CARE HOME ADULTS 18-65
5 Shetland Court Carisbrooke Road West Durrington Worthing, West Sussex BN13 3RL Lead Inspector
Mrs J Aston Announced Thursday, 18 August 2005, 10:00 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. 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 5 Shetland Court Address Carisbrooke Road, West Durrington, Worthing, West Sussex, BN13 3RL 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) 01903 691117 01903 691117 Royal Mencap Society Mrs Christine Davies CRH(PC)- Care home only 7 Category(ies) of LD-Learning disability, 7 places registration, with number of places 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 27 January 2005 Brief Description of the Service: 5 Shetland Court is a Care Home registered to accommodate up to seven people in the Learning Disability Category aged between 18-65. The home is registered to provide personal care only.The accommodation consists of seven single rooms two of which are situated on the ground floor and five on the first floor. The property provides a lounge, dining room and kitchen and easy access to the garden at the rear of the property.The service provides personal care assistance and support to access day care services and appropriate leisure activities for adults with a profound learning difficulty and physical disability.The Royal Mencap Society owns the service. The Responsible Individual operating on behalf of the organisation is Ms Janine Tregelles. The Registered Manager is Mrs Christine Davies. 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was announced and undertaken on Thursday 18th August from 10am to 3pm. Six out of the seven service users were present in the home at some point during the inspection. The Inspector was unable to obtain the views of the residents during the inspection due to their communication difficulties but observed some interactions between members of staff and residents Five comment cards from relatives were received prior to the inspection. Comment cards were also sent to Doctors surgeries used by the residents and other professionals involved with the residents to obtain their views about the service. These comment cards had not been received at the time of writing the report but will be incorporated into the next inspection. The Inspector focused on the needs of two residents in the home. The information was obtained from the Registered Manager; the residents’ care plans, relatives (through comment cards), and the residents’ key worker. The Inspector also looked around the home. What the service does well: What has improved since the last inspection?
The Registered Manager has undertaken a quality assurance exercise that has obtained the views of relatives, staff and professionals about the service provided. Evidence of this has been sent to the Commission. Specific training has been provided to members of staff as required at the last inspection. Training in the needs of a person with autism has been undertaken.
5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 Page 6 The carpet in the hallway has been replaced 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 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 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 standard(s) None There have been no new residents admitted to the home since the last inspection. EVIDENCE: 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 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) 6, 7, 8, 9, No progress has been made in developing the service users care plans and files to ensure that the information provides evidence of how their needs are to be met. Members of staff support service users to make decisions about all aspects of their lives. Residents are encouraged to take part in aspects of household tasks. Risks for residents in daily life are assessed and minimised as far as possible. 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 Page 10 EVIDENCE: Two of the residents care plans and files were examined. The care plans provide the necessary information about the basic needs of the resident. However the home are currently using three files to store information. This is disorganised and does not provide an easy format to find current information. The information about each resident should be clear and concise about the support and assistance required and should link in to the assessment of need and identify long term and short term goals for the service user. A requirement has been made for this work to be undertaken within three months. Residents are unable to be consulted about their needs and have limited ability to make choices and decisions about their lives. Therefore members of staff rely on information gained through observation of residents, from information provided by relatives and other professionals to guide them on how what support and assistance to provide. It was evident that risks to residents are considered before they participate in an activity and the action to be followed to lessen the risk is recorded on a risk assessment. Risk assessments are reviewed regularly. 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 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, 14, 15, A range of opportunities and activities for residents are available outside of the home and provide a variety of stimulation and interest for residents. Some activities are provided within the home. Residents are supported to maintain contact with family and friends EVIDENCE: Most residents attend local day care facilities where a variety of activities are offered. Members of staff support residents to visit local shops, parks, pubs and restaurants. Some residents go horse riding, swimming and trampolining. The staff team are aware of a range of activities liked by the residents that can be undertaken in the home, e.g. Manicures, foot baths games and puzzles etc. The shift plans usually identify which member of staff will undertake activities. It is recommended that an activity programme be recorded on the residents file and the activities liked by residents recorded. Some residents are supported to visit relatives on a regular basis or relatives visit the home.
5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 Page 12 All relatives who responded to the inspection through comment cards said that the home kept them informed and consulted them about the care of their relative. 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 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) None The standards in this section have not been assessed at this inspection. EVIDENCE: 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 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, 23 There is an appropriate complaints procedure in place for the home and organisation. Members of staff have received training in adult protection procedures. EVIDENCE: A complaints procedure is made available to residents and relatives. Records are kept appropriately of all complaints made and are overseen by the organisation. There have been no complaints made to the home or to the Commission. Members of staff confirmed that they have received a refresher-training course in adult protection procedures. There have been no adult protection allegations reported to the home or the Commission. 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 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, 25, 26, 27, 28, 29, 30. The home had no garden furniture and the garden requires some attention. The home provides residents with an attractive comfortable home that is safe and well maintained and clean. EVIDENCE: On the day of the inspection it was noted that the home has no suitable garden furniture and that the garden required some attention. At the time of the observation none of the service users were using the garden. It is recommended that suitable garden furniture be obtained and some work to the garden be undertaken. The carpet in the hallway has been replaced since the last inspection. Residents’ rooms are decorated in a bright and comfortable way with residents’ belongings personalising each room. The communal space is accessible and comfortable. Specialist equipment is provided in bathrooms and bedrooms as required and is regularly checked for safety. 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, Residents’ are supported by competent members of staff and an effective staff team. There are good recruitment procedures in the home. There is a good level of training for members of staff and some specific training has been provided. However the home has not reached the target of 50 of the staff team trained to National Vocational Level 2. EVIDENCE: The organisation provides a good level of training for members of staff. New members confirmed that there was a good induction programme and they felt confident in working in the home after the induction. Further training is provided through a foundation course. The National Minimum Standards for Younger Adults require that 50 of the staff team be trained to NVQ Level 2 by 31st December 2005. Currently one member of staff has NVQ 3, three members of staff are undertaking NVQ 3 or 4 and one member of staff has registered to start in March 2006. The home will not achieve the required target due to two members of staff with NVQ leaving and the organisation ceasing funding for NVQ courses. The organisation must address this matter.
5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 Page 17 The Registered Manager has recruited some new members of staff due to four vacancies in the home. The vacant hours have been filled using teammates or agency staff. Continuity of agency staff is achieved by booking the same agency member of staff. Members of staff confirmed that the level of staffing is currently manageable and there are usually three members of staff on each shift. All relatives who responded through comment cards confirmed that they felt there was always enough staff on duty. The records relating to new members of staff were examined. It was evidenced that the correct recruitment checks were undertaken and new staff supervised until they were confident and competent to do the work. Members of staff spoken with confirmed that the staff team were very caring and worked well together. An agency member of staff said, “this is the only home I have been to where they have given me a good induction and told me where the fire exits are.” “I feel the staff really care about the residents and it’s a nice environment.” 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 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) 37, 38, 39, 42. There is clear leadership and direction for members of staff that ensures residents receive the correct support and assistance. A quality assurance exercise has been completed that has obtained views of the quality of the service. The home ensures the Health & Safety of residents and members of staff. EVIDENCE: An exercise had been undertaken by the Registered Manager to obtain feedback about the service provided. Residents, relatives and other professionals had been consulted. A report of the findings is available and has been submitted to the Commission. Records within the home demonstrated that all matters relating to the safety of the home are adhered to and kept up to date. This ensures that the residents live in a safe environment. 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 Page 19 The manager has the experience necessary to run the home and will have completed the National Vocational Qualification Level 4 by December 2005. Members of staff confirmed that they have regular supervision and staff meetings and feel well supported by the management in the home and the staff team. 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 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 x x x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 1 3 3 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
5 Shetland Court Score x x x x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 3 x H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 Page 21 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 6 Regulation 15 Requirement To develop the service user care plan and file into a format that demonstrates how the service users needs are to be met. Timescale for action 28th November 2005 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 28 32 Good Practice Recommendations Garden furniture to be provided and work to the garden undertaken. To achieve 50 of the staff team trained to NVQ level 2. 5 Shetland Court H60-H11 S14316 5 Shetland Court V235714 180805stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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