CARE HOME ADULTS 18-65
5 Shetland Court Carisbrooke Road West Durrington Worthing West Sussex BN13 3RL Lead Inspector
Mrs J Aston Unannounced Inspection 5th January 2006 09:30 5 Shetland Court DS0000014316.V272893.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 5 Shetland Court DS0000014316.V272893.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. 5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 5 Shetland Court Address Carisbrooke Road West Durrington Worthing West Sussex BN13 3RL 01903 691117 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) H4037@mencap.org.uk Royal Mencap Society Mrs Christine Davies Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th August 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 DS0000014316.V272893.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection undertaken on Thursday 5th January 2006 from 9.30am to 1.30pm. This was the second visit to the home this year and completes the annual inspection programme for the year 2005. This report should be read in conjunction with the last inspection report of the 18th August 2005. On arrival five residents were in the home, two residents returned to the home later in the day so all residents were seen. The Inspector was unable to obtain the views of the residents during the inspection due to communication and comprehension difficulties. However some interactions between members of staff and residents were observed. Comment cards for relatives were sent to the home for distribution prior to the inspection, however as they were only received a few days before Christmas the Registered Manager had not yet distributed them to relatives. Any comments received from relatives through comment cards will be considered at the next inspection. During this visit the Inspector looked around the home, spent time talking with members of staff and the Registered Manager and examined a sample of records. What the service does well: What has improved since the last inspection?
A requirement was made at the last inspection in relation to the development of the residents care plans and files to ensure that the information is condensed and provides evidence of how residents’ needs are to be met. It was noted at this inspection that progress in meeting this requirement had been made and work is nearing completion. 5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 Page 6 A recommendation was made at the last inspection in respect of training as the funding for members of staff to undertake National Vocational Qualifications (NVQ) had been frozen. The Inspector was shown confirmation from the organisation that the freeze on funding for NVQ training has now been lifted. The Registered Manager and two Deputy Managers have now completed the NVQ Level 4 and the Registered Managers Award. A recommendation was made at the last inspection in respect of the home having no suitable garden furniture and that the garden required some attention. Since the last inspection members of staff have tidied the garden and the Registered Manager is in the process of obtaining quotes for garden furniture. 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 DS0000014316.V272893.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 5 Shetland Court DS0000014316.V272893.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): None All Standards in this section were assessed at the last inspection and identified as being met. There have been no new residents admitted to the home. EVIDENCE: 5 Shetland Court DS0000014316.V272893.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. Some progress had been made in making improvements to the residents individual care plans and files. Individual care plans do not provide specific guidelines for members of staff to follow in situations where a resident maybe at risk to themselves or other people through inappropriate behaviour. Standards 7,8 and 9 were assessed at the last inspection and identified as being met. EVIDENCE: Standard six was revisited as a requirement had been made in respect of this Standard at the last inspection. At this inspection the Inspector was shown three out of the four residents care plans that had been completed and developed into a comprehensive format. The outstanding four care plans were nearing completion. The Registered Manager informed the Inspector that the work would be complete within a week. A further requirement has been made with a one month timescale.
5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 Page 10 An incident reported to the Commission for Social Care Inspection by the Registered Manager has highlighted that there are no explicit guidelines in place for members of staff to follow when working with residents inside and outside of the home who maybe at risk to themselves or other people through inappropriate behaviour. This could potentially put the resident and member of staff at risk. A requirement has been made for this to be addressed and for the Registered Manager to ensure that the Department of Health’s guidance on the use of physical intervention with people with learning difficulties is obtained and members of staff given appropriate guidance and training as a matter of priority. There was evidence that the Registered Manager has ensured that five out of the seven resident’s needs have been assessed and the placement reviewed by a Social Worker annually. The Manager is currently in the process of accessing a Social Worker to attend a review meeting for the other two residents. 5 Shetland Court DS0000014316.V272893.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): 16,17. Resident’s rights are respected and upheld. A choice of healthy meals, snacks and drinks are offered and provided. EVIDENCE: The Inspector gained the view from comments made by members of staff, from observations made whilst in the home and from reading daily notes that every attempt is made to ensure that a resident’s rights and choices is upheld as far as possible. Due to the level of disability members of staff at times have to act in the best interests of residents. There was evidence that a resident’s rights to obtain medical attention, treatment or advice or appropriate benefits is promoted on their behalf. On the day of the inspection chicken casserole was being prepared and cooked for lunch. Residents were offered drinks regularly. Members of staff prepare and cook all meals and snacks. There was evidence that training in food hygiene is provided as part of the induction course for new staff and updated as required every three years. Members of staff work to a menu plan that has incorporated the resident’s likes and dislikes.
5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Residents receive personal support in an appropriate manner. Resident’s physical and emotional needs are met as far as possible. Suitable procedures are in place in respect of the administration of medication. EVIDENCE: Each resident has a detailed plan of their personal care needs and how this should be provided. New members of staff receive a comprehensive induction in how to work with each resident that includes assisting with personal care. A new member of staff said that new members of staff are not able to assist a resident with personal care until they had been observed to be competent in that task. A member of staff confirmed that from their observations all members of staff are respectful when assisting with personal care, fully explain what they are doing and promote the resident’s independence as far as possible. Moving and handling equipment is personal to the resident and has been provided through an Occupation Therapist assessment. Members of staff are trained in how to use the equipment as part of the induction course and then the training is updated annually.
5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 Page 13 Organised activities inside and outside of the home are designed to provide a wide range of stimulation that meets a resident’s physical and emotional needs. Activities range from swimming, music therapy, games, going for a drive and hand massage. On the day of the inspection the medication kept in the home appeared to be stored appropriately in an organised and safe way. Good records are kept of each resident’s medication and when given and information held about any side affects that may occur. There was evidence that advice is sought from relevant Professionals in respect of residents’ behaviour that may require a change in medication. 5 Shetland Court DS0000014316.V272893.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): 23 Standard 22 was assessed at the last inspection and identified as being met. Standard 23 was reconsidered at this inspection. Specific guidelines are not in place for members of staff to follow in situations where a resident maybe at risk to themselves or other people through inappropriate behaviour. EVIDENCE: There have been no complaints or any adult protection allegations reported to the Commission for Social Care Inspection. As previously stated an incident reported to the Commission for Social Care Inspection by the Registered Manager has highlighted that there are no explicit guidelines in place for members of staff to follow when working with residents inside and outside of the home who maybe at risk to themselves or other people through inappropriate behaviour. This could potentially put the resident and member of staff at risk and relates to Standard 23. The Registered Manager must ensure that the staff team work in line with the Department of Health’s guidance on the use of physical intervention with people with learning difficulties. If any form of physical intervention is required and used this must be after appropriate training and with specific guidance for staff and well documented of how this has been used. 5 Shetland Court DS0000014316.V272893.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 All Standards were assessed at the last inspection and were met. EVIDENCE: On the day of the inspection the home looked clean and well presented. Shetland Court provides a high standard of accommodation for residents. On the day of the inspection the Inspector was informed that the central heating was not working in all parts of the home. Despite numerous contacts with Downland Housing Association and their contact with the supplier of a new boiler this has not been addressed. A requirement has been made for this to be addressed. 5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 36 National Vocational Training is again being funded by the organisation. Good recruitment procedures are practiced. The frequency of supervision of staff requires improvement. EVIDENCE: The Inspector was shown confirmation from the organisation that the freeze on funding for NVQ training has been lifted. This means that the home can continue to work towards meeting the target of 50 of the staff team trained to NVQ level 2. Two new members of staff have been recruited since the last inspection. Records in relation to new staff were examined. There was evidence to demonstrate that all the necessary recruitment checks had been undertaken prior to the person commencing work in the home. A spot check was undertaken on the frequency of individual supervision for members of staff. The organisation has an expectation that individual supervision is undertaken every six weeks and this meets the requirements of the National Minimum Standards for Younger Adults. However on examining staff records there was no evidence to demonstrate that members of staff had received regular individual supervision in the last year or an annual appraisal.
5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 Page 17 The Registered Manager aims to hold staff meetings on a monthly basis however a staff meeting had not been held since September 2005. A meeting was being held on the day of the inspection. The communication within the home and support for staff will be affected if regular individual supervision and regular staff meetings are not held therefore a requirement has been made for the Registered Manager to address this matter. 5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None Standards 37,38,39 and 42 were assessed at the last inspection and were identified as being met. EVIDENCE: 5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 X 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
5 Shetland Court Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X x DS0000014316.V272893.R01.S.doc Version 5.0 Page 20 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. Standard YA6 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. The Registered Person shall make arrangements by training staff or by other measures to prevent service users being harmed or suffering abuse or being place at risk of harm or abuse. The Registered Person shall ensure that persons working at the care home are appropriately supervised. The Registered Person shall ensure that ventilation, heating and lighting is suitable for service users and is provided in all parts of the home, which are used by the service users. Timescale for action 06/02/06 2 YA6YA23 13 (6) (7) (8) 03/04/06 3 YA36 18 (2) 03/04/06 4 YA24 23 (2) (p) 06/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 5 Shetland Court DS0000014316.V272893.R01.S.doc Version 5.0 Page 21 No. 1. 2. Refer to Standard YA28 YA32 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 DS0000014316.V272893.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Worthing LO 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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