Inspection on 06/01/06 for 5 Saunton Gardens

This inspection was carried out on 6th January 2006.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 Saunton Gardens 07/11/08

5 Saunton Gardens 15/11/06

5 Saunton Gardens 05/04/05

5 Saunton Gardens 02/11/04

5 Saunton Gardens 10/06/04

5 Saunton Gardens 23/02/04

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Treloar College

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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 5 Saunton Gardens Farnborough Hampshire GU14 8UN Lead Inspector John Vaughan Unannounced Inspection 6th January 2006 10:30 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 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 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 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. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 5 Saunton Gardens Address Farnborough Hampshire GU14 8UN 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) 020 7454 0454 www.mencap.org.uk Royal Mencap Society Ms Hazel Margaret Wright Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users are not to be admitted under the age of 18 years. Date of last inspection 5th April 2005 Brief Description of the Service: 5 Saunton Gardens is a small residential service providing care and support to five younger adults with a learning disability. The care and support is provided by MENCAP and the building is owned by a housing association who is responsible for the maintenance of the property. Staff are provided twenty four hours a day to support the needs of service users. The home is located in a housing estate and is indistinguishable from the other houses in the street. The home is on the outskirts of Farnborough. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours. The inspector looked around the home, sampled some of the homes records and talked to the staff members who were on duty. All of the service users were seen and the inspector spent time with service users, talking to and observing their activities during the visit. The manager came to the house for a short period to assist the inspector with accessing confidential information. 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. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 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 the following standard(s): 2 The improvements to information for a new service user demonstrate that needs are assessed and acknowledged by the home. EVIDENCE: The inspector was concerned about the lack of assessment and planning information in place for a new service user at the last visit and looked at this service user’s file again at this visit. A detailed assessment is now in place as part of the person’s support plan together with a care manager’s assessment and further information from specialists. The inspector met with the service user who was very happy and relaxed in their surroundings and said they enjoyed living in the home. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 8 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 and 9 Detailed services users plans and risk assessments demonstrate that service users needs and wishes are acknowledged and responses are in place to meet these needs. EVIDENCE: The inspector looked at two plans and spoke to all of the service users living in the home. The home has set up a care plan for the newest service user and more detailed information was available to show how this individual’s needs have been assessed. The service user was present during the inspection and spoke to the inspector confirming that they continued to enjoy living in the home. Plans for service users are detailed and contain information on their needs and what support is required in each area. These areas included personal care, communication, activities and daily routines. Some plans need to be reviewed and this was discussed with staff on duty who were aware of this. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 9 The manager and staff said that the shortfall in permanent staff has contributed to some plans reviews being overdue and they would be updating these plans as a priority. The home also complete a quarterly review with each service user looking back on what has happened over the last three months and setting goals for the next three months. These are also in need of updating and the inspector stated that good practice like this should be maintained. The inspector examined three service users files to confirm that risk assessments are in place. One service user has two assessments for similar issues of leaving the home. One has limited information on the actions staff take should the person not return and the manager is advised to link these assessments to ensure clear information is available for staff to support this person. Risk assessments have been updated on service users support needs at night. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 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): 16 The practices within the home promote the rights of the service user and support their individual wishes and preferences. EVIDENCE: The plans contain a section on service users rights and information recorded within these sections confirmed that key workers meet with each person and explain their rights and responsibilities. Service users were observed interacting with staff, talking about their activities over Christmas and the conversations were all positive. The contact between staff and service users were relaxed and conducted in ways that supported the service user to make meaningful contributions to topics discussed. The inspector confirmed with service users that they have a key to their rooms and he observed service users locking their doors. People have a specific plan to document their day-to-day routines for getting up and going to bed. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 11 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 The practices of the home demonstrate a safe system of managing and administrating medication however this needs to be improved by documenting the small amount of homely remedies used by service users. EVIDENCE: The home use a monitored dosage system for the administration of medication to service users. This is supplied by a local pharmacy in the form of weekly containers known as the ‘NOMAD’ system. The medication is stored in appropriate secure cupboards and records are maintained of all prescribed medication received, administered and disposed of. The staff member assisting the inspector confirmed that they have had medication training before carrying out this role. The inspector noted a bottle of cough mixture and medication for pain relief in the cupboard. These items are named for individual service users however there are no homely remedy agreements on file to indicate the use of these medicines. The home has been advised to document the use of these medicines on each service users plan. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 12 Staff were not sure if the cough mixture was being used and the inspector advised that they should review this and if not required they should make arrangements for its disposal. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 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): 23 The home can demonstrate that the views and concerns of service users, their families and representatives are documented and acted upon. The practices within the home mean that service users are protected from abuse. EVIDENCE: At the Last visit concerns were raised by the inspector about the lack of action in responding to allegations made about the conduct of a staff member. A senior manager dealt with this on the day of the inspection and an investigation took place. This investigation has been concluded and appropriate action has been taken under the protection of vulnerable adults procedures. The inspector confirmed that other unrelated incidents have been reported and investigated under the Protection of Vulnerable Adults procedures. The home has acted in a timely and appropriate manner in the investigation of these matters. The staff training records confirmed that staff have training in the protection of vulnerable adults and systems and procedures are in place within the home to report any concerns raised. Two service users accounts were examined during the visit and the inspector saw evidence that service users monies are recorded accurately with receipts kept for transactions. Service users are supported to maintain bank, post office and building society accounts. Information was seen on file to confirm that service users are in receipt of their benefits and personal allowances. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 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 Improvements in the condition and décor of the communal areas of the home provide people living in the home with comfortable suitable facilities and give a more positive image of the service. EVIDENCE: The inspector toured the home during the inspection. The kitchen has been replaced as required at the last visit. This has improved the environment and made a more accessible and usable facility. Service users commented on the kitchen and said they were pleased at the changes. The lounge has also been painted and damaged plaster noted at the last visit has been repaired. Staff members told the inspector that they are waiting for the hallway to be redecorated by the landlord. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 An established training programme demonstrated that service users are supported by staff who are obtaining suitable qualifications. The practices of the home when recruiting new staff members protect service users. The lack of improvement to the supervision of staff means that the home cannot demonstrate that staff are effectively supported in their roles. EVIDENCE: Through discussions with the manager, staff members and examining records the inspector was able to confirm that the home has not met the timescales for having 50 of the staff team with a NVQ award. Currently the home has one staff with an NVQ 3, one staff member working on their award and a further staff member starting at the end of January. The home has five staff with just over three vacancies at present. Staff complete their Learning Disability Awards Framework (LDAF) induction and foundation initially and then are put forward for their NVQ. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 16 The manager is aware of the need to meet this standard and will be reviewing the NVQ programme with the potential increase in staffing from the current recruitment programme. Health concerns of one service user, which raised issues about the staff levels at night, have improved and continue to be investigated. The manager stated that risk assessments have been updated through discussions at reviews and with the care manager. Staff levels have not been increased due to this improvement. The inspector advised that the manager must keep this under review and staff levels must reflect the service user’s needs at night. The home continues to use a number of bank staff to fill staff vacancies and maintain satisfactory staffing levels in the home. The manager is hopeful that following today’s interviews further permanent staff will be secured. Recruitment records were examined for two staff and additional information on staff Criminal records bureau checks was seen for five staff. The recruitment records contained proof of identity, and two references. One file has a written record of a verbal reference, which the manager is aware of and is chasing up the written reference. Staff training is wide ranging with evidence that staff have attended courses on health and safety, first aid, moving and handling, medication administration and food hygiene. Additional training is provided in areas such as risk assessment, epilepsy, protection from abuse and autism. Comments from staff indicated that they are provided with opportunities to develop their skills. The supervision programme has not been re-established yet. One staff member has had supervision in the last four months and this has not been updated on the monitoring form used within the home. The manger stated that this will be improved and they are having additional support from another manager with training and development needs in the home. Staff said that they feel supported by the manager who is approachable and discusses issues on a less formal basis. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The home is well managed by a manager who is working towards appropriate qualifications. The service can demonstrate that an established system is in place to develop the service with views from service users and their families included in this process. The home can demonstrate that the home’s equipment is maintained and serviced to keep people safe however staff fire training needs to be updated. EVIDENCE: The manager has significant experience of managing a residential service for people with a learning disability. The inspector was told that they are working through their registered managers award and are expecting to have completed this in the next few months. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 18 Staff commented positively about the approach of the manager and the support that they receive. At the last visit to the home the inspector saw evidence of consultation between the home and service users including the use of surveys. The information is used to complete a service improvement plan and these plans are completed for each person. The documents have not been completed fully since the last survey was carried out to indicate if the improvements have been achieved. The manager stated that these are due to be completed again and the inspector advised that the process should be followed fully to demonstrate that these audits are effective in improving the service. Another manager carries out monthly monitoring visits under regulation 26 and a copy of this report is sent to the commission. Feedback from families and visitors to the home has been very positive. The inspector examined servicing and maintenance records, which demonstrated regular servicing of the electrical, heating and fire alarm systems, take place. Records indicate that weekly and monthly checks are carried out on the fire alarm systems. The last fire drill took place in December 2005. Fire training records indicate that a number of staff need update training. Staff who are noted to have update training do not have a training certificate or information to show how this training has been achieved. One member of staff said that they completed a questionnaire after watching a DVD. Another member of staff said it has been some time since their last update and an external trainer carried this out. The manager will need to ensure that all staff have up top date training in fire safety and this is fully documented within the training records. It would also be helpful if the details and process followed for this training is held in the fire manual. 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 19 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 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 3 X X 2 X 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 20 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 YA36 Regulation 18 Requirement The registered manager must ensure that all staff have regular supervision. Repeated requirement previous timescale of 05/06/05 not met. The registered manager must ensure that all staff have updated fire training. Timescale for action 03/03/06 2. YA42 23 03/03/06 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 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI 5 Saunton Gardens DS0000012060.V276843.R01.S.doc Version 5.1 Page 22 - 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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