Inspection on 22/08/07 for 3a Lansdowne Road

This inspection was carried out on 22nd August 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 found no outstanding requirements from the previous inspection report, but made 1 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 22/08/06

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 1DN Lead Inspector Merle Blakeley Key Unannounced Inspection 22nd August 2007 10:00 3a Lansdowne Road DS0000014212.V354119.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.V354119.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.V354119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3a Lansdowne Road Address Hove East Sussex BN3 1DN 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 01273 731380 sandradaviesftf@tiscali.co.uk 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.V354119.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. 22nd August 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 £700.00 to £1,050.00 per week. 3a Lansdowne Road DS0000014212.V354119.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 six hours on August 22nd 2007. As well as this site visit information was also gained from a returned Annual Quality Assurance Assessment (AQAA) and seven service user surveys. During the visit the inspector was able to spend some time with three residents and talk to several staff and the deputy manager who facilitated the inspection. Document reading was also carried out and a health and safety check was conducted. Staff were observed throughout the day interacting with the residents. What the service does well: What has improved since the last inspection? During the last inspection five requirements were made. A requirement was made for the home to ensure that medication was being dispensed and recorded accurately. Although two minor errors were detected the home is overall correctly managing peoples medicines and staff have received suitable training. Staff recruitment files were required to contain more information and this has been carried out. The complaints procedure needed to be made available in a user-friendlier format. The home has now produced the complaints procedure in a pictorial format and it is also being displayed in communal areas. Policies and procedures needed to be kept relevant and up to date and two radiator covers were required to be securely installed. These items have been addressed. The home will need to be very clear about the new ‘male worker’ policy, which has been written, as it excludes males from carrying out any intimate personal care. This would mean that at no time could two male workers be working the same shift. This could present issues should an emergency arise. 3a Lansdowne Road DS0000014212.V354119.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. 3a Lansdowne Road DS0000014212.V354119.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.V354119.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments are carried out before a person moves into the home. EVIDENCE: The manager will carry out an assessment of a person to ensure that their needs can be met by the home. This assessment will also include the information provided by social services and where relevant the person’s family. One person recently had their care needs re-assessed by the home to ensure that they could continue to meet her needs following several major changes to her health and mobility. The home will continue to review this person’s needs on a regular basis. 3a Lansdowne Road DS0000014212.V354119.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): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are informative and kept up to date. People are able to make informed choices in their everyday lives. EVIDENCE: Each person has their own individual care plan, which they are actively involved with. Four care plans were viewed and they contained good information. Regular reviews are carried out. The home also maintains daily recording sheets and medical notes. Seven easy read service user surveys were returned before this inspection. Overall people felt that they could make their own decisions about certain aspects of their lives. They are able to go out when they wish and make decisions about want they want to do. Staff encourage and support people to make their own choices and decisions. There was also evidence to show that people’s cultural and spiritual needs were being met by the home. 3a Lansdowne Road DS0000014212.V354119.R01.S.doc Version 5.2 Page 10 Risk assessments are carried out for most of the people and they cover areas such as being out in the community, attending activities outside of the home and staying safe. These assessments are also reviewed on a regular basis. 3a Lansdowne Road DS0000014212.V354119.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): 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. People have access to a good level of activities and they are out and about in the local community. People are supported and encouraged to maintain family links. Residents choose their meals. EVIDENCE: Records show that people have access to a good level of activities. Each person has a weekly activities schedule, which includes attending day centres, college and clubs plus bowling, cinema, shopping, day trips and meals out. People who were spoken with on the day said that they felt they had enough to do. Most people are out and about in the local community on a daily basis. Several people stated that they enjoyed going to the pub with the staff. Some people have relatives and friends who come to visit them. Staff stated that they always support and encourage people to maintain their family links where possible. People are also supported to keep in touch with family members by phoning and sending birthday/Christmas cards during the year. 3a Lansdowne Road DS0000014212.V354119.R01.S.doc Version 5.2 Page 12 Staff try to encourage people to adopt healthy food options in their diets. Overall the menu appeared well balanced and residents choose the weekly menu. Staff have said that they have needed to encourage people to eat more salads and a wider variety of home cooked meals, as many people would prefer to eat pies and chips every day. Meal times are kept as flexible as possible and people are supported to be as independent as possible with the preparation their meals. 3a Lansdowne Road DS0000014212.V354119.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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive their personal care in the way they prefer. People’s healthcare needs are being met and medication is being correctly administered. EVIDENCE: Some of the people who live here require support with their personal care. Staff said that personal care was given with dignity and respect. Staff also support people to carry out their own personal care. The home has a ‘male workers’ policy, which excludes them from carrying out any intimate care on female residents. The manager was asked at a later date how this policy affected the staff team. She stated that there are always male and female workers on shift and it should not cause any problems. However, the home needs to be very clear about this policy and there should be a contingency plan to allow for emergency situations should they ever arise. One person’s healthcare needs have changed since the last inspection. This person has had a Percutaneous Endoscopic Gastrostomy (PEG) fitted, so that she is able to receive nutrition through a tube. Staff have received training in 3a Lansdowne Road DS0000014212.V354119.R01.S.doc Version 5.2 Page 14 this type of feeding and they said they have had good support from local nurse specialists. This person has also lost mobility so two staff are always required to assist her with all her care needs. Staff said that they had also been trained in the correct use of the hoist. The home feels that at this time they are continuing to meet this person’s healthcare needs. All residents are registered with their own GP and other visiting healthcare professionals. The home receives good support from the Community Learning Disability Team where speech therapists, physiotherapists, occupational therapists and dieticians are sourced. Each person is supported to attend healthcare appointments either in the home or in other local venues. Medication records were checked and overall they were found to be in order. Two small errors were identified and discussed with the deputy manager. It will be recommended that the lock on the medication cupboard is replaced, as the current lock appears flimsy and difficult to use. 3a Lansdowne Road DS0000014212.V354119.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): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a user friendly complaints and adult protection policy and procedure. Staff have needed to aware of their roles regarding the protection of vulnerable adults. EVIDENCE: The home has devised a complaints procedure, which is in a pictorial format and displayed in a communal area. All the resident surveys that were returned stated that people knew how to make a complaint. A complaint was made to the home about not reporting an incident between two residents. The manager did state that a Regulation 37 form should have been completed and this was duly carried out. This complaint did turn into an adult protection concern, which was investigated by the local authority, however it could not be substantiated. Since this alert all staff have attended training in the protection of vulnerable adults and they understand that any accusations or concerns must be followed through using the correct procedures. A number of resident’s finances were checked and the inspector was concerned that staff were ‘borrowing’ money from one person ‘pocket money’ to top-up another’s. This was discussed with the manager who stated that this practice has ceased and that if a person runs out of money then the homes petty cash float is used not another residents personal finances. 3a Lansdowne Road DS0000014212.V354119.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): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current environment is homely and meets people’s needs. EVIDENCE: The home has adapted one of the rooms on the ground floor to meet the current healthcare needs of one of the residents. As this person now needs a hoist and various other special aids the home felt that her current bedroom was not large enough, so the dining room was turned into a bedroom for this purpose. The room has been decorated and made comfortable and homely. This change of room does not seem to have had any effect on the other people who live there. There is a lounge on the ground floor and another on the first floor so there are still adequate communal areas. One bedroom on the first floor requires a window restrictor. One of the residents showed the inspector her room and she said that she was very happy and liked her room very much. The home needs to ensure that the boiler room door is kept securely locked. On the day the home was found to be clean and tidy. 3a Lansdowne Road DS0000014212.V354119.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): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a stable staff team who receive a good level of training. Only two staff currently hold an NVQ qualification. The home carries out suitable recruitment procedures. EVIDENCE: 3a Lansdowne Road currently employs six full time and six part-time staff. This team has remained stable and has provided residents with a good continuity of care, which has been an extremely important aspect of their continued wellbeing. The staff team were seen to be caring and committed in their work and they also appeared to support each other well. People who returned the resident surveys stated that they liked the staff a lot and get on well with them. They also said that they felt happy about going to a staff member if they had any concerns or worries. Only two staff members hold NVQ qualifications with a further three currently studying for an NVQ qualification. The home has not yet reached the required 50 of staff trained to NVQ Level 2 and above. It will be required that the home encourage more staff to enrol on an NVQ course. 3a Lansdowne Road DS0000014212.V354119.R01.S.doc Version 5.2 Page 18 Five staff recruitment files were viewed and they now contain all the required information. A CRB check is carried out before a person commences work in the home. Staff who were spoken to on the day said that they continued to enjoy working in the home. They also stated that the home had a nice and friendly atmosphere. Records revealed that staff have had access to a good level of training. Courses such as first aid, autism, and introduction to dementia, safeguarding adults, food hygiene and the safe handling of medicines have been attended. 3a Lansdowne Road DS0000014212.V354119.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): 37, 39 & 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 registered manager runs the home. The home has an effective quality assurance programme. The home tries to ensure that the health, safety and welfare of both residents and staff are maintained. EVIDENCE: The registered manager has worked in this home for a number of years and she holds the NVQ Level 4 and the Registered Managers Award (RMA). She also holds an NVQ Assessors Award. The manager was not present during this inspection. The inspection was facilitated by the new deputy manager who had been in post for six weeks. He was very helpful and was able to supply a lot of the required information. Staff said they felt well supported by the manager 3a Lansdowne Road DS0000014212.V354119.R01.S.doc Version 5.2 Page 20 and that she was very approachable. Some of the residents who were spoken to also said that they would go to the manager if they had concerns. The home has a good quality assurance programme, which includes Regulation 26 monitoring visits, weekly residents meetings, staff meetings and an Annual Quality Audit. The last Regulation 26 Visit was carried out in July 2007 and the Annual Audit was done in November 2006. Service user surveys and relative surveys were last carried out in January 2007. A health and safety check was carried out and the inspector identified that a window restrictor was required in one of the resident’s bedrooms on the first floor. As mentioned previously, the boiler cupboard should be kept securely locked. Fire drills are carried out and fire alarms are checked weekly. Hot water temperatures are monitored and recorded. An external company carried out a fire risk assessment in May 2006; as a result the home has produced an emergency fire plan procedure, which is currently being updated by the deputy manager. The manager carries out a monthly health and safety ‘walk through’ check, which covers the communal areas, all bedrooms and bathrooms. 3a Lansdowne Road DS0000014212.V354119.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 2 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 X 3 3 X 3 X X 3 X 3a Lansdowne Road DS0000014212.V354119.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. 1. Standard YA32 Regulation 18(1)(a) Requirement That more staff are encouraged to complete an NVQ qualification. Timescale for action 31/08/08 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. 2. 3. Refer to Standard YA20 YA42 YA42 Good Practice Recommendations That a more robust lock is provided for the medication cupboard. That the boiler cupboard door is kept securely locked. That a window restrictor is provided for one of the bedroom’s on the first floor. 3a Lansdowne Road DS0000014212.V354119.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 3a Lansdowne Road DS0000014212.V354119.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!