Inspection on 28/05/05 for 57 Clarendon Villas

This inspection was carried out on 28th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

57 Clarendon Villas 04/02/09

57 Clarendon Villas 27/02/07

57 Clarendon Villas 26/11/05

57 Clarendon Villas 27/01/05

57 Clarendon Villas 26/05/04

57 Clarendon Villas 14/03/03

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

CARE HOME ADULTS 18-65 57 Clarendon Villas 57 Clarendon Villas Basement Flats Hove BN3 3RE Lead Inspector Jenny Blackwell Announced 28 May 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. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service 57 Clarendon Villas Address 57 Clarendon Villas Basement Flats Hove East Sussex BN3 3RE 01273 774014 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) Southdown Housing Association Mr Anthony Lyons Care Home Care home (PC) 2 Category(ies) of Learning disabilty (2) registration, with number of places 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1 The number of service users must not exceed two (2) 2 The service users accommodated will be between the ages of eighteen (18) and sixty-five (65) years Date of last inspection 27 January 2005 Brief Description of the Service: 57 Clarendon Villas is a detached house in a residential road in Hove, close to local shops. Buses pass near to the home, the shops and train station are within easy walking distance. The accommodation for the people who live there is on the ground floor, this comprises of two individual flats. Each has a kitchen, bathroom, bedroom, and sitting room overlooking the front of the house. Each flat has access to the staff sleep in room. The service is one of several homes in the area run for people with learning disabilities by Southdown Housing Association.There is a small amount of front garden, and, to the rear of the property, the area is concreted. The patio is used in good weather for barbeques. There is a wooden, garden swing seat, herb garden and shed available to the people who live there. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 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 two people who live at the service, some of the staff team and the deputy manager were present during the inspection. As the manager was not available during the inspection another visit was arranged on the 20th June 2005. Time was spent with both people who live at the home. The manager was spoken to individually and four staff was spoken to throughout the two days. The two recommendations made from the inspection in January 2005 were checked to see if they had been met. The manager produced evidence to show that one of the recommendation had been met. One recommendation will be carried forward. Two relative comment cards were returned prior to the inspection. Both contained positive responses, with comments such as “my son is very happy and well cared for.” The people who live at the service and the staff were helpful throughout the inspection and contributed to the report where possible. What the service does well: Daily activities were planned and arranged around each person’s likes and dislikes. During the day both people went out and had an activity. Staff organised their shifts around the people’s wishes. One person has clear preferences about who supports him in his activities. The manager ensures the rota is written to accommodate the people’s wishes. The staff were seen to interact with each person respectfully and were knowledgeable about their support needs and their preferences. The care plans were well written with comprehensive information about individual’s preferred routines during the day. This enabled the staff team to be consistent in their approach to each person. Particular care was taken to emphasise being sensitive in approaching the people in ways that may cause them to be anxious. Southdown Housing Association has a comprehensive induction and training programme for new and existing staff. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 6 Throughout the day staff were seen to act in a friendly, professional manner with the people. The staff team had training and were experienced in specialist support for the people such as sensory disabilities, behaviour support and communication methods. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 7 by contacting your local CSCI office. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 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 standard(s) 1,2,3 and 4 The manager and staff had access to policies and documents that help them to support new people move to the home. The statement of purpose and service user guide accurately reflected the function of the home. Placement assessments were not reviewed in all cases by the funding authorities. EVIDENCE: The statement of purpose was viewed during the inspection. It described accurately the service and facilities provided for the two people. The two flats were converted from a large Victorian house and minor adaptation has been made to support the people with disabilities. The staff team had specialist training in supporting people with learning disabilities. The staff demonstrated comprehensive knowledge of people’s needs and particularly specific health care support. The manager and staff had access to policies and procedures to ensure prospective new people have appropriate introductory visits. Each person has a licence agreement with Southdown Housing Association that are detailed and in a pictorial format. It was noted that Brighton and Hove City Council had not reviewed one person’s placement annually; the last review was conducted in 2003. It was 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 10 required that the manager ensures each person’s placements are reviewed annually. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 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 standard(s) 6,7,8,9 and 10. The people’s individual care plans contained information based on people’s preferences, their likes and dislikes, risk assessments and health care needs. Each plan was well written and was presented in the same format. Assistance was provided to enable each person to make decisions in their lives. Records are handled and stored correctly in accordance with the organisations policies. EVIDENCE: Both people’s care plans were looked at. They contained clear information on the needs and wishes of the each person and were regularly reviewed and updated at staff meetings. One person’s plan had detailed information about the sign language he used. Both peoples “significant others” were listed which helped staff to engage with the people about theirs friends and relatives. It was noted in one person’s plan the language used to describe the support of the person’s behaviours were out dated and could be misinterpreted by the staff team. It was required that the information is updated. The staff team had developed different communication methods to ensure the people were able to make decisions about their lives. One person had an extensive series of large photos of the places he would go to during the week, such as the swimming pool, restaurants and shops. He was able to use these to choose what he wanted to do during the day. He also had a photo of each 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 12 staff member who would be working with him which was put up each day on his notice board. During the two visits staff were seen to offer a variety of options to each person whether it was about food, going out and in one persons case which staff member he wanted to support him. The staff encouraged both people to take measured risks to help them maintain and develop new skills; these included participating in household tasks and participating in their local community. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 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 standard(s) 11,12,13,14,15,16,and 17 The manager and staff were committed in supporting each person with their interests. Personalised activity plans were in place for each individual and the staff were concerned with engaging people on a one to one basis. Each person was actively engaged in their local community and had good links with family and friends. The meals appeared generally nutritionally balanced. EVIDENCE: The people were encouraged to maintain the levels of independence that is appropriate for them. One person attends a day services, and both attended college courses and leisure activities. One person had all his day opportunities arranged by the home. The manager and staff arrange for people to participate in activities in their local community. The service is set in a residential area and their neighbours know the people. During the one of the two visits the inspector went with the two people and two staff out for a take-away meal. The two staff members involved the people in deciding were to go and what to eat. The staff were 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 14 sensitive to the people’s needs during the outing and ensured that the routines that were enjoyed by the people were followed. Other leisure activities that the staff arranges for people included aromatherapy, restaurants and pubs. Each person has an active life and enjoys a variety of indoor and outdoor activities. The support plans describe the significant others for each person. Family involvement is encouraged and supported by the staff. The manager and staff promote independence and choice for each person. Care is taken by the staff to respect individual’s dignity and privacy, staff were seen to knock on people’s doors and ask permission from them before entering their flats. The menus were seen for each person. The staff prepares the meals and do all the cooking. People are encouraged to participate with preparing their meals. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 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 standard(s) 18,19 and 20. Both people who live at the service were supported to maintain their wellbeing. They attend community health care appointments and have access to specialist health care provision. Preferences in the ways people receive personal support were recorded. The medication procedures were clear and the recording of information had improved. EVIDENCE: The preferred routine of people’s personal support was recorded in their plans. Both people attend health care check- ups in the community and have access to specialist support for sensory disabilities and epilepsy. The manager had introduced better recording systems for the administration of medication. The staff team are using this system to monitor stock of medication. Good recording systems are in place when one person visits his relatives. All staff had medication training and were assessed before being are able to administer medication. The staff work with the G.P and psychiatrist to ensure medication is reviewed regularly. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 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 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 staff understood the manager monitored the complaints procedure and the process. The organisation operates within procedures to protect people from abuse. The manager and staff worked in line with the procedures and demonstrated knowledge of their roles and responsibilities in protecting people and reporting suspected abuse. However, training gaps in Adult Protection could lead to a reduced knowledge base in staff. EVIDENCE: The complaints procedure was seen during the inspection within the Service User Guide. The organisation has attempted to make the information accessible to those people who don’t read by producing the information in a pictorial format. The service had not received a complaint since the previous inspection. It was noted from the information supplied in the pre inspection questionnaire that although Adult Protection training was part of the comprehensive induction programme and the managers training, not many of the existing staff had been trained in Adult Protection. It was required that all staff receives Adult Protection training and receives regular updates in training. A check was carried out on the handling of the people’s monies. Appropriate procedures were in place and all staff used the same recording system for each person. Checks were carried out on each person’s money at the change over of each shift. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 17 The service had recently purchased a new vehicle for people to get around in. The manager ensured that the vehicle is used in accordance with the organisation’s policies and that any contributions from the people are recorded and monitored correctly. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 18 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 and 30. Both flats generally met the environmental outcomes for the people. The flats were homely in the lounges, kitchen and bedrooms. The bathrooms were well equipped and domestic in scale. All parts of the home were clean and well presented and the staff team had paid particular attention to designing the garden to improve the enjoyment for the people. EVIDENCE: The people live in two self-contained one-bedroom flats, with a lounge, kitchen, bathroom and bedroom. One room of one flat is used as the sleeping in room for a staff member covering both flats. Each flat reflects the personality of the people and staff have arranged for sensory stimulation lights for one person who has a visual impairment. Each bathroom provides the people with adequate facilities for their needs. Adaptations have been made to the outside of the building to aid with one person’s visual impairment. He also has light boards and spot lighting in his 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 19 room. The staff has had training by the R.N.I.B and continue to access them for advice. During the previous inspection it was recommended that radiator guards be fixed in one person’s flat. During discussions with the manager it was noted that one radiator in the bathroom presented a particular risk. It was therefore required that this radiator is covered. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 20 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 and 36. The staff team were competent in supporting people with disabilities and generally deemed to be effective in their work. The organisation’s policies and procedures for recruitment of new staff are followed by the home. The people are protected by a robust procedure that meets the requirements in the National Minimum Standards. The organisation invests in the induction and training of its staff and the manager monitors each staff member through supervisions and staff meetings. EVIDENCE: The staff spoken to during the two visits understood their roles and responsibilities and would organise the shifts between them. Time was spent with a new relief member of staff. He stated the induction he received from Southdown Housing was useful and he had clear guidelines on when he could work alone with the people. He went on to say the staff had been helpful and supportive. During the trip out, the permanent members of staff showed the new relief worker the routines and preferences of the two people and supported him to engage with them. The two people appeared confident and relaxed with the new person. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 21 Since the previous inspection the organisation had arranged with the manager a system that ensures he viewed the recruitment documents of each new staff member. These documents include identification documents, criminal record check confirmation and references. The manager organised training through individual supervision and through the organisational training plan. The staff received induction within the first six weeks and foundation training within six months. 8 days of training are setaside for each staff member. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 22 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) 37,38,39,40,41,42 ands 43. The people who live at the home benefit from a well run home and the staff team had a clear understanding of the leadership’s ethos. The manager, staff and senior managers conducted a yearly service review. This process meets the intended outcome that the people and their representative’s views contribute to the development of the home. The manager demonstrated knowledge of monitoring health and safety issues. The home was generally a safe enviorment for the people who live and work in the home. EVIDENCE: The manager had recently appointed a new deputy who was previous a support worker at the service for several years. He was asked about his management induction and training. He stated that Southdown Housing had providing him with a management induction and he was having good support from the manager. 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 23 A formal process of obtaining people’s views was sought from family members or representatives via an annual service review of the home. Feedback from people and their representatives are included in the review. Goals are set for the year and are regularly reviewed. Several health and safety documents were viewed including the homes fire plan. Staff was trained in first aid, moving and handling and food hygiene. The home had appropriate fire protection procedures. The manager was unable to locate a gas safety certificate but had forwarded one to the Commission prior to the report being published. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 3 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 57 Clarendon Villas Score Standard No 24 25 26 27 Score 2 3 3 3 Version 1.20 Page 24 HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc 6 7 8 9 10 LIFESTYLES 2 3 3 3 3 Score 28 29 30 STAFFING 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 25 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 2 Regulation 14(1)(a,c) Requirement It is required that the manager ensures the needs of the people who live at the home have been assessed by a suitable qualified person. That the manager ensures the care plans use appropriate language to discribe interventions. That all staff attend Adult Protection training. Timescale for action 30th September 2005 30th July 2005 30th September 2005 2. 6 15(2) 3. 23 13(6) 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 Good Practice Recommendations 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 26 Commission for Social Care Inspection 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 57 Clarendon Villas HH59 H10 S14152 Clarendon Villas V217895 280505 stage 4.doc Version 1.20 Page 27 - 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. 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