CARE HOME ADULTS 18-65
9 Portland Road 9 Portland Road Hove East Sussex BN3 5DR Lead Inspector
Merle Blakeley Unannounced Inspection 2nd November 2005 01:30 9 Portland Road DS0000014167.V250422.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 9 Portland Road DS0000014167.V250422.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. 9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 9 Portland Road Address 9 Portland Road Hove East Sussex BN3 5DR 01273 822103 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) Brighton Housing Trust Geraldine O`Haire Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places 9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The maximum number of service users to be accommodated is nine (9). Service users must be aged 18 years or over on admission. Date of last inspection 21st June 2005 Brief Description of the Service: 9 Portland Road provides accommodation, care and support for up to nine adults aged between 18 years to 65 years who have mental health disorders. The home is owned and managed by Brighton Housing Trust who also run another small home for people with mental health disorders at 57 Sackville Gardens, Hove and supported accommodation services in Westbourne Gardens, Leybourne Road, Buckingham Road and Sackville Gardens. The main purpose of the home is to enable residents to develop personal independence and confidence in their daily lives. The home is situated in an end of terrace fourstorey house where bedrooms are located on the third and fourth floors. All bedrooms are single without en suite facilities. The home would not be particularly suitable for people with mobility problems as there are a lot of stairs and the home does not have a lift installed. The home is located very close to local transport, shops and other amenities. 9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Unannounced Inspection took place over a period of three hours on 2nd November 2005 and included inspecting the remaining standards that were not covered during the Announced Inspection on 21st June 2005. The inspection process involved speaking to several residents and staff on duty, document reading, premises inspection and informal discussions with the registered manager. Several residents were not at home during the inspection as they were attending day care centres and various other activities in the community. What the service does well: What has improved since the last inspection? What they could do better:
The home must ensure that all the required information, as set out in Schedule 2 of the National Minimum Standards is included in all of the staffing files. Residents who self medicate must have a risk assessment carried out and this assessment should be reviewed on a regular basis. It is hoped that work will soon commence to refurbish the dining room area, which is in need of updating and redecorating.
9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 6 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. 9 Portland Road DS0000014167.V250422.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 9 Portland Road DS0000014167.V250422.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): 2 & 4. The home carries out thorough assessments before a prospective resident moves into the home. Prospective residents are offered a variety of visits before moving in. EVIDENCE: Two new residents have recently moved into the home and the assessment records for both these residents were viewed. Records show that thorough assessments had been carried out prior to the residents moving into the home to ensure that the service can meet each persons needs. Prospective residents are offered various types of visits before they move into the home and this enables them to make an informed choice about their future care and support. Residents often just visit for a meal and a chat or sometimes they may take up the option to stay overnight. There is no formal trial period offered to residents but the home states that residents can choose to leave at any time. 9 Portland Road DS0000014167.V250422.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, 8 & 9 The home maintains up to date and relevant care plans. Residents are very much encouraged to participate in all aspects of life within the home and they are supported to take responsible risks. EVIDENCE: Several care plans were viewed and they were found to be up to date and very informative. Regular reviews and risk assessments are carried out on all residents and individual daily diary entries are maintained. As part of the homes ethos, participation in the home is seen as an important aspect of each resident’s plan of support. Residents are encouraged to attend the daily morning meeting to discuss their plans for the day. House meetings are held weekly and residents are involved with food shopping, household tasks, helping with the cooking and choosing their meals for the week. Some of the residents need a lot of motivation and support from staff to maintain their participation levels in the home. Residents are again supported and encouraged to take responsible risks, as this is another important aspect of their lives. Risk assessments will be carried out first and will involve the resident and their link worker.
9 Portland Road DS0000014167.V250422.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 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): 13, 14 & 15 Residents are out and about in the local community and have access and support to attend leisure activities. Where possible, residents maintain links with family and friends. EVIDENCE: The vast majority of residents are out and about in the community either going out shopping, using public transport, going out to cinemas, pubs, clubs, and cafes and attending day care centres. Some residents also attend local churches. During the summer four residents from 9 Portland Road and 57 Sackville Gardens went with staff on a day excursion to Amsterdam, which they all thoroughly enjoyed. Other leisure activities are being organised for the future. Maintaining links with family members and friends is encouraged and staff will often accompany residents on visits if they have requested support. Some of the residents have family members living in the local area. 9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 11 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 & 20 The majority of residents are independent enough to perform their own personal care. Risk assessments are required for any resident who self medicates. EVIDENCE: Most residents are able to manage their own personal care and do not require any assistance. Three residents require prompting from staff and this is usually only in the form of helping them to run a bath. Medications are securely stored in the office and records showed that all medicines were being correctly maintained and administered. There are two residents who self medicate and the home must carry out risk assessments for each person and make sure they are reviewed on a regular basis. The manager stated that the home would be providing more relevant medication training for staff in the future. 9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 12 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 & 23 The home has a comprehensive complaints policy and procedure. The home has produced an Adult Protection Policy & Procedure. EVIDENCE: The home has a well-written policy and procedure for complaints. Two internal complaints had been received and both had been investigated immediately and resolved. One complaint was later withdrawn. The home has recently produced new adult protection forms. One incident was recorded this year and involved two residents. The local rehabilitation team, police and social workers were involved and the matter was resolved between the two residents. At the time the person’s actions had been unintentional towards another resident and not purposefully led. 9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 13 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): 29 & 30 The home has been assessed by a qualified occupational therapist. Overall the home was clean and tidy on the day of inspection. EVIDENCE: A requirement was made during the last inspection for the home to be assessed by a qualified occupational therapist to ensure that no further adaptations were required. A report was sent to the CSCI, which indicated that the home did not require any additional adaptations for residents currently living in the home. The home was generally clean and tidy although there was a slight odour coming from the lower ground floor staircase. It is also hoped that the work to refurbish the dining room area will commence quite soon. Quotes for the work to be carried out have been submitted. This area of the home is in need of redecoration. 9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 14 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, 32, 34 & 36 The home continues to employ a stable and committed staff team. Almost 50 of staff have obtained NVQ Level 3. Recruitment files still need to provide recent photos and proof of identity. Staff receive regular supervision sessions. EVIDENCE: All staff receive formal contracts and job descriptions from Brighton Housing Trust. The staff team are fully aware of their roles and responsibilities within the service. Two staff have currently obtained the NVQ Level 3 qualification and two other staff members are due to complete this level early next year. The deputy manager is currently completing the NVQ Level 4. The staffing recruitment files still need to provide recent staff photos on file and proof of identity. Formally recorded supervision sessions are carried out monthly and staff stated that they felt well supported to carry out their work. Staff who were spoken to on the day said that they were happy working in the home and they all felt that they worked well together as a team. 9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 15 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): 37, 39 An experienced full time registered manager runs the home. The home has a quality assurance programme. EVIDENCE: The current registered manager has run this home for several years and has recently returned to work in the home after temporarily managing the other Brighton Housing Trust home, 57 Sackville Gardens for approximately 18 months. She is currently studying for the NVQ Level 4 qualification and is also completing a two-day ‘Training for Trainers’ course. Other internal BHT training has also been attended. The home carries out a quality assurance programme, which includes a resident satisfaction survey. An independent body carries out these surveys. The home has also undergone various audits and desktop reviews by funding authorities. 9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 X 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
9 Portland Road Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X X X DS0000014167.V250422.R01.S.doc Version 5.0 Page 17 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 YA34 Regulation Schedule 2 Requirement That the home ensures that all staff have recent photos and proof of identity included in their recruitment files. Previous Requirement That risk assessments are carried out and regularly reviewed on all residents who self medicate Timescale for action 02/11/05 2 YA20 13(2) 02/11/05 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 YA28 Good Practice Recommendations That the dining area is redecorated and refurbished as soon as possible. 9 Portland Road DS0000014167.V250422.R01.S.doc Version 5.0 Page 18 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
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