Inspection on 16/01/06 for 54 Leylands Road

This inspection was carried out on 16th 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

54 Leylands Road 15/05/07

54 Leylands Road 10/10/06

54 Leylands Road 22/08/05

54 Leylands Road 09/11/04

54 Leylands Road 29/06/04

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

CARE HOME ADULTS 18-65 54 Leylands Road 54 Leylands Road Burgess Hill West Sussex RH15 8AL Lead Inspector Mr E McLeod Unannounced Inspection 16th January 2006 09:15 54 Leylands Road DS0000014663.V273037.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 54 Leylands Road DS0000014663.V273037.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. 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 54 Leylands Road Address 54 Leylands Road Burgess Hill West Sussex RH15 8AL 01444 870546 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) Sussex Oakleaf Housing Association Limited Mr Prabhooraj Unmar Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2005 Brief Description of the Service: 54 Leylands Road (previously registered as Peppers) is a care home registered for up to six service users in the category of mental disorder (excluding learning disability or dementia), one of whom can be in the category of mental disorder over 65 years of age (excluding learning disability or dementia). 54 Leylands Road is a detached property on two floors in a residential area of Burgess Hill, with nearby bus and train services. The registered provider is Sussex Oakleaf Housing Association Limited, for whom the deputising responsible individual is Ms Tracy Linstead. The registered manager is Mr Prabhooraj Unmar. 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was arranged to follow up recommendations made at the previous inspection. The inspection was not announced, and lasted three hours and forty five minutes. The inspector spoke with three residents, interviewed two members of staff, and made a partial inspection of the premises. Policies and procedures, individual care plans, safety records and staff records were also sampled. The inspector would like to thank everyone who contributed to the inspection. What the service does well: There are good individual care plans for residents in place, which are regularly reviewed. Residents are supported to develop their confidence and independence skills. Some of the residents are self-catering, some self-cater part-time, and some have their main meals provided. Residents are happy with these arrangements, and everyone takes part in Sunday lunch together. The premises are in good decorative order, and provide a comfortable and relaxed environment for residents. The staff team is experienced and has a good skills mix. There is a good rapport between staff and residents. The staffing levels provided allow uninterrupted work with individuals. 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 6 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. 54 Leylands Road DS0000014663.V273037.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 54 Leylands Road DS0000014663.V273037.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): 1, 2 Information on who the service is being provided for on the registration certificate and in the Statement of Purpose should be amended to provide consistent information for residents and prospective residents. EVIDENCE: The Statement of Purpose and Service User’s Guide, which provide information to residents and potential residents on the service, were updated in October 2005. It was noted that both refer to the accommodation being provided exclusively for male residents. As the home’s registration is for male and female residents, the provider will need to consider whether an application to amend the home’s registration details accordingly should be sent to CSCI. At the inspection, staff were unable to locate additional copies of the service user’s guide which prospective residents would expect to receive a copy of. The provider needs to ensure that copies of the Service User’s guide are available to potential residents and that all present residents have a copy of this. No new admissions to the home have been made during the past year. To ensure that only residents whose needs can be met by the service are being admitted, procedures are in place to obtain appropriate assessments before admission. 54 Leylands Road DS0000014663.V273037.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, 9, 10 There are good individual care plans for residents in place, which are regularly reviewed. EVIDENCE: Three sets of care plans were sampled. These indicated that regular reviews, including Care Programme Approach (CPA) reviews were taking place, and that a clear plan of care for the individual resident with aims and objectives is being provided. Care plans seen evidenced that service users are supported to take responsible risks as part of an independent lifestyle, and further examples of this were provided by staff interviewed by the inspector. Care plan information and records seen indicated that residents’ health and dietary needs and social needs are being monitored. Care plans seen had been signed by the resident, or it was indicated that the resident did not wish to sign. Care plans also included risk assessments and guidance for staff for managing any aggressive, threatening or self-harmful behaviour the resident has shown in the past. 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 10 The confidentiality policy was seen. It was not signed by the manager or dated, and did not appear to have been updated as recommended at the previous inspection. 54 Leylands Road DS0000014663.V273037.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): 12, 16, 17 Residents are supported to develop their confidence and independence skills. EVIDENCE: Care plans sampled and discussions with residents and staff indicated that residents are being supported to access further education, peer support, and voluntary work. There was evidence that residents are developing their confidence and independence skills, and this is a planned part of the care provided. Residents have an input into the running of the home through the monthly residents’ meetings – records of which were seen by the inspector. Interactions between staff and residents observed by the inspector indicated that staff respect resident’s rights and encourage them to make their individual choices. There is a good rapport between staff and residents. Some of the residents are self-catering, some self-cater part-time, and some have their main meals provided. Some residents are responsible for their own menus and shopping, and some are assisted by staff with this. Residents are 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 12 happy with these arrangements, and everyone takes part in Sunday lunch together. 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents are receiving personal support in the way they prefer and require. EVIDENCE: Where support with personal care is being provided, care plans agreed with the resident set out how staff should carry this out. Staff seek to ensure the privacy and dignity of residents when carrying out personal care tasks. 54 Leylands Road DS0000014663.V273037.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 Adult protection policies and procedures are in place. Training must be provided for staff to prevent residents being harmed or suffering abuse. EVIDENCE: Policies and procedures seen by the inspector included the missing person’s procedures, self harm, and unruly or unwanted visitors. The protection of vulnerable adults procedures were seen, dated June 2004, and were seen to include guidance for staff on advising the local authority and CSCI of incidents, and the responsibility of the provider to refer staff to the Protection of Vulnerable Adults register as appropriate. Staff training plans seen suggest that since April 2005 none of the staff team have received training in adult protection procedures. 54 Leylands Road DS0000014663.V273037.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 There have been improvements to the premises, which are kept in good order. EVIDENCE: The premises are in good decorative order, and the sun lounge, upstairs hallway and upstairs bathroom have been redecorated since the previous inspection. New kitchen chairs have also been provided. It is a homely and comfortable environment, which meets residents’ needs. The garden is also kept in good order, and the patio has been repaired since the previous inspection. Smoking is no longer allowed in the sitting room. 54 Leylands Road DS0000014663.V273037.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): 33, 35 It is recommended that to provide more safety for residents, staff should receive accredited training in the administration of medicines, training in the medicines used for mental health conditions, training in manual handling, and training in relevant mental health topics. EVIDENCE: The staff team is experienced and has a good skills mix. The staffing levels provided allow uninterrupted work with individuals, and on the day of the inspection staff were available to accompany residents on trips out. The two staff interviewed were due to commence National Vocational Qualification in care training in the present year. The inspector looked at training lists for the staff team, and it was noted that most staff have attended training in basic first aid, food hygiene, and fire procedures since April 2005. The inspector noted that no staff had attended an accredited training in the administration of medicines since April 2005, and that no training in the medicines used for mental health conditions was being provided. Although manual handling has sometimes been needed in the home, it was noted that no manual handling training has been provided for staff since April 2005 – this could present risks for both residents and staff. It was noted that since April 2005 while an individual worker in each case had attended training in 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 17 psychosis, adult survivors of abuse, and behaviour, the majority of staff have not in this time received the amount of training in mental health topics that would be consisted with the work they undertake. 54 Leylands Road DS0000014663.V273037.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): 39, 40, 42 The registered person must provide for consultation with residents and their representatives on the quality of care provided at the care home. Policies and procedures should be updated to reflect current good practice and legislation. The registered person must ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, and shall make suitable arrangements for the training of staff in first aid. EVIDENCE: No evidence was provided at the inspection that the previous recommendation that the views of service users’ family, friends, and stakeholders in the community are sought on how the home is achieving goals for service users has been met. 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 19 Some of the views of residents on the service (dated 2004) have been included in the service user’s guide. Care plans seen indicate that year on year development for service users is being achieved by the service, such as residents being better prepared for independent living, and becoming more sociable and taking up opportunities to progress through education and voluntary work. Discussion with staff indicated that they were aware of updates to the supervision policy policies and procedures, but not aware of other policies and procedures which had been reviewed and updated. The policy and procedures for confidentiality seen has not been updated as recommended to ensure compliance with the Data Protection Act (and subsequently the Freedom of Information Act). The inspector looked at a generic risk assessment provided on the safety of the premises. The assessment however was not dated or signed, and the action to be taken form appended to the assessment had not been filled out. The provider must be able to evidence that a safe environment for residents is being maintained. There has been an agreement that residents do not smoke in the lounge. Hazardous substances are kept in a lockable cupboard. Training records indicated that staff were undertaking an introductory training in first aid, but the inspector was not able to establish how many of the staff team are currently qualified first aiders. It is recommended in the National Minimum Standards that the registered manager ensures safe working practices, with this including a qualified first aider available on every shift. As an example of the safety risks, the inspector established that the introductory training in first aid provided does not include what to do when someone has suffered an electrical shock. 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 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 2 3 x x x Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 54 Leylands Road Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x 2 2 x 2 x DS0000014663.V273037.R01.S.doc Version 5.0 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 YA23 Regulation 13.6 Requirement Training must be provided for staff to prevent residents being harmed or suffering abuse, or being placed at risk of harm or abuse. Clear risk assessments and action plans on all health and safety issues including the environment need to be recorded. The provider shall also make suitable arrangements for the training of staff in first aid. Timescale for action 31/03/06 2 YA42 13.4 (c) 03/03/06 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA10 Good Practice Recommendations It is recommended that the homes written policies and procedures on confidentiality should be updated with due regard for the Data Protection Act 1998, the Freedom of Information Act and the best interests of service users. It is recommended that policies and procedures should be regularly reviewed to ensure compliance with current legislation including the Care Standards Act 2000. It is recommended that the views of service users’ family, friends and stakeholders in the community are sought on how the home is achieving goals for service users. The provider needs to clarify if the service is for male residents only, as in the home’s statement of purpose, or for male and female residents, as per the home’s registration. It is recommended that to provide more safety for residents, staff should receive accredited training in the administration of medicines, training in the medicines used for mental health conditions, training in manual handling, and training in relevant mental health topics. 2. 3. 4. YA40 YA39 YA1 5. YA35 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 23 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 © 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 54 Leylands Road DS0000014663.V273037.R01.S.doc Version 5.0 Page 24 - 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!