Inspection on 14/02/07 for 39-41 Whitehawk Way

This inspection was carried out on 14th February 2007.

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

The inspector 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

39-41 Whitehawk Way 09/01/09

39-41 Whitehawk Way 26/01/06

39-41 Whitehawk Way 07/07/05

39-41 Whitehawk Way 28/02/05

39-41 Whitehawk Way 28/09/04

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

CARE HOME ADULTS 18-65 39 Whitehawk Way 39 Whitehawk Way Brighton East Sussex BN2 5QL Lead Inspector Merle Blakeley Key Unannounced Inspection 14th February 2007 11:00 39 Whitehawk Way DS0000014139.V322331.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 39 Whitehawk Way DS0000014139.V322331.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. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 39 Whitehawk Way Address 39 Whitehawk Way Brighton East Sussex BN2 5QL 01273 603110 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) Southdown Housing Association Limited Ms. Sandra Midgley Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. This home is registered for four (4) service users with a learning disability and physical disability. A maximum of four (4) service users to be accommodated. Service users accommodated will be aged between eighteen (18) and sixty-five (65). 26th January 2006 Date of last inspection Brief Description of the Service: 39 Whitehawk Way is part of the Southdown Housing Association and is registered to provide residence and care to four adults, with a learning disability. The home is a purpose-built bungalow, situated in Brighton. The location of the home offers access to local amenities, including food shops, pubs and restaurants. Each person has their own individually decorated bedroom. Communal areas comprise of a lounge/dining room and kitchen. The building has level access for those service users who use wheelchairs and an enclosed rear garden. The people who live at the home have individual day activity timetables and are supported to participate in their chosen activities by the care staff. The current fees are £1,480 per week. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of five hours on 14th February 2007. As well as this site visit information was also gained from a returned pre-inspection questionnaire, four resident feedback survey forms, which had been completed by family members and carers, informal talks with five staff members and a visitor. Document reading was also carried out and a health and safety check was conducted. Staff were also observed interacting with residents. The staff members on duty facilitated the entire inspection. What the service does well: What has improved since the last inspection? What they could do better: Staff need to remain vigilant when administering medications. Two medication errors have been made in the last three months and these were reported to the CSCI and they were also discussed with staff during the inspection, therefore a requirement has not been made. All the staff have attended 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 6 medication training and understand their responsibilities with regards to administering medicines. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 39 Whitehawk Way DS0000014139.V322331.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 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 2. This judgement has been made using available evidence including a visit to this service. The home carries out a thorough assessment before a prospective resident moves into the home. EVIDENCE: Up until 2006, all four residents lived in this home for many years. One of the residents passed away last year and in July 2006 a new resident was admitted. The pre-assessment records were viewed for this person to ensure that 39 Whitehawk Way could meet her needs. A variety of assessments had been carried out by social workers and other healthcare professionals. The manager also went to meet the resident at her day care centre to make her own assessment and sought the views of family and friends. The resident’s family have since commented that they are very happy that she has been able to go and live at 39 Whitehawk Way. The initial pre-assessment information will form part of the resident’s future support plan. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 6,7 & 9 This judgement has been made using available evidence including a visit to this service. Care plans are comprehensive and informative. Staff support residents to make positive choices and decisions in their lives. EVIDENCE: All four care plans were viewed during this visit and the information they contained was very comprehensive. There was detailed information about each resident’s lifestyle, what they enjoyed and did not enjoy, life histories, personal care support, healthcare needs, daily routines, activities, behaviour, anxieties goals etc. All four residents require support with their personal care, as they have physical disabilities as well as learning disabilities. Two residents require 2:1 support and the other two residents require 1:1 support. Each resident has a key worker. Regular reviews and updates are carried on residents support plans. Resident’s needs are discussed at the fortnightly team meetings. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 10 During this visit the inspector was able to evidence how residents are able to make decisions. Although residents have complex needs some are able to communicate their feelings to staff about the choices they want to make about where they go and who they go out with. Staff were very knowledgeable about the likes and dislikes of each resident and they knew when to stand back and when to give discreet support. Risk assessments are carried out according to each resident’s capabilities and updated if their needs change. During the day residents went out to attend the activities they preferred. One resident had chosen not to go out that morning and she was able to spend some time quietly listening to music in the lounge. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 12, 13, 15, 16 & 17 This judgement has been made using available evidence including a visit to this service. Residents lead active and fulfilling lives and they are out and about in the community on a daily basis. Residents keep in touch with their families. Residents are respected. Residents enjoy a well-balanced diet. EVIDENCE: Each resident has his or her own activities plan and these were viewed. All the residents take part in a number of activities, which include swimming, art classes, music classes, painting, cookery, sensory rooms and social clubs. On this particular day one resident was attending a music group and then was going on to have lunch out with a staff member in Lewes. Another resident had his mother visiting him; another resident had chosen to get up late and was going out for a visit to Shoreham Airport with a member of staff. As residents go out frequently they are very much part of the community and go to local pubs, shops and restaurants. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 12 Most of the residents are encouraged to maintain family links and as stated previously one of the residents was being visited by his mother who stayed for lunch. The relative was asked about the care her son receives and she spoke very highly of the care the manager and staff team provide. She also stated that she was always made welcome in the home and that the staff were very caring and friendly. She said that she knew her son was ‘in good hands’. Other residents have family members and friends who visit on occasions. Friendships are also encouraged and supported, as many of these residents from 39 Whitehawk Way and 41 Whitehawk Way have known each other for a long time and often enjoy being in each other’s company. Staff prepare the meals during the day. One resident is on a restricted diet at present due to particular healthcare needs. Two of the residents are able to say what they want to eat, so staff take their cues from this. The inspector was able to join three residents, staff and a relative for lunch. Most of the residents require staff support during meal times. Resident’s diets were discussed with staff who stated that they support residents to make appropriate decisions about food and try to ensure they eat a healthy balanced diet. Menus provided by the home indicated that residents receive a varied diet that includes vegetarian options. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good 18, 19 & 20 This judgement has been made using available evidence including a visit to this service. Personal care is given to residents in a sensitive and respectful manner. Resident’s healthcare needs are being met. Medication is normally administered correctly. EVIDENCE: During this visit the inspector was able to view how residents personal care needs were being met. Staff worked with the residents in a sensitive and caring manner and ensured that their dignity and respect was maintained throughout the procedures. Residents can choose when their personal care is given. The home provides the specialist toileting and bathing equipment that is required. Each resident has their healthcare needs written into their support plans and the inspector was able to read these. Residents have access to a broad range of health professionals and their visits are recorded in the resident’s health appointment record sheets. Currently all of the residents are in good health. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 14 Medication records were checked. Two medication errors have been made in the past three months and the home had notified the CSCI about these errors. These errors were discussed during this inspection and therefore a requirement will not be made, however the staff must remain vigilant when administering medications. During the last inspection improvements had been made to the medication system. Medications are signed by two staff members, which should eliminate any errors. All staff have attended medication training. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 22 & 23 This judgement has been made using available evidence including a visit to this service. The home has produced policies and procedures regarding complaints and the protection of vulnerable adults. EVIDENCE: The home has produced a policy and procedure about how people can complain if they are not happy about any aspect of the service. This policy was last reviewed in February 2006. Returned comment cards from relatives did state that they knew how to make a complaint. Staff also stated that they would soon be aware if a resident was not happy as they are able make their feelings known, some with words and others with body language and gestures. The home has a policy and procedure to protect vulnerable adults and this policy was last reviewed in May 2006. All the staff team have attended training in adult protection so they are aware of their responsibilities as regards to reporting and whistle blowing. There have been no adult protection alerts received. Resident’s finances were viewed and one was checked with the assistance of one of the residents. Staff stated that resident’s finances are always checked daily and recorded. All resident’s finances were found to be in order. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 24 & 30 This judgement has been made using available evidence including a visit to this service. Residents live in comfortable environment. The home was found to be clean and tidy. EVIDENCE: All four residents have their own individualised bedrooms, which appeared comfortable and homely. The corridors, the lounge and bathrooms have sufficient space for wheelchair access. All rooms are on ground level with a good ramp access out to the front of the building. The home also has a pleasant rear garden area, which is accessible to all of the residents. The premises are well maintained. During this unannounced visit the home was found to be clean and tidy. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 32, 34 & 35 This judgement has been made using available evidence including a visit to this service. Staff are continuing to complete the National Vocational Training (NVQ). Staff recruitment procedures are in place. The staff team receive a good level of training. EVIDENCE: 39 Whitehawk Way has an experienced and stable staff team who were seen to care for residents in a friendly and sensitive manner. The rotas showed that there are normally three staff on duty in the morning and three on duty in the afternoon. Another staff member was also working in the home but they were having a dedicated administration day. Four staff were spoken to during the day and they have been working at the home for varying periods of 2 years, 13 months, 18 months and 6 years respectively. They all stated that they got on well together as a team and were supportive of one another. One new member of staff was present and she was undergoing her induction training. Staff also said that they felt the home was well run and that they were well supported and provided with a good level of training. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 18 Staff are continuing to gain qualifications in NVQ training. Currently five of the permanent staff have obtained NVQ Level 3 and two staff are just about to complete this qualification. A further two staff are due to commence NVQ Level 3 training in April and September 2007. Three of the relief staff hold the NVQ Level 3 qualification. The assistant manager has gained NVQ Level 4 and the Registered Managers Award (RMA). Staff recruitment files could not be viewed as Southdowns Housing Association keeps these personnel files at the Head Office. A new check-list form has been devised, which includes a set of tick boxes that indicates which type of recruitment check has been carried out e.g. references, returned CRB check, proof of identity. Two of these were viewed. Staff were asked about the level of training they received and all staff responded that Southdowns Housing Association were very supportive regarding training. Staff records indicate that staff have access to a good level of training, which has included first aid, communication, medication, adult protection and vehicle training. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 37, 39 & 42 This judgement has been made using available evidence including a visit to this service. The home appears well run and organised. The home has a quality assurance system in place. The health and safety of both residents and staff is promoted. EVIDENCE: On the day of this visit the manager was away on annual leave. The staff on duty were very helpful and assisted the inspector with the information, which was requested. The registered manager has been in post for seven and a half years and she has obtained the NVQ Level 4 qualification and the Registered Managers Award (RMA). Staff stated that the manager was approachable and supportive and overall they felt the home was well run and organised. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 20 The home has a quality assurance programme, which includes seeking feedback from families and friends of the residents. Southdowns Housing Association also carries out a number of internal audits to ensure the quality of care is maintained. The service is also looking into how they may seek feedback from visiting professionals who come into the home on a regular basis. Regulation 26 visits are carried out monthly and recorded. Staff also carry out a ‘quality monitoring day’, which involves them discussing a number of care issues and standards. A health and safety check was carried out during this visit and no issues were raised. As in other Southdowns homes the manager is responsible for carrying out ‘walk through’ monthly health and safety checks which cover areas such as fire safety, security, equipment, vehicles, appliances, evacuation plans and outdoor areas. Fire drills are carried out six monthly and hot water temperatures are checked on a monthly basis. Staff have received training in safe food handling, manual handling and first aid. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations That staff remain vigilant when administering and recording medications. 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 39 Whitehawk Way DS0000014139.V322331.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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