Inspection on 26/09/05 for 3a Lansdowne Road

This inspection was carried out on 26th September 2005.

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 but made no statutory requirements on the home.

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 24/01/06

3a Lansdowne Road 03/09/04

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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 3a Lansdowne Road Hove East Sussex BN3 1FE Lead Inspector James Houston Unannounced 26 September 2005 08:30 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 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 Stationary 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 H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 3a Lansdowne Road Address 3a Lansdowne Road Hove East Sussex BN3 1FE 01273 731380 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Frances Taylor Foundation Mrs Sandra Davies Care Home (CRH) 9 Category(ies) of Learning Disability (LD), 9 registration, with number of places 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum number of 9 people to be accommodated 2. The people accommodated will be aged 18 to 65 years on admission Date of last inspection 15 February 2005 Brief Description of the Service: 3a Lansdowne Rd is registerd to provide accomodation and personal care to nine adults with learning disabilities. The home is located in Hove with very good access to local transport and amenities. It is a two storey building that offers a range of communal space and and nine single bedrooms. The registered provider is The Frances Taylor Foundation and the registered manager is Sandra Davies. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the twenty-sixth of September 2005. Before the inspection the inspector read records held on the home by the Commission for Social Care Inspection and prepared to inspect those sections of the standards to be covered at that visit. The actual inspection in the home took 6.6 hours. The inspector made a tour of the premises, and read a variety of policies, procedures, and records. The deputy manager, three staff and six residents were spoken with. Eight residents were living in the home on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 7 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 standard(s) 1,3, and 5. The home has a statement of purpose and service users guide giving full information. The home meets the needs of those living there. The home has a suitable contract with each resident. EVIDENCE: The home has reviewed its statement of purpose since the last inspection. This was further considered during the inspection to ensure that it is clear that the home is not registered to admit residents with diagnosed mental health needs. Minor changes needed to the home’s service users guide were noted during the inspection. The home is able to meet the needs of residents and records showed that other professionals are involved as needed. The home has some residents over the age of 65 and since the last inspection training has been given to staff in meeting the needs of older people. The deputy manager said that the home has not as yet been assessed by a competent person such as an occupational therapist as a resident who had caused particular issues has had to move on, thereby removing the need for this assessment. The home has reviewed with care managers the needs of its older residents and is awaiting the review outcome. Observation showed that staff are able to communicate with residents. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 8 The home provides residents with a statement of terms and conditions. A sample is included in the home’s welcome pack of information. It is recommended that new residents or their representatives sign the statement. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 and 10. Comprehensive care plans are kept and regularly reviewed. Residents are involved in the running of the home. Information about residents is handled appropriately. EVIDENCE: Good care plans are drawn up and are reviewed regularly. Staff said that they had read them and are familiar with them. Staff said that they had been given training recently on report writing and records seen confirmed this. Daily reports are up to date and well written. Residents have a key-worker and there is regular informal discussion. There is also a weekly residents meeting chaired by a member of staff and minutes are kept. These were made available to the inspector. A new staff member confirmed that residents had been involved in giving informal feed back as part of her appointment process. Staff confirmed that they use risk assessments to assist residents lead lives which are as full as possible, and that they give training and guidance to residents. Each resident has an individual plan of action for staff to follow if they go missing and staff confirmed that these are available to them. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 10 Residents’ records are accurate, secure and confidential. The inspector found staff were clear when information given them in confidence must be shared with the manager or others. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 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 standard(s) 11,12,13,15 and 16. Residents have opportunities for personal development. They are part of the local community. Visitors are made welcome. Residents’ rights are respected. EVIDENCE: Records inspected showed residents with complex needs receive specialist interventions. Staff said that residents have opportunities to fulfil any spiritual needs. Residents attend day centres, and said that they enjoy doing so. A resident said that they like working in a charity shop during the week. Staff said that the staff group as a whole is knowledgeable about the services facilities and activities in the local community and local specialist organisations. They said that relationships with the local community are good. Residents are encouraged to go out on their own where possible, and the home has a car and a minibus to assist staff in giving opportunities to residents. . Residents said that families and friends are made welcome and given a cup of tea. Staff said that they have the time to make visitors welcome. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 12 Staff said that they only enter rooms with the residents’ permission. They said that most residents go out to day centres, and at the weekends are able to get up when they choose. Staff were seen to talk with residents and not just with each other. Residents were seen to choose whether to be alone or in company. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 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 standard(s) 18,19 and 21. Residents are given appropriate personal support. Residents’ healthcare needs are met. Ongoing consideration of residents’ needs as they grow older is needed. EVIDENCE: Staff confirmed that personal support is given in private and where needed guidance and support regarding personal hygiene is provided. A resident said that they choose their own clothes, and staff said that residents make choices where possible. The deputy manager said that the home works in close partnership with family and friends. Records inspected showed that careful arrangements are made to meet the healthcare needs of residents. Residents said that they are usually taken to see healthcare professionals but records inspected showed when possible residents keep appointments on their own. The home two has older residents and since the last inspection their care needs have been reviewed and specific staff training offered. The home keeps details of the action to by taken by staff in the event of the death of a resident to ensure that residents’ wishes are met. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 22 and 23. The home has suitable systems for dealing with complaints. The home’s policies and procedures on adult protection are designed to protect residents in the event of abuse or allegations of abuse. EVIDENCE: The home has a suitable complaints policy available to residents. Residents said that they were aware of their right to raise issues with the manager. No complaints have been received by the home in the last year, and the commission for Social Care Inspection has received none. The home has a system to deal with any complaints received. Staff said that they had received training in adult protection and records inspected confirmed this. The home has reviewed and updated its adult protection procedures as required at the last inspection. Staff have had training in dealing with challenging behaviour. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 15 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 standard(s) 24,26,28, and 30. The home is well maintained. Communal areas and bedrooms are well presented. Laundry facilities are suitable. EVIDENCE: The home is a large detached building over two floors in its own large grounds. It has ample parking to the side. The premises are safe, bright cheerful and airy. They are in keeping with and offer good access to the local community. They are accessible to all residents. The gardens have a decked area and a patio, and further improvements have been made since the last inspection. Furnishings and fittings are of good quality and domestic in style. Communal areas are well furnished. The home has two lounges and a dining room and a small seating area by the front door. Furniture and lighting are domestic in style. Residents’ rooms are personalised. Residents said that they are able to bring in their own possessions if they wish. Inventories of possessions are kept. Residents said that they are able to lock their rooms if they wish and several do so. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 16 The home has a laundry facility with two washing machines, one of which staff said is used for soiled laundry. A machine with a sluice cycle is being sought. Staff said that residents help with doing laundry as much as possible. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 36. The home has an effective staff team that operates in the best interests of residents. Some attention is needed to increasing the frequency of staff supervision. EVIDENCE: Residents said that they find staff friendly and helpful. Staff were observed to be accessible to residents. Staff said that they find the home to be a good place to work. The home has a current staff rota. This showed that sufficient staff are on duty to meet the needs of residents. The manager confirmed that because of the changing needs of residents staffing levels are kept under review. There has been a considerable turnover of staff recently and new staff have been recruited. Bank staff are used but staff said that agency staff have not been needed. Staff receive regular supervision, but not quite to the recommended level of six times per year in all cases. Staff receive appraisals, but not at the recommended annual frequency. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,40,41 and 42. The management approach creates an open and inclusive atmosphere. Procedures are thorough and comprehensive. Required records must be available. The health and safety of residents is promoted but fire safety and provision of core training need some review. EVIDENCE: Residents are consulted informally and through weekly residents’ meetings. Staff have regular minuted meetings and copies of the minutes were made available to the inspector. Staff said that they are able to put forward ideas for improving the delivery of the service. Since the last inspection the home has reviewed its procedures. Staff confirmed the procedures are available to them. It is recommended that the manager sign the procedures. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 19 Records required to kept in the home and available for inspection were not all to hand on the day of the inspection. A requirement has been made. The home has procedures to manage health and safety issues. Records inspected show that staff carry out monthly health and safety audits and regularly check hot water temperatures. Since the last inspection all portable appliances have been tested but the record of testing was not available. The fire risk assessment could not be located. Several fire doors were wedged open during the inspection. This should cease. Staff receive regular training but update training for some staff in fire safety is required. Update training in first aid and food hygiene is being arranged. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 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 3 x 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3a Lansdowne Road Score x 3 3 3 Standard No 37 38 39 40 41 42 43 Score x 3 x 3 2 2 x H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 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. 2. Standard 41 42 Regulation 17(2) 13(4)(c)& 23(4)(c) (i) 23(4)(e) Requirement Keep available in the home for inspection all the required records. The registered provider must ensure that fire doors are not propped open.(Previous immediate requirement not met). Provide update fire training as needed. Timescale for action 3/10/05 Immediate 3. 42 31/12/05 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. Refer to Standard 36 40 Good Practice Recommendations Provide formal recorded supervision for staff at least six times a year, and annual appraisals. Policies and procedures are signed by the registered manager. 3a Lansdowne Road H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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 H59-H10 S14212 3a Lansdowne Road V245714 260905 Stage 4.doc Version 1.40 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. 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