Inspection on 06/11/06 for 34 and 36 Shaftesbury Road

This inspection was carried out on 6th November 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

34 and 36 Shaftesbury Road 20/04/07

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 Shaftsbury Road Southsea Portsmouth Hampshire PO5 3JR Lead Inspector Annie Kentfield Unannounced Inspection 6 November 2006 10:30 th 34/36 Shaftsbury Road DS0000011832.V310249.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 Shaftsbury Road DS0000011832.V310249.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 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 34/36 Shaftsbury 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 Shaftsbury Road DS0000011832.V310249.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 1st November 2005 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 new manager has recently become 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 £56.14 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 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In order to make an overall judgement on the quality of this service evidence was gathered from a number of sources. Comment cards were sent to service users, GP’s, relatives, and mental health practitioners in the community services. Information was also requested from the manager in the form of a ‘pre-inspection questionnaire’. The unannounced visit to the home included discussion with service users, staff and manager, a tour of the premises, and inspection of some of the home’s records. 8 comments cards were received from service users and generally they said they were satisfied. 3 comment cards were received from relatives and one person was satisfied overall with the care provided, one person was not satisfied and made a number of comments, and one person said they were sometimes happy with the care provided to their relative but overall their satisfaction was “mixed”. 5 comment cards from mental health practitioners expressed a number of concerns about the level of care provided and 4 comments specifically stated that they had concerns about the level of alcohol use in the home and the affect on service users’ mental health. What the service does well: What has improved since the last inspection? What they could do better: There are a number of improvements required, to both the practice in the home, and to the home’s recording keeping. In addition, improvements are needed to the home environment to ensure this is safe and comfortable for the service users. 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 6 Service users should not be admitted to the home until an assessment of their care has been carried out and the manager is confident that there are sufficient numbers of experienced staff to meet the assessed needs. Care plans must be developed to demonstrate how the home is meeting all physical, mental and social care needs and systems need to be in place to monitor service user development plans. Systems for the safe administration of medication must be reviewed and staff given clear guidelines in the home’s medication policy and procedures. The manager must ensure that staff training in medication is sufficient in content to meet policy, procedures and regulatory requirements. Systems to monitor the use of alcohol in the home should be introduced in response to concerns expressed by visiting professionals about the affect alcohol use has on the mental health of service users. Staffing levels must be reviewed, particularly at night when there is one member of staff on duty to support two homes. Staff training and development should be planned to ensure that staff have the specific skills and knowledge to meet the home’s statement of purpose and service users’ needs. Improvements are needed to the general environment and specific repairs have been highlighted as well as a requirement for an overall plan for decoration and refurbishment. 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 Shaftsbury Road DS0000011832.V310249.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 Shaftsbury Road DS0000011832.V310249.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all of the service users felt that they had enough information about the home before moving in. Although there is an assessment process for identifying the needs of service users there are some inconsistencies and the manager must demonstrate that the home can meet the needs of service users, before they move into the home. EVIDENCE: In the written comment cards some service users said they had enough information about the home and others said they didn’t. The recent quality audit made the same conclusion. However, this is an issue that the manager plans to address. The home has a comprehensive assessment process to gather all the relevant information about prospective service users and their individual needs. In the two care files looked at; one assessment clearly identified individual care needs and relevant information had been received from other professionals involved in the care of the service user, before the service user was admitted to the home, and the assessment had been discussed and agreed with the service user, and signed. In this case, the manager had made sure that the individual 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 9 care needs of the service user could be properly met before the service user was admitted. However, in another assessment, the process had not been completed before the service user moved into the home and there was no evidence that the assessment had been discussed and agreed with the service user and there was no signature. Where an assessment identifies complex care needs the manager needs to ensure that there are sufficient staff on duty at all times to meet those needs. A requirement to review staffing levels has been made over the last two inspections and there is no evidence to demonstrate that this had been met. In addition, comments from health and social care professionals and relatives indicate that there are concerns about the level of care provided by the home and not enough experienced staff on duty at all times to meet the needs of the service users. Some comments also indicated that the home does not communicate clearly and work in partnership with the community mental health services, and “there is not always a senior member of staff on duty to confer with”. These comments were discussed, in general terms, with the manager, during the inspection visit. Following the outcome of the quality audit earlier in 2006, the manager stated that she considers joint working with professionals involved in the care and support of service users, to be crucial, and wants to put into place ways of improving communication. 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 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): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is evident from comments from service users that they are involved in some of the decision making about what they do each day, and staff provide assistance and support, but this needs to be developed. The involvement of service users in their care plan and review of the plan is variable. EVIDENCE: Comments from service users and inspection of some of the records show that the home has a commitment to involving service users in their plan of care and to supporting service users in their daily living and social activities. However, this must be developed to fully include all service users and for care plans to include all goals, aspirations and choices of daily activity, identified with the individual service user and their key worker. There is evidence of risk assessments in place but not all of these were discussed with the individual service user, and in one case, the risk assessment had no management plan, care plan, or evidence of service user 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 11 involvement in the process. Service users who have had a cooking assessment are able to purchase, prepare and cook their own meals. However, this approach to developing independent living skills could be also be recorded for all areas of identified skills development and how these are being achieved. Service users said they were able to come and go in the home as they chose to. The manager plans to introduce an in/out board by the front door so that staff know who is in or out as a fire safety procedure, but this has yet to be implemented. Service users are supported by staff to keep their bedrooms clean and tidy, and the kitchen clean and tidy but there was no evidence of how this is organised on a regular basis. The manager is keen to encourage service users to meet regularly to discuss daily activities in the home and these meetings take place from time to time. Service users were recently involved in choosing the colour of the decoration of the upstairs living room. 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally, the comments from service users showed that the lifestyle of the home was satisfactory and they were happy there. Concerns were expressed by a number of professional visitors, and relatives, that there is a “culture of alcohol” in the home and that this is affecting the general well being of all the service users. EVIDENCE: Staff are approachable and flexible and clearly supportive of the service users’ individual needs and choices but this needs to be reflected in a more structured approach with clear guidance on how service users are consulted and listened to and how they are supported in their personal development. Staff know the service users well and it was evident that staff spend as much time as they can listening and talking with the service users. Staff are clear about issues of privacy and confidentiality. Many of the service users are very 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 13 independent and during the visit were seen to be following their own activities, making visits to friends and relatives, or going shopping. Service users are able to arrange their own bedrooms how they choose and privacy is respected in the home. There are two sitting rooms and a dining room and service users have a garden they can use so there is a good choice of communal space. Visitors are welcome in the home and a notice by the door recommends that visitors call between 10 am and 10pm. The manager and staff actively encourage personal creativity and the manager has been involved in producing a book that celebrates the many skills that service users have in writing and painting. It is evident that the home encourages and promotes individual independence and the right to live in a flexible environment but there is no evidence that there are systems in place for checking practice or recording how service users achieve their goals and aspirations for developing independent living skills. Some of the service users receive a weekly allowance from Southern Focus Trust so that they purchase and prepare their own meals and the home has two kitchens, one for the sole use of service users who cook for themselves. Otherwise meals are prepared by staff with assistance from service users and there is no set menu, service users can choose daily. The flexible and independent lifestyle that service users experience needs to be balanced with the concerns that were received before the inspection visit. 8 comment cards were received from health and social care professionals and relatives, and of these, 5 expressed concerns about the use of alcohol in the home and the affect on service users mental health. In discussion with the manager, it was evident that the home’s policies and procedures allow moderate use of alcohol, but only in individual bedrooms and not in the communal rooms. One visitor felt that there are no “necessary boundaries” in the home and there was no evidence that the use of alcohol is regularly monitored or reviewed. General discussion with staff and service users indicated that sometimes there are incidents in the home involving service users and there have been incidents of verbal aggression but there has only been one incident reported to the Commission. The manager was reminded that all significant incidents involving the safety and welfare of service users must be reported to the Commission under Regulation 37 of the Care Homes Regulations 2001. 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 14 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 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It is evident that consideration is given to providing personal support to service users in a way that respects their privacy and dignity. However, there are conflicting views about how effectively the home is meeting service users’ physical and mental health care needs. The management of service users’ medication must be reviewed and systems put into place that properly record how medicines are recorded and dispensed or returned. EVIDENCE: Generally service users are consulted about how and when they need personal support or prompting and in some cases there are clear guidelines on the care that is being provided. This appears to be inconsistent and several comments from professional visitors and relatives indicate that they are not satisfied overall with the care provided. One person commented that staff do not have clear guidelines on how they monitor service users’ mental health and that referrals for specialist support are not always made appropriately, and that there is no agreed information for staff on relapse triggers or behaviour indicators that may indicate a service user becoming unwell. These must be recorded in individual care plans. The home’s policies and procedures need to include specific policies on dealing with emergencies and crises, dealing with 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 15 admissions to hospital under the Mental Health Act 1983 and a copy of the Mental Health Act Code of Practice should be available to staff. Although it is evident that care plans are reviewed monthly with each service user and their key worker, there is no evidence of how health care needs are regularly monitored and reviewed to ensure that service users have access to dentists, opticians, eye tests etc or that physical health care needs are being reviewed and met. Some of the care plans include evidence of care reviews as part of the Care Programme Approach (CPA) but not all of the care plans contain clear information for staff about whether service users are subject to parts of the Mental Health Act or are subject to CPA. The home has some good systems in place for supporting service users to manage their own medication where this is has been agreed in the assessment but there are errors and omissions in the recording of medication and gaps in the medication administration records. The storage cabinet for medicines is not large enough and some medication was being stored in the controlled drugs cabinet. Some medication was not properly labelled and staff were not clear what it was or who it belonged to. There were old medicines in the cupboard that should have been recorded and returned to the pharmacy and it was evident that there are no clear policies and procedures for staff on how to record medication or how to ensure that all unused medication is returned, or that practice is regularly monitored. Immediately following the inspection a letter was sent to the Southern Focus Trust with a number of requirements, including medication, and the trust has made a prompt response with an action plan to address these concerns. 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All of the service users except one said they were aware of the home’s complaints procedure and everyone said they would know who to talk to if they had any concerns. The manager and staff are aware of the policies and procedures to follow if they have any concerns about the potential or actual risk of harm or abuse to service users in the home. EVIDENCE: The home has a complaints procedure and copies were seen in service user files. There is also a copy on the notice board in the hallway, although this needs to be updated to reflect that the home is now registered with the Commission for Social Care Inspection (rather than the National Care Standards Commission). The home’s annual audit also checks whether service users are aware of the complaint procedure. The manager and staff are aware of the need to ensure the safety of the service users and follow the home’s policy and procedure for reporting concerns to the local authority to be investigated. Staff confirmed that awareness of adult protection is part of their ongoing training programme. 34/36 Shaftsbury Road DS0000011832.V310249.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home environment meets the needs of the service users in that there is sufficient space, the home is clean, and all bedrooms are single occupancy, but some areas of the home look old and worn and there is no planned programme for decoration or refurbishment. Of particular concern for the safety of the service users is the excessively hot water in sinks, baths and wash-hand basins. The home would not be suitable for any service users who are not independently mobile. EVIDENCE: The home employs a cleaner for 13 hours per week, however, the home is a large period property and there are four floors. The policy of the home is that service users are responsible for maintaining their own rooms with support from care staff. The ground floor sitting room has recently been decorated although the carpet is in need of replacement. All bathrooms and corridors are painted the same colour and although there are personal touches of decoration and ornaments around the home, the bathrooms are very bare and institutional. Flooring in 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 18 the shower must be replaced and consideration given to replacing all worn and stained flooring in bathrooms and toilets. Some of the bedrooms have been decorated and bedrooms seen were comfortable and furnished and personalised as service users chose. Some of the beds and furniture have been replaced, however, it is recommended that the manager makes a regular check on the premises to ensure that damaged furniture, loose curtain fittings, and damaged bed headboards etc. are repaired and maintained. There is a pleasant dining room and additional sitting room on the lower ground floor. There are two kitchens, the one for the use of service users is in good condition but the other kitchen has worn and broken units and is in need of refurbishment. Water tested in the kitchen and some of the bathrooms runs excessively hot to touch and the manager must ensure that this is assessed and appropriate action taken to control the temperature of hot water. The garden area is accessible from both kitchens and although a pleasant outside sitting area, the garden chairs are old and worn and need replacing and rubbish stored there should be disposed of. 34/36 Shaftsbury Road DS0000011832.V310249.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Comments from service users demonstrate that staff in the home know the service users well and are supportive and caring. However there is evidence that the number of staff is not sufficient to fully meet the needs of the service users and although this has been an issue of concern for some time, the staffing levels in the home have not been reviewed. Recruitment procedures are not thorough and robust to ensure that service users are protected. EVIDENCE: The home has been required to review staffing numbers over the last two inspections and although there are now some additional cleaning hours there is no evidence that staffing levels have been reviewed. Records show that a large number of staff hours on the rota are covered by agency or bank staff. Comments from relatives and visiting professionals have expressed concern that the care provided in the home is inconsistent and at times there are insufficient experienced staff on duty to meet the specific needs of the service users. There is one member of staff on duty at night to provide support to the residents of 34 Shaftesbury Road and 29 Shaftesbury Road. The manager has done a risk assessment for this practice but this needs to be reviewed to 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 20 ensure that the staffing is meeting the needs of service users in both homes. The risk assessment should also include consideration of staff age, experience, and gender and how this meets the needs of the service users. In discussion with some of the staff it is evident that staff are keen and motivated to attend training and gain experience and qualifications. A programme of in-house training covers all areas of safe working practice and staff are encouraged to achieve NVQ qualifications in care. At present 3 of the 6 staff have an NVQ level 2 in care. There is evidence of some training in specialist areas of care but the manager needs to demonstrate that there is a clear training plan for staff that covers all of the specialist areas of support that the home is registered to provide. Some essential policies for staff are not available in the areas of mental health, emergency admission to hospital, or dealing with emergencies or crises. Recruitment of new staff is organised centrally by the Southern Focus Trust and although records contain much essential information and written references there is a lack of understanding of the regulatory requirements to provide evidence of criminal record checks and POVA checks (a check that new staff are not on the Protection of Vulnerable Adults List). The POVA check must be satisfactory before staff start working in the home and if new staff are awaiting a criminal record check, they must be supervised until this is received and is satisfactory. 34/36 Shaftsbury Road DS0000011832.V310249.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home now has a registered manager who has a commitment to providing a user focussed service and now that she in permanently in post needs to develop and improve record keeping systems and monitor practice and compliance with the home’s plans, policies and procedures. EVIDENCE: The manager jointly manages both 29 and 34 Shaftesbury Road (the two homes are separately registered but directly opposite each other in the same road) and has been in post for one year. However, some of this period was spent as temporary manager and she was also managing another service. In discussion, it was evident that the manager is committed to providing a service that is user focussed and to work in partnership with relatives and professionals involved in the care and support of the service users. The manager is aware that improvements are needed in many areas of practice in the home and is keen to ensure that the home meets all of the National 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 22 Minimum Standards and Care Homes Regulations 2001. Comments from service users and staff indicated that the manager is approachable and supportive. The manager has continued the home’s policy to carry out an annual quality audit and this took place in March 2006 and included service users, relatives and health and social care professionals. The manager has produced a summary of the audit with some recommendations and plans to put these into practice. It was evident from information supplied by the manager before the inspection visit that records are kept of maintenance and checks to health and safety systems in the home, however, the manager needs to ensure that all records required by the relevant legislation are maintained and kept up to date; records were not available for checks on the central heating system or the electrical wiring certificate. Regular checks are maintained on fire safety equipment and the fire alarm and emergency lighting. The last recorded fire practice was June 2006. The home has smoke alarms installed. The manager must ensure that hot water is stored and distributed at the recommended temperatures. Only half of the registration certificate was in display and was out of date, but a new one is being issued with updated details of the registered manager. 34/36 Shaftsbury Road DS0000011832.V310249.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 2 2 X 3 1 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 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 3 X 3 X X 2 X 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 24 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 YA3 Regulation 14 Requirement Service users must not be admitted to the home until a full assessment of need has been completed and the manager is confident that the home can provide staff that are experienced and in sufficient numbers to meet the assessed care needs. Individual care plans must clearly identify, record and review service user choices, goals and aspirations with regard to all aspects of daily living skills. Individual care plans must record how assessed risks are managed, in consultation with the service user and/or their representative. The registered manager must demonstrate that the use of alcohol in the home is regularly monitored and reviewed and does not pose a potential risk to service users in the home. Individual care plans must clearly identify, record and review how the physical and mental health care needs of the service users are being met. DS0000011832.V310249.R01.S.doc Timescale for action 31/01/07 2. YA6 15 30/12/06 3. YA7 YA9 15 30/12/06 4. YA16 13(4) 30/12/06 5. YA19 12 30/12/06 34/36 Shaftsbury Road Version 5.2 Page 25 6. YA20 (13)(2) 7. YA24 23 8. 9. YA30 YA32 YA35 23 18 10. YA33 18 11. YA34 19 and Schedule 2 The registered manager must ensure that all medication is stored, recorded, dispensed and returned in accordance with the home’s policies and procedures. The registered provider must provide a plan of decoration and refurbishment that addresses all of the issues highlighted in the report (Environment) Damaged flooring must be replaced in the shower to ensure good hygiene. The registered manager must provide evidence of a training plan that meets the needs of the service users in the home. The registered manager must review staffing levels and demonstrate that there are sufficient number of experienced staff on duty to meet the needs of the service users at all times of the day, and particularly at night. (this has been a requirement from previous inspections but has not been fully met) The registered manager must provide evidence of POVA checks before new staff start working in the home and evidence of satisfactory CRB checks. 24/11/06 31/12/06 31/12/06 31/01/07 31/12/06 24/11/06 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 YA1 Good Practice Recommendations A review of the home’s service user guide is recommended to ensure that all details about the service are up to date and a copy is available for all existing and new service users. DS0000011832.V310249.R01.S.doc Version 5.2 Page 26 34/36 Shaftsbury Road Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 34/36 Shaftsbury Road DS0000011832.V310249.R01.S.doc Version 5.2 Page 27 - 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!