There had been a requirement from the previous inspection that care plans must identify, record and review how the physical and mental health needs of service users are being met. Examination of the files showed that healthcare needs were regularly monitored and recorded. Steps had been taken to support service users to use healthcare services where necessary and records were kept. Service users spoken with confirmed that staff in the home were good at supporting them to monitor their own health and to use relevant healthcare services. This requirement has now been met. There had also been a requirement from the previous inspection that medication must be stored, recorded, dispensed and returned in accordance with the home’s policies and procedures. Examination of the policies and procedures, as well as the records and storage of medication, showed that 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 14 medication was currently being administered correctly within the home. Staff were aware of the correct procedures and records showed that there had been no errors. Service users spoken with did not have concerns about how their medication was managed. This requirement has now been met. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from having information on how to complain and are protected by the home’s adult protection policies and practices. EVIDENCE: Staff were sensitive to the rights of people living in the home and this was evident on the day of the inspection visit through discussions they had with each other and through the way they interacted with people using the service. The home has an abuse policy in place to ensure that service users are protected from any kind of abuse. There was also a very clear whistleblowing policy which staff were aware of. Staff had received training on identifying and responding to instances of suspected abuse and those spoken with were clear about the relevant issues and their responsibilities in this area. Service users spoken with felt that they were safe living in the home and that staff protected them from any kind of abuse. There was a clear complaints procedure in place that was written in a userfriendly way. All service users spoken with were clear about the complaints procedure and were clear what they would do if they felt the need to complain. They were also clear that, if their complaint was not dealt within the home, they could complain further. The home had a clear procedure in place for recording and responding to complaints, although none had been received since the previous inspection. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 16 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from the improvements currently being made to the building, but would benefit further from the home being cleaner. EVIDENCE: There had been a requirement from the previous inspection that the home must provide a plan of decoration and refurbishment that addresses the issues identified in the previous inspection report. A plan is in place and so the requirement has been met. The plan is currently being implemented and work was being undertaken on the day of the inspection visit. There had also been a requirement from the previous inspection that the damaged flooring in the shower be replaced. This has now been done and the requirement has been met. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 18 Some bathroom tiles were old and chipped and some of the grouting was very dirty. This could cause problems with infection control and a requirement has been made in respect of this. The general levels of cleanliness within the home were not entirely satisfactory. One service user spoken with commented on this, saying he thought the home ought to be cleaner. The main areas of concern were high level dusting and the cleanliness of the shared bathrooms. Observation of these areas confirmed that there had not been a lot of attention to detail when they had been cleaned. Care staff were spending large amounts of their time cleaning the home and this suggested that the cleaning hours for the home were insufficient. A requirement has been made that the cleaning hours be reviewed so that they are at a level that can maintain reasonable cleanliness in the home without the need for care staff to spend their time doing these tasks when they could be supporting people who live in the home instead. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by well trained staff and are protected by the home’s recruitment policies and practices. EVIDENCE: There had been a requirement from the previous inspection that the manager must provide evidence of a staff training plan in the home that meets the needs of service users. There was a clear plan in place and records demonstrated that staff had begun receiving training in accordance with the plan. Training events covered all mandatory training as well as specific training in areas such as physical intervention, personality and behavioural disorders, epilepsy, understanding schizophrenia and drugs awareness. This requirement has now been met. Staff spoken with during the inspection visit said they felt that the organisation’s training courses were good and that they had access to all the training they needed. They also said that there was some access to external courses from time to time. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 20 There had been a requirement from the previous inspection that the provider review staffing levels and demonstrate that sufficient numbers of experienced staff are on duty at all times to meet the needs of service users. This requirement has been met. The review took place and further staffing has been put in place. Significantly, there are extra management hours with the addition of a Deputy Manager. This has proved useful in ensuring that the requirements from the previous inspection had been addressed and in planning service developments for the future. There had been a further requirement from the previous inspection that the manager must provide evidence of POVA checks before new staff start working in the home and evidence of satisfactory CRB checks. Examination of staff recruitment records showed that the home can now demonstrate that all checks are made prior to employing new staff and that their recruitment practices protect service users. Staff spoken with confirmed they had necessary checks prior to beginning their employment. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a service that is responsive to their views and are protected by the home’s management of health and safety issues EVIDENCE: The manager is registered and has demonstrated that she has the skills, knowledge and experience to manage the service. The home is clearly run in the interests of service users and this was confirmed in discussion with people living in the home. The home has a development plan in place and this showed that development issues had been highlighted through a range of methods including direct and regular consultation with service users. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 22 All staff had received health and safety training and workplace risk assessments were in place and regularly reviewed. Staff spoken with said they knew about and understood these assessments. Records were kept to show that all equipment was regularly serviced. All accident and incident records were clear and the manager regularly monitored and reviewed these in order to look for patterns and plan to decrease future occurrence of these. Regular health and safety checks were made as part of the provider’s monthly assessment of the home. Fire records were kept up-to-date. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 24 No 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 YA30 Regulation 13 Requirement Timescale for action 30/07/07 2 YA30 13 The registered person must review the number of cleaning hours the home needs in order to maintain a satisfactory level of cleanliness Broken tiles and stained and 30/07/07 dirty grouting must be replaced 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 YA6 Good Practice Recommendations Service users’ care plans should be reorganised so that old care plans are not mistaken for current ones. 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 34/36 Shaftesbury Road DS0000011832.V334377.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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