Inspection on 24/01/06 for 3a Lansdowne Road

This inspection was carried out on 24th January 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 no outstanding requirements from the previous inspection report, but made 4 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 22/08/06

3a Lansdowne Road 26/09/05

3a Lansdowne Road 03/09/04

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Southfields

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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 3a Lansdowne Road Hove East Sussex BN3 1FE Lead Inspector Jon Wheeler Unannounced Inspection 24th January 2006 12:00 3a Lansdowne Road DS0000014212.V273237.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 3a Lansdowne Road DS0000014212.V273237.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. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 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.V273237.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 9 people to be accommodated The people accommodated will be aged 18 to 65 years on admission Date of last inspection 26th September 2005 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. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection started at 12:00 noon and lasted for four and a half hours. The inspection involved talking to the manager, deputy manager, two members of staff and seven of the service users. Staff and service users were observed working together. The process included a brief tour of the premises; reading care plans, policies and records; checking the administration and recording of medication. Those key standards not assessed at this inspection were assessed at the inspection of 26 September 2005. There was a wide range of evidence that the home provides good quality care to the service users and enables them to lead fulfilling lives. What the service does well: What has improved since the last inspection? What they could do better: 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 6 Care plans and risk assessments should be reviewed and updated to clearly indicate where the needs of the service users have changed. Medication should be signed for when it is dispensed to ensure the health and safety of the service users. All staff should have a Criminal Records Bureau check prior to them commencing employment. All staff files should contain photographic identification. 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.V273237.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 3a Lansdowne Road DS0000014212.V273237.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): 2, 3, 4. The service has a comprehensive pre-admissions process, which enables the service to identify the needs of prospective service users and for the service users to visit the home prior to moving in. EVIDENCE: There was documentary evidence that the service undertakes a comprehensive pre-admissions process, prior to service users moving in to the home. There was evidence that a service user who has recently moved in, had visited the home on a number of occasions in order to meet the other service users, the staff and familiarise herself with the home. There was documentary evidence of the manager undertaking a preadmissions assessment, in conjunction with a social care assessment. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 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, 9. Care plans and risk assessments did not all contain up to date information and therefore did not identify the current needs of the service users. EVIDENCE: Whilst staff were knowledgeable about the needs of the service users and care plans contained comprehensive information, the information in some care plans had not been recently reviewed. The care plans contained background information about the service users as well as identifying their individual needs. There were a range of risk assessments in place for activities and opportunities in the home and in the community. However, some of the risk assessments had not been reviewed and updated to reflect the changes in needs or opportunities. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 16, 17. Service users are supported to take part in a wide range of activities to lead fulfilling lives, meet their needs and ensure their personal development. Service users play an active and fulfilling role in the life of their community. The ethos of the homes promotes the right of service users to make choices in all aspects of their lives. EVIDENCE: Service users are supported to access a wide range of vocational, educational and leisure activities, which meet their individual needs and preferences. They are supported to attend formal day care services or regular college courses. Activities are accessed in services for people with learning disabilities as well as mainstream community activities and facilities. One service user who recently moved in has a plan of activities arranged by the home. The service users spoken with said they were happy with the range of activities on offer and that they were able to choose the things they do. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 11 Service users are supported to do a wide range of leisure opportunities including reflexology, the cinema, attending a slimming group, knitting, ten pin bowling as well as trips and meals out. One service user works in a shop, whilst another is supported by staff to go to an Internet café to keep in contact, via emails with family and friends. Service users are encouraged and supported to make choices in all aspects of their lives. There is a residents meeting once a week, where they discuss issues affecting the home. Service users are able to choose their activities, what they eat, and to maintain their independence. The service has provided sensitive support to enable one service user to walk to her leisure activity, to enable her to safely maintain her independence. The service users play an active role in doing the cooking, cleaning and their own personal laundry. The service promotes healthy eating, whilst enabling service users to choose what they would like to eat. There is a planned evening menu, which recognises the choices of the service users as well as their dietary requirements. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21. Gaps in the recording of dispensed medication did not ensure the health and safety of the service users. The service provides sensitive and dignified support to meet the changing needs of aging service users. EVIDENCE: The service uses a monitored dosage system for the storage and dispensing of medication. All staff who administer medication have received training. A number of gaps were found in the recording of where medication had been dispensed and an immediate requirement was left for the service to ensure all medication given is accurately recorded. The manager and staff in the home have a clear knowledge and understanding of the needs of the service users and how those needs change with age. The service users are treated with dignity and respect and are encouraged and enabled to maintain their skills and independence, whilst also being offered a range of age-appropriate activities, which meet any changes in needs. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Service users are able to raise concerns and complaints. They are protected from abuse by robust policies and procedures, in conjunction with staff receiving appropriate training. EVIDENCE: The service has a complaints book, although no complaints had been received. Staff confirmed that service users are supported to raise any issues or concerns they may have, either in one-to-one time with staff or during the tenants meetings, which are regularly held. Three of the service users spoken with said they were able to talk to staff and the manager if they were unhappy about anything. There was evidence that all staff had completed adult protection training. Staff confirmed that adult protection issues are discussed during team meetings. They were also able to describe how any potential adult protection issues would be raised and recorded. The home has a clear policy and procedure to ensure service users’ money is kept safely and appropriately accounted for at all times. There was documentary evidence that all income and expenditure of service users’ money is recorded and checked daily. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30. The home offers a friendly and relaxed environment that is kept in good decorative order and offers sufficient communal space. There are sufficient bathroom and toilet facilities that meet the needs of the service users. The home is kept clean and tidy. EVIDENCE: There was evidence of the service having an effective on-going maintenance programme, which ensures the home is kept in good decorative order. Each service users has their own bedroom, whilst there are two lounges, a dining room and kitchen providing communal space. Service users are able to decorate their rooms with their own pictures, ornaments and possessions, to suit their own needs and tastes. Bedrooms were homely, comfortable and met the needs of the individual service users. Three of the service users who expressed their views, said they were happy with their bedrooms. Service users are able to spend time in their own bedroom, or in either of the lounges. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 15 Four of the service users have en-suite facilities in their bedroom, whilst there are two bathrooms and three toilets upstairs as well as two toilets downstairs. At the time of the inspection, the home was clean, tidy and free from offensive odours. There was evidence of there being sufficient time available for the cleaners to keep the home clean and tidy. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 16 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): 31, 32, 33, 34, 35, 36. There is a skilled and dedicated staff team who continue to work hard to meet the needs of the service users. The staff team are supported to provide consistent care and meet the needs of the service users with regular supervision and staff meetings. Some gaps in the organisation’s employment procedures do not ensure the protection of the service users. EVIDENCE: Skilled and knowledgeable staff were able to describe their individual roles and responsibilities and those of their colleagues. Staff had a clear and in-depth knowledge about the individual needs of each of the service users and how the staff team consistently meets those needs. Staff were able to describe the changes in needs of some of the service users. At the time of the inspection, the home was fully staffed and had no vacancies. There was documentary evidence that there are sufficient staff on duty for each shift to provide good quality care to the service users and to enable them to undertake a varied programme of activities throughout the week. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 17 There was documentary evidence that the service has a system for the recruitment of staff. However, one employment file viewed did not contain a Criminal Records Bureau check or photographic identification. There was documentary evidence that the staff team are well trained to enable them to effectively carry out their jobs. There was evidence that staff had recently done update training in fire safety, managing challenging behaviour and first aid. There was evidence that courses had been booked on dementia awareness and manual handling. Seven of the fourteen contracted staff have relevant NVQs. The service has a comprehensive induction pack for new staff, in line with the sector skills council guidelines. The induction and foundation programme training is linked to NVQ courses to provide a clear progress training system for staff. There was documentary evidence to demonstrate that staff receive regular supervision. In addition, staff reported that there is good communication in the team to ensure all staff are aware of any significant issues or changes affecting service users. All staff spoken to said they felt well-supported and were able to raise any issues or concerns they may have. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 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, 38, 39, 41, 42. A skilled and experienced manager provides clear direction and support to enable the staff to provide good quality care to the service users. A range of robust quality monitoring systems enables service users’ views to influence the service. A range of regular health and safety checks ensures the health and well-being of service users and staff. EVIDENCE: The manager has worked at the home for many years and is a skilled and knowledgeable practitioner, who provides a clear sense of direction and values in the home. The manager has an NVQ level 4 in care and the Registered Managers Award. Service users and staff reported that the manager is friendly, approachable and supportive. The service has regular monitoring visits, in line with regulations. There are weekly service user meetings, where they are able to raise and discuss any 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 Page 19 issues that affect their life in the home. There was documentary evidence of a thorough quality review process run by the company, in line with the National Minimum Standards. New staff have to complete a six month probationary period, whilst all staff have an annual appraisal. The service has a range of policies available in the office. Staff were able to describe how a range of the policies worked in practice. The service has systems for checking and maintaining the health and safety of the home environment. Staff had completed fire safety training, checks were carried out on the fire systems and doors had been fitted with automatic closing devices to ensure the safety of service users and staff in the event of a fire. 3a Lansdowne Road DS0000014212.V273237.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3a Lansdowne Road Score X X 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 3 3 x DS0000014212.V273237.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2. 3 4 Standard YA6 YA9 YA20 YA34 Regulation 15 (1) (2) 13 (14) (b, c) 13 (2) Requirement Review and update care plans. Review and update risk assessments. Ensure all medication is dispensed and recorded accurately. Staff recruitment information is available for inspection. Timescale for action 24/03/06 24/03/06 24/01/06 24/02/06 19 (1) (b) Sch 2 (7) 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.V273237.R01.S.doc Version 5.0 Page 22 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.V273237.R01.S.doc Version 5.0 Page 23 - 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. 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