Inspection on 12/09/05 for 4 Seafarer`s Walk

This inspection was carried out on 12th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 Seafarer`s Walk 23/05/07

4 Seafarer`s Walk 27/06/06

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 4 Seafarer`s Walk Sandy Point Hayling Island Hampshire PO11 9TA Lead Inspector Ms Sue Kinch Unannounced Inspection 12th September 2005 12:00 4 Seafarer`s Walk DS0000064985.V249149.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 4 Seafarer`s Walk DS0000064985.V249149.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. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 4 Seafarer`s Walk Address Sandy Point Hayling Island Hampshire PO11 9TA 0151 420 3637 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) Community Integrated Care Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of two service users requiring the use of a wheelchair can be accommodated. This is the first inspection of this home since it was registered by Community Integrated Care. Date of last inspection Brief Description of the Service: The home is situated in a quiet residential area to the southeast of Hayling Island and within easy each of the beach. Local shops and amenities can be accessed but to use a wider range of facilities travel is necessary to locations off the island such as in Portsmouth, Southsea and Havant. The home is purpose built and is situated next to a similar registered home .The homes share the front car park. The home was purpose built with suitable adaptations and all of the facilities are provided on one level with the exception of the garden. This slopes away to the front and rear of the home making independent use difficult and restricting the amount of usable space. The home is suitable for people who have physical as well as learning disabilities. All of the service users have single rooms. They have use of the kitchen /diner, a lounge and another room known as the recreation room. The home has one bathroom and a separate WC. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory inspection took place over 5.1 hours. This was the first visit to the home since Community Integrated Care registered in July 2005. A partial tour of the premises was carried out. All of the shared areas and three bedrooms were viewed. All of the five service users were spoken with. Due to their reliance mainly on non-verbal communication few direct comments were received about the service. Observations were made of the interaction between staff and residents. Individual conversations were held with four of the staff working during the day and, the manager. What the service does well: What has improved since the last inspection? What they could do better: The impact of changes at the home was considered during the visit. Without doubt services have been disrupted and the home now needs the manager to establish clear leadership and direction for the home. Staff levels need to be kept to and the minimum of three a shift must be provided with the present resident group. There needs to be a reduction in the use of agency staff and a re-establishment of services based on the preferences of residents and offering them more varied and interesting lifestyles. There needs to be more opportunities for skill maintenance and development. Person centred planning is needed. Staff must be adequately supported through supervision and meetings. Adequate records such as staff records need to be held for all those providing care. Resident’s records need to be reviewed and CIC paperwork needs to be used for care plans and risk assessments. The records need to be stored securely and held together for each resident making them easily accessible and clear. The bathroom needs attention, as does the garden to ensure that they are safe and meet resident’s needs. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 Page 6 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. 4 Seafarer`s Walk DS0000064985.V249149.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 4 Seafarer`s Walk DS0000064985.V249149.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 A system is in place to ensure that prospective residents’ needs are assessed. EVIDENCE: The home has not recently had a change of residents. However an admissions policy is available in the home and includes a policy statement regarding pre admission assessments and sharing information prior to admission. This standard will be assessed fully following any future admission to the home. 4 Seafarer`s Walk DS0000064985.V249149.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): 6,7, 9,10 Residents would benefit from person centred planning to ensure their needs and wishes are known and plans are in place to meet them. Effective systems are needed to foster skill development and retention based on the priorities of residents. Residents would benefit from their records being held securely. EVIDENCE: Some case tracking took place and records were seen for two people. Care plan information was held in a number of files, which made finding up to date information difficult. The care plans in place were completed by the previous registered service. Much information about each resident is available. No work has taken place so far by CIC to re assess residents’ and draw up new care plans. No goals have been established. Person centred planning is needed. There are no daily record sheets to demonstrate how skills are being maintained or developed. There are daily sheets, which provide some key information for each shift, but overall it is not possible to establish what has 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 Page 10 happened in relation to the care plans. This is compounded by monthly reviews, where sampled, not having been completed. Risk assessments were held in two files on the open shelf for all of the residents rather than individually. As these contain action plans they should be with the individual care plans. The previous care providers left the risk assessments and whilst they have been reviewed, and are still in use, risks have not yes been re assessed using CIC’s format. This is needed. Care plan information was not held securely. The office is left open and some personal records were on the shelves. The manager agreed to deal with this. Attention is needed to ensure that the service is organised around the needs of the residents. During the week of the inspection two of the days were to be disrupted by staff interviews in the home, and a third by staff training leaving staff, less known to the residents, to provide the service. This is to be considered in the context of recent changes and an increase in stress and tension, reported by staff, among residents. Although staff were still deployed to work with the residents, the home is a domestic sized dwelling with little free space. The interviews for three posts were planned to take place in one of the resident’s shared spaces. It is advised that consideration should be given to most of the interviewing, in the future, taking place elsewhere. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 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): 11,12,13,14,16 Service users would benefit from an increase in opportunities to join in with a range of activities in the home and local community taking account of personal preferences and needs. EVIDENCE: Much work is needed to re establish the service based on residents needs and wishes. Records for two residents were carefully viewed to establish the nature and frequency of staff supported activities within a two-week period in July. For one person six external activities had occurred but there was little evidence of much else happening other than listening to the radio. For another, over a four-week period, there were seven external activities but little was recorded about in house activities except watching television. So there has been less use of the community and less activity at home. One member of staff commented on the disruption and unsettling effect on residents. Another said that residents had been getting frustrated and there had been more challenging behaviour because of not enough to do. Records held about residents did not show how skills were being developed or maintained. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 Page 12 The day service worker, who had previously offered a half weeks support to residents for activities, had stopped and in July and early August suitable transport for all residents was also not in place. The day service worker had involved residents in many activities outside the home and these were not taking place regularly. Staff commented on a resident missing a college course on the Friday before the inspection because of staff shortages and on the day of the inspection because of sickness. Other activities were reported by staff to have been missed because of agency staff not being sufficiently familiar with resident’s needs. Whilst occasional disruption will occur, in the context of the above findings, action is needed to safeguard course and other commitments. The manager spoke of establishing a weekly planner for residents tailored to individual needs. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 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): Not Assessed EVIDENCE: 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 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 the following standard(s): 22 A complaints procedure is available in the home but residents would benefit from a more active response to concerns raised on their behalf. EVIDENCE: A copy of the complaints procedure is posted in the front hall. The inspector was not informed of the home having received any formal complaints in recent months. However one staff member said that a relative had raised the issue of not enough activities happening. It was unclear as to how this had been dealt with. Two staff members were asked about the complaints procedure. One was aware of it. A book is held in the office for reporting complaints. None had been reported. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 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 the following standard(s): 24,30 The home is bright, fairly fresh and comfortable, but the signs of wear and tear continue to detract from it looking and being homely and from minimising risks of infection control. EVIDENCE: The manager reported to have reviewed the environment and had made proposals to CIC. The residents’ room opposite the office had already been improved. Carpets are to be replaced in the corridor and lounge and new flooring in the room opposite the dining room. The shared areas and three bedrooms were seen. The home was adequately clean and mainly free from odours. There was a smell of stale urine by the lounge door and some signs of wear and tear by the door where a crack in the wall was appearing and paint was splitting. Some of the lower kitchen cupboards need attention as some are damaged exposing bare wood presenting a hygiene problem. The bathroom floor needs attention to ensure that there are no infection control risks to the left of the bath. The sealant around the base of the shower is permeable and needs attention to prevent risk of infection. A discussion was held with the manager about only one bathroom available for residents and her assessment was that 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 Page 16 this was not adequate to meet service users needs. She has proposed plans to deal with this and is waiting to agree plans. The garden is uneven and offers little usable space for service users to use freely or with support. The manager spoke of ideas and suggestion to improve these in order to meet resident’s needs. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 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): 32,33,34, 36 At times resident’s needs are not met because insufficient numbers of suitably trained and supported staff are deployed on shift. Recruitment procedures in the home are not robust leaving the residents at risk. EVIDENCE: Staff records were sampled and discussed with the manager. These were incomplete. No information was in the home regarding agency staff. Requirements in respect of this were discussed with the manager. A file for one of the permanent staff was incomplete and there was no information for another. Staff levels were discussed. There were three staff vacancies. Agency staff members have been used but not fully. The consequence is that not all of the staff hours of 510 a week have been used weekly. In addition at times, especially at the weekends, the shift is only planned to be covered by two staff. This is not enough to meet the residents’ needs or to get work done and this concerned staff. Evidence for this was acquired from viewing rotas, talking to staff at the home and consideration of the resident’s needs and associated risks. Recruitment of new staff was planned for the day after the inspection and another day later in the week. The manager is advised to consider the 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 Page 18 possibility of establishing a relief bank of staff to further minimise the use of agency staff not known to residents. As the service users have high support needs in and out of the home, too much reliance on agency staff reduces the ability of the home to provide staff that know the service users needs. Two staff commented on how this then affects their ability to meet needs and unsettles the residents. It was noted that staff training has been taking place although the outcomes for residents were not assessed at this inspection. However, one member of staff also raised a concern about agency staff being left in the home in charge. This would not be acceptable in any circumstance. The inspector checked plans for the following Thursday when staff training was planned .The inspector was informed by the manager that the person left in charge would be a member of the relief team known to the residents and that it was not policy to leave the home without CIC staff in charge. Individual supervision has lapsed and needs to be established as soon as possible to ensure that an acceptable standard is maintained. It is important to recognise that through periods of change staff need more regular individual support and the manager’s decision to re establish this a fortnight after the inspection is fully supported. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,42 Strong leadership and direction needs to be re established in the home to ensure that residents’ needs and wishes are prioritised and met and the home is safe. EVIDENCE: Management of the home was discussed with the manager and some staff. The management of the home has been disrupted during the change of registration. Although a new manager was recruited she was not in post until August 9th2005. The home had therefore had a five week period in which the home did not have an allocated manager or deputy leading the team. The Commission was not kept informed of developments. Although a manager could be called on in an adjacent project, this was a period of inadequate leadership and management in the home. There was also no evidence on the rotas of management planned for the home in July and early August. The impact of the above left the staff without clear leadership, supervision, staff meetings, and feeling unsupported. Continuity of care has been affected by the change coinciding with staff taking annual leave, increased use of agency staff not known to service users, and lack of transport in the first few weeks. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 Page 20 The home now has a manager who is not yet registered. An application is required. The new manager is aware of the above and had spent time meeting with all staff individually with plans to have a team meeting the week after the inspection when summer annual leave had finished. This would be followed by supervision. It was advised to ensure that all of the staff were fully aware of this. The manager recognised that the staff and residents had had a difficult time. The staff were seen to need support and guidance and the manager was intending for each resident to have two key workers and for person centredplanning to influence activity in and out of the home. One member of staff said that staff morale was now improving with a new manager arriving and that the manager was approachable. Health and safety was not fully assessed but it was noted that one of the cupboards holding hazardous substances was not locked and contained a range of dangerous substances. Diligence is required in respect of the potential risks to one resident. 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 Score 2 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 x 2 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 x 16 2 17 Standard No 31 32 33 34 35 36 Score 2 X 2 2 x 2 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 4 Seafarer`s Walk Score X X X x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x DS0000064985.V249149.R01.S.doc Version 5.0 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 YA6 Regulation 15 Requirement The registered person must ensure that service users needs and wishes are met, skills are maintained and developed and up to date care plans are provided. The registered person must ensure that residents make more decisions about their daily lives and that this is documented. The registered person must ensure that residents’ information is held securely. The registered people must ensure that residents have opportunities for personal development and take part in a range of activities. The registered person must increase opportunities to use the community. The registered person must provide a plan of action in respect of the physical internal and external environment. A record of complaints must be held in the home. The registered person must ensure that the care staffing level of 510 hours a week is DS0000064985.V249149.R01.S.doc Timescale for action 12/11/05 2 YA7 12(1)(a) 12/11/05 3 4 YA10 YA11YA12 17(1)(b) 16(2)(m) 31/10/05 12/11/05 5 6 YA13 YA30YA24 16(2)(m) 23(2)(j) & (o) 13(3) 22 18(1)(a) 12/11/05 12/11/05 7 8 YA22 YA33YA31 31/10/05 31/12/05 4 Seafarer`s Walk Version 5.0 Page 23 maintained. 9 10 YA33 YA34 18(1)(a) 17(2) Schedule 4 18(2) 8(b) Adequate numbers of staff must be provided for each shift to ensure residents’ needs are met. The registered person must ensure that sufficient staff records are held in the home for each member of permanent, relief and agency staff. Staff supervision must be provided. The registered person must ensure that an application for registering a manager is submitted. The registered person must ensure that substances hazardous to health are locked away. 31/10/05 12/11/05 11 12 YA36 YA37 31/10/05 31/10/05 13 YA42 13(3) 31/10/05 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 Refer to Standard 16 Good Practice Recommendations It is recommended that residents’ involvement in the house and the responsibilities that go with it are reviewed 4 Seafarer`s Walk DS0000064985.V249149.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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