CARE HOME ADULTS 18-65
52 Mill Lane Hove East Sussex BN41 2DE Lead Inspector
Jenny Blackwell Unannounced Inspection 17th November 2005 10:00 52 Mill Lane DS0000014149.V249750.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 52 Mill Lane DS0000014149.V249750.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. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 52 Mill Lane Address Hove East Sussex BN41 2DE 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) 01273 439156 Southdown Housing Association Limited Ms Patricia Margaret Hyland Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. This home is registered for 5 people with a learning disability and a physical disability The number of people accommodated must not exceed 5 Date of last inspection 16th May 2005 Brief Description of the Service: 52 Mill Lane is run by the Southdown Housing Association, and provides longterm accommodation in a ‘dormer’ style bungalow for up to five adults of either gender. The people live on the ground floor of the property and have their own single bedrooms, while sharing the communal living/dining room, kitchen, bathrooms and garden. The home is located in the residential area of Portslade, on the outskirts of Brighton, within reasonable distance of local shops and other amenities. Although established as a service for younger adults with learning disabilities, within the current group of people four are also wheelchair users, and the home provides adapted facilities to them. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. During this summary and report the people who live at the home will be referred to as people/person (except in the requirements section), and the people who work at the home as staff or by their job title. The people who live at the home, some of the staff team and the deputy manager were present during the inspection. Time was spent with four of the five people who live at the home. The deputy manager was briefly spoken to as she was finishing her shift. The deputy was acting up as manager in the manager’s absence, as she was on planned leave from the home. The requirements made from the inspection in May 2005 were checked to see if they had been met. The deputy manager produced evidence to show that most of the requirements and recommendation had been met. Two requirements will be carried forward. Relative comment cards were not distributed, as this was an unannounced inspection. The people who live at the home and the staff were helpful throughout the inspection and contributed to the report where possible. What the service does well:
The manager and staff continue to provide individualised support to the people who live at the home. The manager and organisation ensure that it reviews each person’s support needs and goals regularly, including the person in the process. Staff were seen to interact sensitively with the individuals and were knowledgeable about their support needs. During this inspection two of the three members of staff were relief workers (one of which was on a temporary contract to cover maternity leave.) The staff worked as a team and provided continuity of care regardless of their job role. The staff team had received specific training in supporting people with complex needs. The skills and knowledge of the staff team can support the needs of the current group of people and the staff encourage the people to be as independent as possible. The current group of people rely on the staff to assist them in most aspects of their care. The staff team work in supporting the people’s wellbeing. Some of the people have complex health care support needs and the staff are well trained and competent in supporting the individuals. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 6 During the inspection the staff demonstrated an understanding that the support plan information belonged to the individuals and asked permission from them before sharing any information with the inspector. The staff reported that they felt supported by the deputy manager in the manager’s absence. They did not have any concerns about any reduction in leadership or direction as they were familiar with the deputy and felt confident about the organisation’s support in the absence of the manager. What has improved since the last inspection? What they could do better:
The staff could not find the Statement of Purpose during the inspection. At the previous inspection it had been required that the manager amend some of the information to accurately reflect the home’s function. It was not possible to check to see if this had been achieved, therefore this requirement continues. It was also required that the staff are aware of the document and where it is held. Not all of the people’s placements had been reviewed annually. The manager and organisation ensure that it reviews each person’s support needs and goals regularly, including the person in the process. However the placing authorities had not conducted the annual review of some of the people’s community care assessments. Although the manager could not guarantee the social workers from the placing authorities would conduct the reviews, he must provide evidence that he has requested the reviews take place annually. On this visit it was noted that one person was still having the ready meals at lunchtime during the week. It was not evident if the person’s diet had been reviewed by the manager. It is required that the manager ensures that the person is not receiving a substandard diet and that she seeks advice from dietician. During a check of the people’s monies it was noted that there was a discrepancy in the amount of money held and the total recorded. The error had been picked up by the homes checking procedures and a senior member of staff from the organisation was due to investigate the discrepancy. However
52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 7 the organisation had not informed the Commission of the investigation or made clear if the investigation was due to be looked at under adult protection procedures. It was required that the home ensures it reports all incidents that effect the well being of the people. A company contracted to service the fire equipment in the home had carried out a fire safety check. It was noted that the contractor’s had recommended that a backup power supply was needed for the fire detection system. The deputy manager was unable to confirm if this had been arranged. It is required that the home meets the recommendation from the fire safety report and identify a backup power supply. 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. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 8 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 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 9 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): 1,2 and 3 The staff were unable to locate the Statement of Purpose for the home during the inspection. The placing authority had not reviewed the placement assessments for the people. The current group of people were having their needs met by the home. EVIDENCE: At the inspection the staff were unable to locate the Statement of Purpose document. At the previous inspection it was required that the document was amended to more accurately reflect the home’s function. As the document was not available the requirement could not be checked and would therefore carry over to this report. It was also required that the home make available the Statement of Purpose to the people who live at the home, staff and other interested parties. The manager and organisation ensure that it reviews each person support needs and goals regularly, including the person in the process. This happens according to the organisation’s policy and the staff demonstrated a commitment to this process. The manager had written to Brighton and Hove City Council to invite a representative from the social work team to attend the Southdown Housing in-house reviews for each person. However the placing authorities had not conducted their annual review of the people’s community care assessments. Although the manager could not guarantee the social workers from the placing authorities would conduct the 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 10 reviews, she must provide evidence that she has requested the reviews take place annually. The staff team had received specific training in supporting people with complex needs. The skills and knowledge of the staff team can support the needs of the current group of people. Staff were seen to have knowledge of supporting people’s postures, using equipment for lifting and positioning and helping people with special nutritional support. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 11 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): 8 and 10 The people are supported to make decisions about their lives and are consulted on daily aspects of life. The information about people was stored appropriately, in accordance with the organisation’s policies. EVIDENCE: It was observed that the staff consult the people regularly throughout the day about their preferences. Due to the situation with some people’s disabilities, staff were seen to use the observation of people’s body language to be guided by their choices. The staff and managers plan the functions of the home. The current group of people are encouraged to participate in the daily aspect of the home, this was noted at the mealtime when staff worked on a 1:1 basis with people, asking them about their preferences. Two of the members of staff on shift were relief members of staff, with one having a contract to cover maternity leave. They were seen to know the people well and encourage people to make choices. At dinner one person was not keen to eat his dinner - the staff member working with him was sensitive to his responses to the meal and respected his choices.
52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 12 The staff were seen to use records containing information about the people. They replaced the records back from were they got them and did not leave them lying about. Some daily notes about what the people had done during the day were kept in the lounge, in each person own diary. The information in these notes were generally about what people had done during the day, and would not compromise a person’s confidentiality. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 13 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 and 17 The staff enable the people to have the opportunities for personal development. Generally people are offered a healthy diet and enjoyed their meals. EVIDENCE: The staff encourage the people to be as independent as possible. The current group of people rely on the staff to assist them in most aspects of their care. It was noted during the evening meal that a person was encouraged to help herself with eating and was given support when she needed it. The staff support the individuals with the disabilities by ensuring that they are well positioned during the day and have regular exercise techniques that help people to stay mobile. During the last inspection it was noted that one person had a fairly high number of ready meals sent with her to her day service. It was recommended that the nutritional content of the amount of ready meals be checked to ensure the person was not having a substandard diet. On this visit it was noted that the person was still having the ready meals. It was not evident if the person’s diet had been reviewed by the manager. It is required that the manager
52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 14 ensures that the person is not receiving a substandard diet and that she seeks advice from dietician. The main evening meal was prepared by the staff from the pre-planned menu. The menu was based on the preferences of the people. The meal was presented nicely and in a manner that suited the individual. The mealtime was unhurried and relaxed, and people were supported on a 1:1 basis. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 15 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 and 21 The medication procedures had improved and the home’s policies and procedures are appropriate for dealing with medication. The ageing and illness of the people was dealt with respectfully and based on the wishes of the individual or their representatives. EVIDENCE: The medication cabinet had been moved to a more suitable position in the people’s dining room. The medication given out during the evening was observed. The staff handled the procedures well and demonstrated knowledge about the medicines people were on and their function. Since the previous inspection the home has developed a recording system of any P.R.N (as and when) medication that has the potential to be misused. The recording of the medicines was checked and found to be recorded accurately. The medication was given out according to the home’s policy and the staff were seen to tell the people that the medication was being given to them. The staff team work daily in supporting the people’s well being. Some of the people have complex health care support needs. The staff are well trained and competent in supporting the individuals. The wishes of the individual or their representatives were recorded in the people’s care plans. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 16 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 and 23 The organisation’s policies and procedures enable the people who live at the home and their representatives the opportunity to raise concerns and make complaints. The organisation’s procedures protect people from abuse. The staff worked in line with the procedures and demonstrated knowledge on their roles and responsibilities in protecting people and reporting suspected abuse. EVIDENCE: The organisation has attempted to make the complaints information accessible to those people who do not read, by producing the information in a pictorial format. The home or the Commission had not received any complaints since the previous inspection. The manager had ensured that all the staff have access to Adult Protection training. Since the previous inspection the deputy stated that the staff’s adult protection training was monitored through supervision. During a check of the people’s monies it was noted that there was a discrepancy in the amount of money held and the total recorded. The error had been picked up by the home’s checking procedures and a senior member of staff from the organisation was due to investigate the discrepancy. However the organisation had not informed the Commission of the investigation or made clear if the investigation was due to be looked at under adult protection procedures. It was required that the home ensures it reports all incidents that effect the well being of the people. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 17 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): 28 The shared spaces of the home complemented the people’s bedroom space. EVIDENCE: The lounge and dining room for the home are of a reasonable size. Most of the people who live at the home use wheelchairs and have large adapted “easy” chairs. These take up quite a lot of space when all the people are in the lounge together. The staff have thought carefully about ensuring the shared space does not become too crowded. The staff support the people to be actively engaged in a variety of activities so that most of the time people are not in the shared space at the same time. The kitchen is open plan and accessible. The staff team had worked hard with the people to improve the access and enjoyment of the home’s garden. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 18 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): 31 and 36. The staff understood their roles and responsibilities, which the people benefited from. The staff were supported well by the management of the home and all staff had structured supervision. EVIDENCE: During the inspection the staff handbook was viewed. This was a file that was kept in the hallway of the home and was available to all staff. The file contained a job description for each position in the home, including the managers. The file also contained a code of practice, and policies and procedures for the home. This was a useful and accessible tool for the staff to use, particularly when the managers were not on duty. The staff were asked about their roles. The relief member of staff had been working at the home for some years. He was able to describe his daily tasks and the limitations of his role. During the shift the relief members provided continuity of care to the people and were only not involved in administering medication. The relief member of staff also received regular supervision from the manager or the deputy. The supervision would be arranged depending on the frequency of the shifts covered by the staff. The staff said that if he worked more often then his supervisions would increase. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 19 The permanent member of staff said that she had regular supervision and would look at issues in the house with her manager and use supervision to develop her training needs. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 20 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): 40,41 and 42 The home’s policies and procedures protect the people’s rights and ensures their interest are priority. The deputy manager demonstrated knowledge of monitoring health and safety issues. The home was generally a safe environment for the people who live and work in the home. EVIDENCE: The organisation has comprehensive policies and procedures that comply with current legislation. The staff have access to the policy in the organisation’s main policy file in the office or in the staff handbook in the downstairs hallway. The policies are also reviewed appropriately and a programme of reviewing the policies is set by the organisation. The home stores the information about the people and staff appropriately. They are kept secure and only general information like the communication books are in the living areas. The personal support plans of each person are kept in their room. The staff demonstrated an understanding that the support plan information belonged to the individuals and asked permission from them before sharing any information with the inspector. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 21 Several health and safety documents were viewed, including the home’s fire plan, water temperature checks, food storage temperatures and monthly house health and safety checks. Accidents and incidents records were looked at and all were recorded and reported appropriately. Staff are trained in First Aid, moving and handling and food hygiene. The home had appropriate fire protection procedures. A fire saftey check had been carried out by a company contracted to service the fire equipment in the home. It was noted that the contractors had recommended that a backup power supply was needed from the fire detection sytem. The deputy manager was unable to confirm if this had been arranged. It is required that the home meets the recommendation from the fire safety report and identify a backup power supply. 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 22 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 2 2 3 X x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X 3 Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X 3 X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X X X X 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
52 Mill Lane Score X X 3 3 Standard No 37 38 39 40 41 42 43 Score X X X 3 3 2 x DS0000014149.V249750.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 14(1)(a-c) Requirement It is required that the manager shall keep the Statement of Purpose under review and revise where appropriate. (From previous inspection 16/5/05) It is required that the manager ensures the needs of the service user have been assessed by a suitable qualified person. (From Previous inspection 16/5/05) It is required that the manager ensures that the person is not receiving a substandard diet and that she seeks advice from a dietician. Timescale for action 17/11/05 2 YA2 14(1)(a-c) 17/11/05 3 YA17 16(2)(i) 30/11/05 4 YA23 37(1)(e,f,g) It was required that the 13(6) manager ensure all incidents that effect the wellbeing of the people are reported to the Commission. 23(4)(c) It is required that the home meets the recommendation from the fire safety report and identify a backup power supply for the fire detection system. 17/11/05 5 YA42 30/11/05 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 24 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 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 52 Mill Lane DS0000014149.V249750.R01.S.doc Version 5.0 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
