Inspection on 15/02/06 for 374-376 Winchester Road

This inspection was carried out on 15th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

374-376 Winchester Road 18/05/09

374-376 Winchester Road 16/07/08

374-376 Winchester Road 27/11/07

374-376 Winchester Road 18/05/07

374-376 Winchester Road 24/10/06

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 18-65 376 Winchester Road 376 Winchester Road Southampton Hampshire SO16 6TW Lead Inspector Christine Hemmens Announced Inspection 10:00a 15 February 2006 th 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 376 Winchester Road Address 376 Winchester Road Southampton Hampshire SO16 6TW 023 80 789786 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) Integra Care Management Ltd Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Newly registered service Brief Description of the Service: 376 Winchester Road is a small home providing twenty-four hour care and support to up to five service users with learning disabilities with complex needs and who may have challenging behaviour. The service provider is Integra Care Management Limited, a Midlands based service. The home provides a comfortable environment where the residents have a room of their own which has been designed and decorated to meet their individual needs and personal preferences. The home has one bathroom and all residents have their own shower or bathroom facility. There are two lounges, a communal kitchen and large enclosed garden. 376 Winchester Road is situated close to local community facilities, Southampton Common, Southampton Sports Centre and shopping facilities in Shirley and Southampton. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 376 Winchester Road is a newly registered service, and this was the inspection of the home. The inspection was undertaken over one day and the manager assisted the inspector. The inspector spoke with staff, viewed one resident’s personal file and documents held in respect of staff and the home, and toured the home. Due to the residents’ complex communication difficulties the inspector was unable to verbally seek the views of the residents. However observation of staff with residents demonstrated that the residents appeared happy at the time of the visit. At the time of the visit the home was supporting a prospective resident to trial the home, the staff were provided with assistance by the service users current staff team. The inspector acknowledges the prompt response to the feedback form left following the visit, however the requirements issued at the time of the visit will remain until such time the service can demonstrate they have been fully met. The feedback form identified observed good practice and identified a number of concerns that have been reflected in the body of report, however further requirements have been recorded following the review of notes taken at the time of the visit. What the service does well: The service does well to obtain information on the residents prior to moving into the home, working closely with specialist health care teams and current staff to ensure they are able to meet the residents needs. The home does well to provide a comfortable environment for the resident to live, with individual bedrooms that reflect their needs and personalities and alternative communal space to allow residents to have time on their own of they wish and appropriate furnishings. The service does well to provide a staff team who appear dedicated and willing to learn. The staff were observed going about daily activities in a professional manner and respectfully engaging with the residents. The home does well to support the residents to maintain community and family links, on the day of the visit residents were observed going out shopping and a leisurely walk. The service does well to meet the health and welfare needs of the residents ensuring referrals are made to primary and specialist health care professionals such as GP’s and occupational therapists when required. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 6 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. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 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 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 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): 1,2 and 4 The home does well to obtain information on prospective residents to judge if they are able to meet their individual needs and aspirations, they do well to provide opportunities for the prospective residents to trial the home. However the home must do better to provide information to assist residents and their representatives to make an informed choice about the home. EVIDENCE: On the day of the visit the inspector viewed one personal plan which held assessment information obtained from the resident’s placing authority, the inspector did not see evidence that the home had obtained or undertaken its own assessment process. However on the day of the visit the home was supporting a new resident to test-drive the home with the support of its current staff team. The staff have been provided with comprehensive information on the residents strength and needs and in particular how to support the resident with behaviours that can potentially challenge. The inspector observed good work and interaction between both teams of staff supporting the prospective resident through his transition to the home. The current staff team worked with individual staff with the resident to support him with various activities through out the course of the day including taking the resident for a walk, assisting with personal care, administering medication and providing information regarding the residents various communication needs. This was seen as a very positive piece of work between teams. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 9 The inspector viewed the home’s Statement of Purpose. However this requires updating to reflect changes made since the home was first registered and to ensure each resident and the Commission are issued with a Service User Guide as required in regulation 5(2) of the Care Homes Regulations This must be produced in an accessible format for those residents with cognitive and sensory disabilities. The inspector saw a mission statement in a personal file, which stated the “home recognises that each resident is a unique individual with their own needs and wishes. The purpose of the plan is to support your needs and wishes, the things you want to do, assist you to be fully involved in decision making and to keep you safe” (This statement has not been recorded verbatim). This is a good statement to evaluate the standard and quality of care provided to each residents individual needs and desires. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 The home does well to get to know the new residents’ assessed needs and associated risks, however the home must ensure these are accurately reflected in the residents personal plans to ensure consistent and person centred approaches. EVIDENCE: The inspector recognises the good work undertaken by staff to support and obtain information on new residents entering the home, however the manager must ensure that personal and working information are appropriately held in order that staff can easily access when required. The inspector viewed one resident’s personal files. There were two files one for personal information and the other as a daily working file. The personal file held relevant contact details, such as DOB, NOK, GP, details of placing authority and dates to remember such as relative’s birthdays etc. The second daily file held good documentation to record the resident’s daily routine, daytime activity, health and medication and behaviour charts. The package of documentation the home has brought into is very comprehensive and would provide staff and relevant persons with a clear 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 11 understanding of the holistic needs, risks and interests of the residents. However the inspector found a number of areas of concern that the home is required to attend to. 1. The manager must ensure if the home is going to use two files, that it clearly identifies its use and ensures the relevant information is held in the appropriate file. 2. The manager must ensure all documentation requiring a signature is signed, either by the residents and/or the residents representative, the manager and staff, i.e. reviews, care plans, behaviour plans, and daily recording records. 3. The manager must ensure all daily plans and behavioural plans are completed and signed. 4. The manager must ensure care plans truly reflect the support required. Bath time routine conflicted with the routine the manager described to the inspector 5. The manager must ensure residents have risk assessments in place for all associated risks to the residents, such as risk of burning, scalding, drowning, wandering around the home at night and behavioural risk management plans. This is not an exhaustive list as it is the responsibility of the manager to ensure all areas of risk are documented and staff are made aware of them. 6. The registered persons are advised to thoroughly review all documentation held in the residents’ personal plans to assess its relevance and remove if not applicable to the resident. 7. The manager must consider its current approach to person centred planning and evaluate and assess if the home is truly empowering the residents and meeting their needs, wishes and desires in the way they want? 8. The manager is advised to network with other learning disability homes in the area or see the support and advice of the person centred coordinator for Southampton. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 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): 12,13, and 15 The home works well to support the residents to maintain links with its local community, take part in peer and age appropriate activities and maintain links with family and friends. However the home needs to demonstrate through clear documentation that it is providing a person centred approach. EVIDENCE: The inspector observed on the day of the visit that the residents were supported to access the local community and the manager and staff with whom the inspector spoke with described how they supported residents to develop personal skills manage their behaviours in other environments other than the home and continue to maintain relationships with people who are special to them. On the day of the visit two residents were observed accessing the community with the support of staff, the manager described how one resident had adapted to living in the home having moved from an institutional environment, how the residents was now encouraged to exercise choice and engage successfully in activities that would have not been considered prior to moving in. Another 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 13 resident was out for the day accessing a day service provision. In the residents’ plans the inspector saw evidence of weekly activity, the interests of the resident and the importance of maintaining family links. On return from the day service the resident was observed to be supported by staff to follow his preferred routine. The inspector spoke with two members of staff who demonstrated positive values and were aware of the rights of the residents to live an independent life as possible with the same choices and respect as anyone else. The members of staff spoke positively of the differences they had seen in two of the residents since they moved into the home. It appears through discussion and observation that the home has done very well to provide an environment where the residents are respected and provided with opportunities to express themselves and develop their skills, however at referred to in the section “Individual Needs and Choices” the home needs to demonstrate through clear documentation and recording that it is providing a person centred approach, i.e. developing person centre plans that are accessible, giving the residents ownership to personal plans, developing circles of support and further exploring and recording the dreams and aspirations of the residents. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 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): 19 and 20 The home does well to ensure the residents’ physical and emotional needs are met and uses appropriate systems for administering medication. EVIDENCE: The inspector was advised by the manager and saw evidence in one resident’s personal plan that the home ensures the residents receive all required support with their physical and emotional health. The inspector was informed that the residents are generally in very good health, however need regularly specialist support to manage their behavioural and emotional needs. The home access’s the assistance of psychologists, psychiatrists and other specialist health care professionals such as occupational therapists and speech and language therapists. The inspector was informed and saw evidence that the home had received extensive input from an occupational therapist to provide advice on the environment to ensure it meets prospective residents needs. The home supports residents very complex needs and behavioural difficulties and with the assistance of the occupational therapist has made safe the residents immediate environment. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 15 One of the members of staff supporting the prospective resident on the day of the visit is a registered nurse for service users with Learning Disabilities and was able to provide valuable support to the staff. The home’s medication polices and procedures were not fully inspected on this occasion, however the inspector was informed that the home supports all the residents with their medication, which is kept safe within an appropriate medication cabinet. The inspector was informed that the home uses individual dossett boxes, which are dispensed by a reputable local pharmacist. The manager informed the inspector that the pharmacist is contracted to provide training and regularly audit the medication processes, stock and storage safety. On the day of the visit discussion was taking place on how the home will ensure the prospective resident will obtain further stocks of medication. The home was very quick to act and on the same day was arranging to speak with the resident’s pyscharitrist, GP and the pharmacist. The inspector was advised that the pharmacist was very good at dispensing medications at short notice. The inspector observed the supporting member of staff showing staff how to respectfully administer eye drops. This is seen as good practice however the manager must ensure that all staff receive training in administering medication and specific procedures such as administering eye drops and applying topical lotions. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 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 The home does not provide information on how residents or their representatives can complain and fully protect residents from potential harm of abuse. EVIDENCE: The manager provided information for the inspector to view with regards to complain. The manager confirmed that the information provided was the complaints procedure. The information provided gave guidance fro the manager and staff on how to receive a complaint and the current Statement of Purpose does not inform, how to make a complaint and the Service User Guide which should inform the residents how to complain is currently not in existence. Therefore the home cannot demonstrate residents’ views are being listened to. The inspector acknowledges the complex communication and behavioural needs of the residents provides difficulty for the staff team to establish if the residents wish to make a complaint, however the home must consider alternative solutions to meeting this need. Residents’ representatives, including advocates must be informed how they can make a complaint on behalf of the resident. The inspector met with two members of staff who confirmed they were aware of the different types of abuse, how to report suspected or witnessed abuse. Neither staff had received training in abuse awareness. The home does not fully protect residents from abuse as it does not carry out a robust recruitment procedure by obtaining the appropriate checks such as 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 17 criminal record bureau (CRB) and protection of vulnerable adults (POVA) checks. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27 and 30 The home provides a homely and comfortable environment, which has been adapted to meet the complex needs of the residents. However the responsible individuals must ensure all areas of the home are safe for the residents to live. EVIDENCE: The home is a two-story house currently providing accommodation for three residents. The home is registered for five adults with learning disabilities. The home provides spacious communal facilities and alternative rooms for the residents to use if they wish. The home has been tastefully decorated with relaxed and calming colour schemes and furnished throughout with furniture and furnishing recommended by occupational therapists, such as recessed lighting and rounded edges on furniture. The home has a separate kitchen and laundry facilities and a spacious safe enclosed garden. The manager informed the inspector that one of the residents especially liked accessing the garden and made good use of it in the summer months. The manager is advised to keep kitchen cupboards clean and ensure corrosive substances hazardous to health (COSHH) kept in the kitchen such as 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 19 dishwasher powder are safely locked away. The COSHH cupboard in the hallway must be kept locked at all times as stated on the door. A temporary arrangement is in place to convert one of the rooms upstairs to a lounge/dining room to accommodate the two residents who require less support to manage their behaviours. The manager spoke of placing a kettle and other facilities in the room to encourage independence. The manager must ensure the risk of having such appliances unattended are considered and risk assessments are undertaken on both the residents concerned. The manager must consider other potential risks related to this temporary provision such as staff cover, risk assessing the radiator, placing restrictors on the window and any concerns there maybe with the compatibility of the two residents sharing the same room. Each resident has a bedroom of their own that has been decorated to their liking and personalised to reflect the resident’s character and interests. Two bedrooms on the ground floor have been specifically designed to meet the complex needs of the residents, such as boxed in radiators, specialist flooring and easy to clean walls and robust quality furniture. Currently the en suite shower rooms have been boxed in as advised by the occupational therapist with a view to changing when and if the residents need change. The residents have access to a bathroom and toilet facility on the ground floor. The residents situated on the first floor also have their own bedrooms, which are spacious clean, and tidy and they have access to their own bathrooms. The bathrooms have been tastefully furnished and decorated, however uncovered radiators pose a risk of burning and therefore the manager must cover the radiators in the bathrooms. This must also be considered for the residents’ bedrooms and radiators covered dependent on risk. The manager must repair or replace the broken window in the first floor front bedroom. The home has considered the privacy of the resident and placed frosted glass on the window, however one of the windows does not close properly and the windows require restrictors on them. At the time of the visit the inspector observed staff carrying out domestic duties, the care staff are responsible for the cleaning and cooking and to support the residents to maintain and develop daily living skills. The home was observed to be clean and tidy, with the exception of some of the cupboards in the kitchen. The manager must ensure these are regularly cleaned. Staff are equipped with gloves and aprons to avoid cross infection and the home has a contract for clinical waste and laundry facilities to deal with soiled laundry. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34 and 35 The residents are currently supported by adequate numbers of staff who have received basic training to meet the basic needs of the residents, however the home has not followed the appropriate recruitment polices and procedures in order to protect the residents from potential harm. EVIDENCE: The home currently has six members of staff to support two residents, however on the day of the visit the home was supporting a prospective resident to test-drive the service. The needs of the resident and another soon to visit the home are described as very complexed and challenging. The home is currently staffed three staff in the morning, three in the afternoon and two staff sleeping in at night. The manager informed the inspector that they were hoping to employ two further staff that have specific skills in supporting people who challenge, but is currently back filling gaps in the rota with agency staff. The manager must assess the dependency levels of the all residents and adapt and increase staffing levels to reflect to reflect the level of need. This will be reviewed during the next visit to the home. The inspector met with two members of staff who said they felt adequately supported and had received appropriate training to meet the needs of the residents, such as food hygiene, moving and handling, first aid and fire and 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 21 was soon to receive training from the specialist health care team in communication and epilepsy. The manager informed the inspector that staff had received training in Team Teach and were hoping to soon undertake Approach training, both these forms of training are specific to supporting residents with challenging behaviour. The home must ensure that the training is receives that requires the use of restraint has been accredited by BILD, The British Institute of Learning Disabilities and the trainer has been accredited to undertake the training. The staff with whom the inspectors spoke with said they had found working with the specialist health team and the staff supporting the prospective residents very beneficial. The home is providing a complex service to a group of unique and complex individuals that will challenge the thinking of the manager and staff when ensuring the residents wishes and desires are addressed using a person centred approach, therefore the inspector advises that staff receive training in person centred planning. The inspector viewed all staff recruitment files, the files shown to the inspector were kept in a filing cabinet behind the manager’s office chair. The inspector was not shown any other records in respect of staff. The inspector observed that the recruitment files were not complete with all documents required to demonstrate that staff have been correctly recruited, the files lacked evidence of application forms, proof of ID, references, protection of vulnerable adults check (POVA) and up to date criminal record bureau checks (CRB). The inspector was informed that the CRB’s currently held in the file dated January 2005 had been done by a previous agency who had taken on the staff specifically to work in the home once it opened. The manager was advised that CRB’s are not transferable and the home needed to demonstrate that correct recruitment procedures have been undertaken. The manager was advised to speak with her immediate line manager as soon as possible and take appropriate action to obtain CRB’s and POVA checks and to ensure all staff had the required recruitment documentation. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 22 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 and 42 The resident’s benefit from a comfortable home with dedicated and respectful staff, however the home fails to provide a home that fully protects and safe guards the residents from potential harm. EVIDENCE: At the time of the visit to the home it had been operational for five months accommodating two residents and a staff team of six. The home has had two managers in the respect of two months and the current manager is waiting to be registered. The manager and staff show commitment, dedication and respect towards the residents. They are especially pleased with the hard work they have applied to support and minimise the behavioural of one of the residents. However as evidenced throughout the report the home lacks the evidence to demonstrate that it is currently providing a well run service that is required by law. Therefore the requirements issued in respect of this visit to the home must be followed to improve standards. The staff as far as feasibly possible safeguard residents from harm, staff are appropriately trained in fire safety and health and safety and they maintain a 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 23 clean environment for the residents to live, however as evidenced throughout the report the home must improve its standards in protecting the residents from risk of harm, such as covering radiators, risk assessing areas of potential harm, keeping COSHH equipment safely stored away and providing certificates to evidence that the homes utilities such as the boiler and electrics have been serviced. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 24 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 3 X 3 x Standard No 22 23 Score 1 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X 2 X X 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 1 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 376 Winchester Road Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 1 X DS0000062649.V260201.R01.S.doc Version 5.0 Page 25 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 YA1 Regulation 4&5 Requirement The registered persons must ensure the Service User Guide and Statement of Purpose are updated to reflect the actual service provided. The registered persons must ensure each residents and the Commission for Social Care Inspection are issued with the revised Statement of Purpose and Service User Guide. The registered persons must ensure if the home is going to use two files that it clearly identifies their use and ensures the relevant information is held in the appropriate file. The registered persons must ensure all documentation requiring a signature is signed, either by the residents and/or the residents representative, the manager and staff, i.e. reviews, care plans, behaviour plans, daily recording records. Timescale for action 30/05/06 2 YA1 4,5 & 6 30/05/06 3 YA6 17 Schedule 3 30/05/06 4 YA6 15 30/05/06 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 26 5 YA6 15(1) The registered persons must ensure care plans truly reflect how the support is to be provided. The registered persons must ensure residents have risk assessments in place for all associated risks to the residents. 30/04/06 6 YA9 13(4) (a)(b)(c) 30/04/06 7 YA24YA42 13(4)(a)(c) The registered persons must ensure all substances subject to COSHH are safely locked away at all times. The door to the COSHH cupboard in the kitchen must have a lock fitted. The door to the COSHH cupboard in the hallway must be kept locked at all times. 30/04/06 8 YA24YA42 13(4) (a)(b)(c) 23(2)(p) The registered persons must ensure the residents using the first floor lounge/dining room are risked assessed: Use of windows Use of kettle Radiators Compatibility And actions taken to minimise the risks. 30/04/06 9 YA27YA42 13(4) (a)(b)(c) 23(2)(p) 23(2)(b) The registered persons must cover exposed radiators in the first floor bathrooms. The registered persons must replace or repair the broken window in the first floor front bedroom. 30/04/06 10 YA25YA42 30/05/06 11 YA25YA42 13(4)(a)(c) The registered persons must 23(2)(p) place restrictors on the first DS0000062649.V260201.R01.S.doc 30/04/06 376 Winchester Road Version 5.0 Page 27 floor windows to prevent the risk of falls. 12 YA23YA34 19(1) (a)(b)(i)(c) The registered persons must ensure all required recruitment documentation is obtained before starting new staff in the home. The registered person must ensure current staff have up to date CRB’s and evidence is provided to demonstrate the staff have been checked against POVA list. 30/04/06 13 YA23YA34 19(1)(a) (b)(i)) 31/03/06 14 YA42 13(4)(a)(c) The registered persons must 23(2)(b) produce evidence to demonstrate the homes utilities have been serviced and in working order. These documents must be maintained in the home at all times. 30/04/06 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 The registered persons are advised to develop the Service User Guide in an accessible format taking into account the residents’ sensory and cognitive disabilities. The registered persons are advised to thoroughly review all documentation held in the residents personal plans to assess its relevance and remove if not applicable to the resident. The registered persons are advised to ensure all daily recording plans and behavioural plans are completed and signed by the staff member completing them. DS0000062649.V260201.R01.S.doc Version 5.0 Page 28 2 YA6 4 YA6 376 Winchester Road 5 YA35 The registered persons are advised to provide training in person centred planning for staff. 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 376 Winchester Road DS0000062649.V260201.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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