Inspection on 22/08/06 for 3a Lansdowne Road

This inspection was carried out on 22nd August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3a Lansdowne Road 30/09/09

3a Lansdowne Road 22/08/07

3a Lansdowne Road 24/01/06

3a Lansdowne Road 26/09/05

3a Lansdowne Road 03/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 3a Lansdowne Road Hove East Sussex BN3 1FE Lead Inspector Merle Blakeley Key Unannounced Inspection 22nd August 2006 09:30 3a Lansdowne Road DS0000014212.V301545.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 3a Lansdowne Road DS0000014212.V301545.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. 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3a Lansdowne Road Address Hove East Sussex BN3 1FE 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) 01273 731380 The Frances Taylor Foundation Mrs Sandra Davies Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of residents to be accommodated is nine (9). Residents with a learning disability only to be accommodated. The residents accommodated must be aged eighteen (18) to sixty-five (65) on admission. 24th January 2006 Date of last inspection Brief Description of the Service: 3a Lansdowne Rd is registered to provide accommodation and personal care to nine adults with learning disabilities. The home is located in Hove with good access to local transport and amenities. It is a two-storey building that offers a range of communal space and nine single bedrooms. Service users access a range of day, leisure and vocational activities. The home is run by the Frances Taylor Foundation. Current fees range from £450.00 to £1,200.00 per week. 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over a period of seven and a half hours on 22nd August 2006. As well as this site visit information was also gained from a pre-inspection questionnaire, feedback survey forms from several residents and five relatives, informal talks with four residents, three staff and the deputy manager. The site visit consisted of a tour of the premises, looking at the needs of four particular residents, document reading and observing staff interactions with residents. There are currently nine residents living in 3a Lansdowne Road. What the service does well: What has improved since the last inspection? What they could do better: The home must make improvements in how they administer and record medications as several errors were again found during this inspection. A requirement was made during the last inspection for the home to ensure all medication is dispensed and recorded accurately. Records show that staff have 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 6 received training in medication administration. Staffing recruitment files do not contain all the required information and the home must be aware that CRB checks are not transferable between homes. All staff that work in the home must have a CRB check to indicate who employs them. The homes complaints policy and procedure needs to be provided in an easy read format and also made available relatives/friends etc. The two radiators in the second lounge need to be securely attached to the wall. The homes policies and procedures need to be reviewed and updated where necessary. 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. 3a Lansdowne Road DS0000014212.V301545.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 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are carried out. EVIDENCE: Before a prospective resident moves into the home the manager will assess their needs. This assessment will be carried out in conjunction with information received from a social care assessment. 3a Lansdowne Road DS0000014212.V301545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents care plans and assessed needs are informative and regularly reviewed. Residents feel they can make certain decisions about their lives. Risk assessments are carried out and reviewed. EVIDENCE: Four care plans were looked at during this visit. They all contained comprehensive information about each of the residents needs. Recent key worker reviews had been carried in May 2006. Risk assessments were also seen to be regularly updated. The home is due to start using monthly resident review sheets. Several residents were spoken to during the day and they were asked if they could make their own decisions about certain aspects of their lives. They stated that basically they could make decisions about certain things. They also stated that staff helped them a lot with things. They also felt they had choices in their lives. Residents meetings are held every Sunday and here they can discuss issues and raise any concerns or suggestions. 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 10 The home carries out a range of risk assessments to cover such areas as activities, out in the community and inside the home. These assessments are regularly reviewed and updated. 3a Lansdowne Road DS0000014212.V301545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a wide range of activities. Residents are out and about in the community on a daily basis. Residents are supported and encouraged to maintain family links. Resident’s choices are respected. The home offers residents a well balanced diet. EVIDENCE: Residents attend a good range of activities, which include day centres, college courses and day trips. Most of the residents attend their preferred day centres several times a week and several also attend short courses at Brighton City College. They also have opportunities to go out shopping, to the cinema, pubs, markets etc. During the weekly residents meeting they are asked about what they would like to do during the week. As residents are so active they are out and about in the community on a daily basis. The home has a flexible routine and residents do not have to adhere to any set times if they do not wish to. Resident’s records show that they have contact with family and friends. Visitors are welcome and several come to see their relative every week. There is also a phone in the office and residents are able to use this to call family or friends. 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 12 This was seen during the inspection where a resident was helped to dial a number and then the staff member left the room so that the resident could talk in private. The home tries to promote healthy eating and includes daily vegetables and fruit in their diet. One resident has become over weight and the home has involved a dietician for advice. Generally there were no complaints about the meals and overall residents are happy. Residents are encouraged and supported to participate with the cooking, cleaning and washing their own personal laundry. 3a Lansdowne Road DS0000014212.V301545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s personal and healthcare needs are met. Medication is not being correctly recorded. EVIDENCE: The current residents ages range from 53 years to 72 years and several need some assistance with their personal care. Staff stated that all personal care is carried out in the privacy of the resident’s bedroom. All rooms are single and four have en suite facilities. There are two baths in the home and the service is considering changing one of the baths into a walk-in shower, which would provide more easy access to those residents who have mobility problems. There are currently two residents who are wheelchair users. The healthcare needs of residents appear well met by the home. Records show that all residents are registered with their own doctor and they have access to dentists and opticians. The home receives good support from the Community Learning Disability Team who organise visits from Community Psychiatric Nurses, Occupational Therapists, Speech Therapists, Physiotherapists and Dieticians. All residents are supported to attend healthcare appointments either at home or in local venues. 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 14 Medication records were checked and again errors were found. A requirement was made during the last inspection for the home to accurately dispense and record all medications administered to residents. The home must improve its medication procedures. The home has a very good rapport with their local doctor and resident’s medications are reviewed annually. One resident self medicates and a risk assessment has been carried out. 3a Lansdowne Road DS0000014212.V301545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy & procedure needs to be made available in an easy to read format. EVIDENCE: The home has produced a policy and procedure regarding complaints, however these documents need to be made more accessible to both residents and family and friends. The home will need to look at how they can make these procedures more user friendly and easy to read. The complaints policy and procedure also needs to be displayed in a public area, so that it is accessible to all. The home has produced a policy and procedure regarding the protection of vulnerable adults. All staff have attended training in adult protection in June this year. All staff have undertaken CRB checks before they commence employment and staff recruitment files showed that several staff did not have CRB checks in their files. All residents have their own bank accounts and family and/or advocates provide financial advice and assistance when required. 3a Lansdowne Road DS0000014212.V301545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a friendly and relaxed environment. The home is kept clean and tidy. EVIDENCE: 3a Lansdowne Road has a friendly and relaxed environment. All residents have their own bedrooms; four have en suite facilities. The home is well maintained and has a large rear garden area, which has a patio and BBQ area. Suitable covers have been provided for the radiators, however there are two radiator covers in the second lounge which need securing to the wall. The home is kept clean and tidy and an ancillary worker is employed for 18 hours a week. 3a Lansdowne Road DS0000014212.V301545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home employs stable staff team. Staffing files do not contain all the required information. Five care staff hold NVQ qualifications. EVIDENCE: The home has a caring and committed staff team. The current staff team is stable and several have worked in the home for a number of years. Staff who were spoken to on the day stated that they were happy working in the home and felt they all worked well together as a team. Staff did appear knowledgeable about each residents needs. There is a good mix of both female and male staff. Staff recruitment files were viewed and they did not contain all the required information as set out in Schedule 2 of the National Minimum Standards. Several files did not have the correct CRB checks and some were missing proof of identity documents. One file only contained a single reference, where there should be two. CRB checks are not transferable between homes or services and the home needs to address this. To date five staff have obtained NVQ qualifications. Staff receive a good level of training and recent courses attended have included supporting people with Downs Syndrome, Dementia, Personality Disorder, Medication, Nutrition, Fire Training, Food Hygiene and Manual Handling. 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced and qualified manager runs the home. The home has an effective quality assurance programme. The home needs to review its policies and procedures. The home tries to ensure that the health, safety and welfare of residents and staff are maintained. EVIDENCE: The manager has worked at the home for a number of years and she holds an NVQ Level 4 qualification in care and the Registered Managers Award. Staff and residents both stated that the manager was friendly, supportive and approachable. The manager was not present during this site visit. The inspection was carried out with the assistance of the deputy manager who was extremely helpful. The home has an effective quality assurance programme which includes regular monitoring visits, weekly residents meetings, staff meetings, an annual 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 19 development plan and carrying out feedback questionnaires for residents and family members. Several policies and procedures were viewed and several are not very up to date. The home needs to review its policies and procedures and include others such as physical restraint and continence promotion, as these have become more relevant to the service and its current residents. The home carries out measures to ensure the health and safety of residents and staff is maintained. Fire drills are carried out regularly and the fire officer’s last visit was in March 2006. All maintenance records are kept updated. As mentioned previously the home needs to ensure that the two radiator covers in the second lounge are securely attached to the wall. There were no other health and safety concerns. 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 20 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 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 2 X 3 X 3 2 X 3 X 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) Requirement To ensure that all medication is dispensed and recorded accurately. Previous Requirement 2. YA34 19 (1) (b)Sch 2 (7) 22(2)(5) To ensure that staff recruitment files contain all the required information, as set out in Schedule 2. To produce the complaints procedure for service users in an easy read format and to ensure it is also made available to visitors. To ensure that the homes policies and procedures are relevant and up to date. To ensure that radiator covers are securely installed. 31/10/06 Timescale for action 31/08/06 3. YA22 31/01/07 4. 5 YA40 YA42 13(7) 23(2)C 31/03/07 31/10/07 3a Lansdowne Road DS0000014212.V301545.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 3a Lansdowne Road DS0000014212.V301545.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: 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 3a Lansdowne Road DS0000014212.V301545.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. 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!