Inspection on 08/11/05 for 59 Bury Road

This inspection was carried out on 8th November 2005.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

59 Bury Road 13/08/08

59 Bury Road 08/08/07

59 Bury Road 26/06/06

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 59 Bury Road Gosport Hampshire PO12 3UE Lead Inspector Nick Morrison U nnounced Inspection 8th November 2005 10:30 59 Bury Road DS0000064247.V264453.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 59 Bury Road DS0000064247.V264453.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 Natio l 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. 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 59 Bury Road Address Gosport Hampshire PO12 3UE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered ma ger (if applicable) Type of registration No. of places registered (if applicable) 020 8544 8900 Care Ma gement Group Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: This is a newly registered service owned by the Care Ma gement Group. The provider has two houses next door to each other in Bury Road and they are registered separately. The house has been refurbished to a good standard and provides a home for up to six people who have a learning disability and/or autism and challenging behaviours. At the time of inspection there were five service users living in the home. 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 8th November 2005 and lasted for four and a half hours. The Inspector toured the premises, spoken with the Ma ger and staff, observed interactions with service users and looked at records. What the service does well: 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. 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Perso l and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Ma gement of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 7 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): 2 Service users benefit from having their needs identified prior to admission. EVIDENCE: The Inspector looked at the files for all service users and saw comprehensive assessments of need for each. The assessments covered a full range of need areas were thoroughly completed. Dates showed that they had been completed prior to admission to the home and had been completed by competent people in consultation with families, service users where possible and other professio ls who knew the service user well. 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 8 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 perso l 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, 7 and 9 Service users benefited from having clear and effective care plans and were able to make decisions about their lives. Service users would benefit from risk assessments being reviewed regularly. EVIDENCE: Individual plans for each service user were seen and these had been written in response to the issues highlighted by the initial assessments. The plans provided clear guidance on action to be taken by care staff in order to meet the needs of service users on a day-to-day basis. Specific behavioural plans were in place to e ble staff to support service users consistently. Staff spoken with said the consistency of approach had contributed to the decrease in problematic behaviour issues in the home. The plans also contained risk assessments where potential risks had been identified. Risk assessments were clear and highlighted the control measures to be put into place to ma ge each risk. Although the care-planning format was comprehensive, some service users’ plans were not complete in that they did not contain information on the goals of individuals or action plans to meet those goals. The Ma ger acknowledged this and a recommendation has been made. 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 9 The Inspector observed staff offering choices to service users about food and activities on the day of inspection. Staff demonstrated an awareness of the need to offer clear choices and to respond to the choices made by service users. Risk assessments were in place where potential risks had been identified. Service users were supported to learn new skills and use the community despite risks involved and this was achieved through a thorough risk assessment process. Risk assessments were used to support service user development rather than hinder it. Despite the fact that the process on paper was thorough, some assessments had not been completed fully and lacked information on when they needed to be reviewed. A recommendation has been made in respect of this. 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for perso l 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 perso l, 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, 13, 15, 16 and 17 Service users benefited from having their rights respected and being supported to maintain contact with families and friends. Service users would benefit from having access to a wider range of activities. EVIDENCE: Each service user had an activity plan on file and these were being followed on the day of inspection. Planned activities were relevant and suitable for the people living at the home and based on known interests and preferences. Staffing was arranged so that service users could be involved in activities safely according to their risk assessment. The Ma ger stated that the range of activities they were able to plan for service users at present was “poor” and that this was due to staff needing to find out exactly what activities were available and due to some difficulty appointing new staff to ensure that staffing levels were adequate to support activities safely. A recommendation has been made in respect of this. Service users were encouraged and supported to maintain contact with their families and friends and their sexual needs were responded top appropriately. Staff observed and spoken to on the day of inspection demonstrated an understanding of the rights of service users and an ability to ensure these 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 11 rights were upheld. This was supported by clear policies and information for staff on the rights of service users. The home did not use weekly or monthly menu plans as service users often changed their minds about what they wanted to eat. Meals were planned nearer to the time and shopping was done to ensure that the meals on offer were what service users wanted. Records of food provided showed that service users had a varied and nutritious diet. The mealtime observed on the day of inspection was relaxed and service users appeared to enjoy it. Staff were available to provide any support service users needed and people were able to choose to have their lunch at whatever time fitted in with their other activities. 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 12 Perso l and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive perso l support in the way they prefer and require. Service users’ physical and emotio l 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 and 20 Service users benefited from effective perso l support and had their health needs met. Improved training for staff administering medication would further protect service users. EVIDENCE: Service users’ care plans contained information on their perso l preferences in respect of perso l care and detailed specific needs clearly. The healthcare needs of service users were regularly monitored and reviewed and good records were kept. They were supported to access healthcare services as necessary. Records detailed any action to be taken in response to medical appointments and care plans were adjusted to reflect this. The home had a medication policy in place and good, clear, accurate records were kept of all medication going into and coming out of the home as well as what had been administered. There were some guidelines on administering ‘as and when necessary’ medication to some service users, but some of these had not been agreed and signed by the GP. A recommendation has been made in respect of this. The training for new staff administering medication consisted of them being shown the process and observed doing it on three occasions by existing staff. There were no identified errors in the medication administered so far at the home, but this kind of staff training has proved problematic in other homes. The Ma ger explained that two members of staff were about to 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 13 undertake some exter l, accredited training for administering medication. A requirement has been made that accredited training be provided for all staff involved in administering medication. 59 Bury Road DS0000064247.V264453.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): 22 and 23 Service users benefited from a clear complaints policy and were protected by some of the policies and procedures in the home. They would be further protected by staff receiving training in responding to instances of suspected abuse. EVIDENCE: The home had a clear Complaints Policy in place, which was also available in a picture format so that service users could more easily understand it. Records were kept of the ture and outcome of each complaint along with details of what action was taken in response. Behavioural plans in place at the home helped protect service users from harm from themselves or other people living in the home and staff training in physical intervention techniques helped to protect service users from injury. Records were kept of all incidents happening in the home and al occasions where physical intervention was necessary. The Ma ger acknowledged that staff had not received any training in responding effectively to potential abuse and a requirement has been made in respect of this. 59 Bury Road DS0000064247.V264453.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 and 30 Service users benefit from a clean, safe, hygienic and comfortable environment. EVIDENCE: The home is adequate for its purpose and provides sufficient space for service users. It is close to local amenities and local transport networks and is in keeping with the other homes in the neighbourhood. The furnishings and fittings in the home are new and are of good quality. The home is kept clean throughout and procedures were in pace to control the spread of infection. The home had been made safe in response to potential difficult behaviours from service users, for example kitchen appliances had been secured to the work surface. 59 Bury Road DS0000064247.V264453.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 and 35 Recruitment practices protected people living in the home. Service users would benefit from being supported by staff who had received more training. EVIDENCE: Although staff spoken with were positive about the training provided by the organisation, there were significant gaps in the training staff at the home had received. All staff had undertaken the Dignified Ma gement of Conflict Training. Two staff had done First Aid training and four had done Fire training. The Fire training and First Aid training for the rest of the staff was lacking, as was training in Food Hygiene, Infection Control and Moving and Handling for all staff. A requirement has been made in respect of this. 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 17 Conduct and Ma gement 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 ma gement 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 ma gement 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 and 42 Service users benefited from living in a safe environment but would benefit further from being involved in monitoring the service. EVIDENCE: The home has no quality assurance process in place and the Ma ger explained that this was due to the fact that it was a new service. A requirement has been made in respect of this. The Inspector was informed that the organisation had just appointed a Quality Assurance Officer. Apart from the gaps in staff training (see standard 35), Health and safety in the home was well ma ged. Fire records (apart from training) were up to date and regular mainte nce checks took place. Health and Safety was included in the induction programme for staff and all incidents and accidents were well recorded and responded to appropriately. 59 Bury Road DS0000064247.V264453.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the Natio l 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 3 X X X Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 1 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 59 Bury Road Score 3 3 1 X Standard No 37 38 39 40 41 42 43 Score X X 1 X X 3 X DS0000064247.V264453.R01.S.doc Version 5.0 Page 19 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 Natio l Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard YA20 YA23 YA35 Regulation 18 18 18 Requirement Staff administering medication must have adequate training All staff must receive training in the protection of vulnerable adults All staff must receive training in First Aid, Moving and Handling, Fire Safety, Food Hygiene and Infection Control The Ma ger must ensure that a quality assurance system is in place in the home Timescale for action 31/12/05 31/12/05 31/12/05 4 YA39 24 31/12/05 RECOMMENDATIONS These recommendations relate to Natio l Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA6 YA9 YA13 YA20 Good Practice Recommendations All service users’ care plans should be fully completed All risk assessments should contain details of when they should be reviewed The Ma ger should ensure that service users have the opportunity to be involved in a wide range of activities Guidelines for PRN medication should be signed by the Ma ger and the GP DS0000064247.V264453.R01.S.doc Version 5.0 Page 20 59 Bury Road Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW Natio l 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. 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