Inspection on 09/08/05 for 36 Station Road

This inspection was carried out on 9th August 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

36 Station Road 20/06/06

36 Station Road 27/02/06

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 36 Station Road Petersfield Hampshire GU32 3ES Lead Inspector John Vaughan Unannounced 9 August 2005 th 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 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 Stationary 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. 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 36 Station Road Address Petersfield, Hampshire GU32 3ES Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 017 3026 1535 Community Integrated Care Care Home 3 Category(ies) of Learning disability (3) registration, with number Learning disability over 65 years of age (3) of places 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28/10/04 Brief Description of the Service: 36 Station Road is a small residential service providing care and support to three adults with a learning disability. The care and support is now provided by Community Integrated Care (CIC) who took over the service on the 1st July 2005 from the previous provider. The building is owned by a housing association that is responsible for the maintenance of the property. Staff are provided twenty four hours a day to support the needs of service users.The home is located on a busy road and is indistinguishable from the other houses in the street. The home is close to the shops and public transport in the town of Petersfield. 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four hours and involved the manager, a service user and two staff on duty. The inspector spoke to the service users about living in the home and was helped by the service user to look around the home. The inspector sampled records in the home. He also spoke to the manager and both staff on duty. 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. 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 7 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 standard(s) 1 and 2 The lack of information and an approach to assessing service user’s needs mean that the home cannot demonstrate how they will assure service users that they can meet their needs. EVIDENCE: The home was unable to provide the inspector with a Statement of purpose or a service user’s guide to the home. The manager stated that they need to develop both of these documents and he will be speaking to his manager to discuss the content. The inspector was unable to sample assessment documentation for service users, as there was nothing in place except for the previous providers care plan and risk assessments. Care manager’s assessments were not available. The inspector could not assess how the home will support service users or assess their needs as a format for carrying out this task was unavailable and the manger was not aware of what approach is to be taken however the manager intended to meet with service user’s care managers. 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 8 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 standard(s) 6 and 9 The lack of service user plans and clear risk assessments mean the home cannot demonstrate that they can meet service users needs and have the potential to place service users at risk. EVIDENCE: The inspector sampled the documentation in place in the home following the change to a new provider. The home is currently using information left by the last organisation and no care plans or responses to service users needs could be provided for inspection. The home could not provide any evidence that they have carried out any assessment of service user’s needs to determine the service required. The manager could not provide any plans for service users and he also did not have a clear timescale for putting these in place. The manager did state that they are planning to work with care managers and service users to develop plans. The inspector could not assess how the home will support service users or assess their needs as a format for carrying out this task was unavailable and the manger was not aware of what approach is to be taken. 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 9 The previous provider put the current risk assessment strategies in place and none of these have been reviewed and replaced with a response from Community Integrated Care. The manager has been required to take action to develop a service user plan for each person, which documents the support required, and how they intend to meet these needs. They must also update the risk assessment strategies for each person. 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12 and 13 Service users benefit from regular activities outside of the home. The lack of a service user plan means that the home cannot demonstrate how the are providing support to access appropriate activities. EVIDENCE: The inspector spoke to a service user who was at home on the day of the inspection. The two other service users were out of the home engaged in activities. The staff have managed to maintain activities for service users during the transition period and this was confirmed in conversation with the service user. The inspector was told about trips to the seaside and a theme park, which the service user enjoyed. This morning the service user went to their regular art group this morning. The home is located very close to local town amenities and service users use facilities such as the shops, pubs and the library. The manager told the 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 11 inspector that they have received a house vehicle, which should provide greater opportunities for accessing activities and events. At the last inspection of the home concerns about the level of staff impinging on the ability of staff to respond to the recreational needs of service users was discussed. No additional hours are being provided in the home and only one staff is on duty in the evenings and weekends. This means that should a service user wish to go out the only option is for all service users to go. The manager must look at the provision of staffing to ensure they are able to meet service users needs however the absence of a care plan does not help identify how the home intends to meet the educational and recreational needs of each service user. 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 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 standard(s) N/A These standards were not assessed at this visit. EVIDENCE: 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Complaints procedures are in place demonstrating that the views and concerns of service users, their families and representatives are recorded and responded to. EVIDENCE: The home has a clear complaints procedure, this included details on how to contact the commission. The complaints procedure is on display in the home. The inspector discussed the complaints procedure with the manager who is setting up a file to monitor any complaints made. The inspector was able to confirm that no complaints have been made. 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24, 25 and 30 Service users benefit from a comfortable and well-maintained home with only minor repairs needed to improve the décor. EVIDENCE: The inspector toured the home with help from a service user. The home was found it to be in a generally good stated of repair, clean and tidy and free from any unpleasant smells. The manager stated that they are working with their maintenance team to address some areas that need painting and redecorating. The manager and inspector looked at the bathroom that needs some attention to the décor and ceiling which shows signs of damp. The inspector had the opportunity to see a service user’s bedroom and the individual said that they were very happy with their room and they have lots of personal items including photographs displayed in their room. 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 The lack of clear approaches to the training and development of staff mean that the home cannot demonstrate that a well-trained and supervised staff team supports service users. The home cannot demonstrate that an effective team supports service users and the lack of recruitment checks have the potential to place service users at risk. EVIDENCE: The inspector looked at the current staffing levels within the home. This was an area that has been raised as a concern in previous inspection reports and CIC have given an undertaking to maintain the level of staff agreed with the previous provider. These hours were a response to the concerns raised by the inspector about the lack of additional staff to ensure service users needs could be met and were to be kept under review. The home’s rota was examined and the inspector spoke to the staff member on duty who confirmed that one staff is on duty throughout the day with a person 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 16 sleeping in at night. They were also able to confirm that the extra hours provided at weekends are not in place at present. The inspector also noted that a deputy home manager is not in place as agreed at registration because the manager is also expected to manage another service. The manager stated that they do not have such a position and they are in the process of recruiting a senior carer who will fulfil this role. The inspector was unable to see a job description for this role and asked the manager to forward one to the commission. A new member of staff has just started this week and the inspector was able to confirm that this individual has begun an induction into the home. This includes meeting service users, colleagues and looking around the home. Topics covered in a signed record include health and safety, fire, use of equipment, meeting service users and what to do when on a shift. The manager was advised that the staff member needs to be given a copy of the General Social Care Council’s code of conduct. The inspector cannot confirm that the homes recruitment procedures are thorough a policy is in place on recruitment however no documentation for the new member of staff was available in the home. The manager stated that a Criminal Records Bureau (CRB) Check has been applied for and a POVA first (Protection of Vulnerable Adults List) check has been completed. The manager has not seen the results of this and no evidence was available in the home. The manager was unable to provide a training and development plan for his staff team and the inspector was unable to determine the approach of the home to identify training needs and respond to these needs. The inspector also noted that the home does not have a supervision programme in place and this will need to be established. The manager told the inspector that two staff are undertaking person centre planning training and that they will be undertaking facilitator training in September. 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) N/A These standards were not assessed at this visit. EVIDENCE: 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 18 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 2 2 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x x x Standard No 31 32 33 34 35 36 Score x x 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 36 Station Road Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 19 N/A 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. 2. Standard 1 1 Regulation 4 5 Requirement The registered person must ensure that a statement of purpose is in place in the home. The registered person must ensure a service users guide is produced and made available to each service user. The registered person must ensure that each service user has a full assessment of their needs in place The registered person must ensure that each service user has a plan which fully documents their assessed needs and includes clear methodologies for supporting these needs. The registered person must ensure that staffing levels are in place to meet service users assessed needs. The registered person must ensure that all records required for staff including proff of identity, two writtten references and a CRB check are in place and available for inspection. The registered person must ensure that a staff training and development programme is in 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Timescale for action 9th November 2005 9th November 2005 9th November 2005 9th November 2005 3. 2 14 4. 6 15 5. 33 18 9th October 2005 9th October 2005 6. 34 19 7. 35 18 9th November 2005 Page 20 36 Station Road Version 1.40 place. 8. 36 18 The registered person must ensure that staff supervision and support and an appropriate programme to deliver this is in place in the home. 9th november 2005 9. 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 Good Practice Recommendations 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Hampshire Area Office 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 36 Station Road 20051018 H54 S64989 36 Station Road V243136 090805 Stage 4.doc Version 1.40 Page 22 - 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!