Inspection on 17/01/07 for Francis House

This inspection was carried out on 17th January 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Francis House 30/05/08

Francis House 28/02/06

Francis House 05/12/05

Francis House 03/02/05

Francis House 01/11/04

Francis House 03/02/04

Francis House 11/12/03

Similar services:

Flint House

The Ley Community

Yeldall Manor

Cherwood House Care Centre

The Manor Clinic

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

CARE HOME ADULTS 18-65 Francis House 2 Hulse Road Southampton Hampshire SO15 2JX Lead Inspector Liz Normanton Unannounced Inspection 17th January 2007 09:25 Francis House DS0000011915.V320154.R01.S.doc Version 5.2 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 Francis House DS0000011915.V320154.R01.S.doc Version 5.2 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. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Francis House Address 2 Hulse Road Southampton Hampshire SO15 2JX 023 8022 4481 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) Streetscene Mr Peter Vincent Swift Care Home 18 Category(ies) of Past or present alcohol dependence (18), Past or registration, with number present drug dependence (18) of places Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Francis House is situated in a residential area of Southampton near to the city centre and Southampton common. The home is registered with the Commission for Social Care Inspection as a treatment centre to accommodate eighteen service users, with drug and alcohol related problems. Francis House is part of the Street Scene organisation with two other treatment centres in Bournemouth. The treatment programmes consist of cognitive behavioural therapy, motivational enhancement and twelve-step therapy. The home offers both primary and secondary treatment courses. All adults over 18 years of age can be accommodated at the home. Fees:£530.00 per week. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 17/01/07 and focussed on what the commission considers to be core standards for a care home for younger adults as defined in the Department of Health (DOH) National Minimum Standards and looked for evidence of compliance with regards to requirements made at the last inspection. The information in this report has been collected from a variety of sources, which includes a pre-inspection questionnaire completed by the manager, six resident’s feedback questionnaires a visit to the home, discussion with three residents, manager, and three staff. Three residents’ care files and three staff files were audited. There was evidence that the manager had complied with the majority of requirements made at the last inspection however one remains outstanding. This will be an ongoing issue due to the shared room having limited space for separate storage for hanging clothes. Some further requirements have been made at this inspection which are detailed in the section what they could do better and the requirement section. There were eleven people living at the project at this inspection visit and all were satisfied with the service. People were asked how they would like to be addressed in this report and they agreed that resident would be appropriate. The majority of residents consulted were very satisfied with the service and outcomes of the project. What the service does well: People using the project can expect to learn to manage their addiction and move into recovery. They are involved in decision-making and are fully supported with their physical healthcare needs. They receive a good level of support with maintaining substance free lifestyles and gain skills and coping mechanisms to deal with the recovery process. Residents feel safe and are protected by the homes’ policies and procedures. Staff and the management are committed to providing a good level of support to residents. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 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 Francis House DS0000011915.V320154.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents to use the service and their representatives have the information needed to choose a home, which will meet their needs, however some areas of the information require updating. Prospective residents have their individual needs assessed and are provided with a contract, which clearly tells them about the house rules and about the service they will receive. There are outstanding requirements from previous inspections, as the house does not always obtain a copy of the care manager assessment and care plan. EVIDENCE: Standard 1 was not audited as part of this inspection however when the inspector looked at the service user guide (for information only) it was noted that this now requires updating to reflect the current circumstances in the house this matter was raised with the manager who agreed to review and update the service user guide. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 9 With regards to admissions the project manager reported that prospective residents are invited to visit the house following a referral from the care management team. At this meeting a needs assessment will be undertaken using information gathered from the referrer and that provided by the prospective resident. The manager also explained that some people moving in to the house may live outside of the geographical area and also come directly from prison in these circumstances as much information as possible is gathered over the phone to inform the assessment prior to a placement being offered. In discussion with three residents one stated that they had visited prior to moving in and had taken part in a needs assessment. One resident had been to the project before and had chosen to return following a relapse, as they knew the service had worked in the past. Another resident stated that they had had the opportunity to visit but had declined this offer however they confirmed that an assessment was undertaken within 48 hrs of admission. Three residents files were viewed and were found to contain a comprehensive needs assessment and also risk-assessments which looked at all aspects of an individuals care needs, including mental health, suicidal tendencies, self-harm. The three files viewed did not contain Care Management Assessments or information from probation or detox services, this issue has been raised in previous reports and requirements have been made for the home to obtain this information. This matter was discussed with the manager who reported that it is often difficult to obtain this information from referrers, as they do not provide it as requested. To deal with this problem the organization are considering having one individual member of the staff team to be designated as the gate-keeper and it will be their responsibility to chase up missing information. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in the decisions about their lives, and play an active role in planning the care and support they receive. Those staff responsible for the writing of care plans must ensure that they take care to make sure that the information recorded from the needs assessment is factually accurate. EVIDENCE: Three residents files were viewed and were found to contain care plans, which had been drawn up using the information gathered in the needs assessment/risk-assessment. The manager reported to the inspector that the homes counsellors are responsible for the drawing up and review of care plans. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 11 Information in one of the care plans did not correlate to information on the needs assessment/risk-assessment which had identified that the person had previously had suicidal tendencies and had been written that the risk was low when in fact the information supplied suggested that the risk would at least be medium or high. It is important that when drawing up information from the assessment that counsellors, do this accurately as people could be placed at risk of harm if project workers do not know the full extent of their support needs. This matter was discussed with the manager who agreed to look in to it with the counsellor responsible for the drawing up of the care plan. There was a manager visiting the house from the Bournemouth project who in discussion explained that the houses care plan recording system was in the process of being reviewed and updated as it had been found that information supplied on the care plans could be improved and also the format for recording of information. The new care plans will include treatment goals, personal goals and social goals and all staff will be given one to one training in how to record these accurately. In discussion with three residents they confirmed that they are involved in the reviewing of their care plans in one to one sessions with their counsellors. There was evidence on their files that they had been involved and had signed and dated the review details. It was observed that in free time residents are able to make choices on a dayto -day basis within a therapeutic regime, which does have restrictions. In discussion with one resident they confirmed that people living at the home have a right to make choices and that they are aware of the restrictions prior to moving in and that as they progress thorough the programme the limitations are reduced and they can make greater choices. In four returned questionnaires two residents stated that they could choose what to do during the evening and at weekends whilst two others said they could not do what they want. Each resident has a risk-assessment undertaken prior to or just after admission to the house. Ways to minimise risks identified are recorded on the care plan and altered as required. Residents in the primary stage of the treatment have less opportunity to take risks but more risks can be taken as trust is built. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the house are able to make choices about their lifestyle within the house rules and are supported to develop their life skills. Social, cultural and recreational activities meet individual’s expectations. EVIDENCE: At the time of the inspection visit none of the residents was in education or employment as their addictions had taken over their lives and their ability to hold done employment or education. In discussion with the manager they reported that the house tries to encourage residents to take up voluntary work as their health improves. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 13 Residents have links with the local community and can access local amenities. At the time of the inspection visit a walk over the common had been planned in the afternoon. In discussion with one resident they said that they go swimming, can use the gym and sometimes go out to the cinema. Those residents with alcohol addictions can attend local Alcoholic anonymous meetings on an evening as part of their recovery programme. The house does not allow visits from relatives or friends in the early stages of the treatment programme and details of these restrictions are written in the service users guide. Visitors are allowed usually on a Sunday and there are a number of areas in the home were people can meet in private. In discussion with the manager they reported that visitors are not allowed in residents bedrooms other then to have a look at how a person may have personalised their room. Residents spoken with are happy with the visitor arrangements at the house. The house has a structured weekly regime in which residents are involved in household tasks such as cleaning their own rooms and communal areas, as part of their therapeutic duties, which gives their day structure and also helps them to develop independent living skills for the future. There had been an improvement in the quality of meat products purchased by the house since the last inspection. All meals are prepared by the resident’s, who take it turn to make meals for the whole group; one acts as cook and is supported by an assistant cook this is done on a rota basis. At the time of the inspection visit the group had the benefit of a professional cook in there midst who had been coaching them in food preparation. All meals are served in the dinning room in a buffet style so that people can get what they want to eat. The meal served at lunchtime looked appetising and was in plentiful supply. The whole group was asked what they thought of the food and the majority said it was excellent. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, emotional and spiritual care needs of the residents are met and based on the individuals needs. The principles of respect, dignity and privacy are put in to practice. Attention needs to be paid in respect to medication procedures. EVIDENCE: Residents living at the house require very little in the way of personal care support but require more emotional and spiritual support this is provided in the one to one sessions with counsellors and in the group meetings. In discussion with the manager they reported that an Imam had recently visited the house when they had some Muslim residents. Residents with religious beliefs can attend services of their choice. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 15 There was evidence on resident’s files that they are registered with a general practice. Details of health needs were written on care plans. Dental problems were an issue for a number of residents and in discussion with two they confirmed that they had been to the dentist since moving in to the house. One resident spoken with said, “I have been to the opticians” since I moved in. The house has a locked medication room and medication is stored safely in metal cabinets. The person responsible for medication procedures in the home explained that they had recently converted to the Boots system (pre-packed medication in blister packs) and that there had been some errors. As a result of this those staff responsible for the administration of medication had been given additional training. There were a number of omissions on the medication record sheets. Resident’s can self-administer creams and lotions but all tablets are administered by designated projects workers. The house keeps homely remedies and these are stored in a separate cupboard and there is a separate record book. There was evidence that medication is booked in to the home. The person responsible for the medication procedures explained that the returns book was at the chemist. A sharps bin is available in the medication room. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: Residents are aware of how to make complaints and there was evidence that three complaints received since the last inspection had been recorded and investigated. Two people were satisfied that their complaints had been resolved and the manager reported that one had moved to a different house before the situation could be resolved. Details of how to make a complaint are made available to residents as part of the welcome pack. A copy of the Southampton Social service adult protection procedures was available in the office with easy access to staff. In discussion with two staff they demonstrated that they were aware of the houses “whistle-blowing” policy. There was evidence of staff training in adult protection awareness. The house has policies and procedures in place to safeguard residents monies. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 17 Financial records are kept and safe storage is provided for money and valuables. Residents are given their personal allowance once a week and they are then responsible for the management and safekeeping of this. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The house was clean and comfortable and provided a homely environment, however the house is in need of maintenance to improve the overall environment for the benefit of the residents. The layout and design promote independence for those without mobility difficulties. EVIDENCE: A partial tour of the premises was undertaken which included all communal areas, three resident’s rooms and a vacant double room. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 19 The lounge was spacious, fitted with two comfortable settees and a large tropical fish tank, coffee tables and computer. In discussion with the manager they reported that the lounge had recently been the office and that there had been a rearrangement since the last inspection. The dining room was very spacious, with plenty of natural light, it is also used for recreation purposes and lectures. The kitchen was dimly lit; the manager explained that the matter was being looked into and improvements were going to be made to the lighting. The house has no grill as the grill on the cooker has been decommissioned and removed and the replacement grill is broken. The cooker had broken arms on the pan rests and these need replacing as they could lead to pans tipping over and could be an accident waiting to happen. In discussion with the manager they reported that the cooker had been fitted with door seals recently as heat had been escaping and it was taking along time for things to cook. Food chopping boards were well worn with lots of scratches, which are a potential breeding ground for bacteria and need replacing. In discussion with the manager they reported that at the last environmental health visit they were advised to install a wash hand basin as there is not one present and residents are washing there hands in the sink used for washing coffee cups. The ladies toilet leading from the dining room had a spacious vanity area, which would benefit from being made more feminine as it lacked any warmth. It was noted that in the toilet cubicles there were no lampshades, which left exposed light bulbs, the toilet seats did not have lids and one door had no lock. In discussion with the manager they reported that the house had recently purchased some new toilet seats and that these would be fitted shortly. The gents toilet leading from the dining room had a tiled floor, which was not impermeable and the tiles closest to the urinals were very blackened with old lime scale and looked unsightly. Both toilet facilities were clean and the floors had been mopped but no warning signs had been put up to notify people of wet floors. The vacant bedroom requires two new mattresses as those in situ are out of shape and springs can be felt through the mattress covers. The en-suite tiles need re-grouting as the grouting is cracked and missing in parts. The carpet is torn and needs replacing. There are storage issues in this room, which has been ongoing and several requirements have been made to improve this. In discussion with the manager they reported that they have looked at ways of providing additional storage space but the room is not big enough. The Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 20 manager explained that the double room could not be converted in to a single room, as it is an important part of the house ethos in settling people in. It is suggested that some creative thinking be done to utilise the room’s space more effectively. The walls in one residents room requires repainting as they were grubby and had sellotape marks on and toothpaste blobs where the previous occupant had put up pictures. The bed in this room had a creaky base and the mattress was too big for the bed and hung over the edges. The resident spoken with said that the bed was uncomfortable. The resident stated that the window in the en-suite is broken and cannot be closed and the bathroom is cold. The paintwork on the windowsill and lower window frame was flaking and looked unsightly and requires repainting. The other two bedrooms were decorated and furnished to a reasonable standard and both residents were happy with their rooms. The rear stair well leading from the ground floor to the first floor had plaster coming away from the skirting which looked unsightly. The carpet was also frayed and worn and presented a health & safety risk. The carpet on the front stairs is also badly worn, a stair runner had been put on the top step and in discussion with the manager they reported that the maintenance person has plans to fix stair runners to all the stairs which will isolate the worn carpet and reduce the risk. There was evidence that some re-decoration was being undertaken in the annexe and new double glazed windows have been installed on the corridor on the top floor. The lighting in this area was dimly lit and needs improving. The two Jacuzzi baths had broken bath panels which are a health and safety risk, attempts had been made to cover sharp edges on one of the baths using tape however this looked unsightly. In one of the bathrooms six tiles were cracked which is a breading ground for bacteria as well as looking unsightly. The laundry is situated in the resident’s tea & coffee making area confined in a cordoned off area. The floor is impermeable. The washing machine is fitted with a special disinfection programme. In discussion with the manager they reported that washing is brought down by residents in laundry baskets but in the past been advised to use plastic bags for the purpose of washing however this method was not currently being used. There is no access to a hand wash - basin. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 21 The grounds were well tended and in good condition. Wooden elements of the outdoor furniture had gone green and are need of some attention. In discussion with the manager they explained that the windows of the property are rotten and require replacing and that there are plans for this work to be undertaken but it has not been identified as a priority. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Counsellors and project workers employed at the house receive training, which is relevant to their roles and responsibilities. The induction programme needs to be reviewed to comply with induction training accredited by the social skills council. The house has robust recruitment procedures to ensure the safety of residents. EVIDENCE: Three staff files were viewed, which included two recently employed staff. The most recently recruited staff had all the required documentation to evidence that the manager had used robust recruitment procedures. There was evidence in the third of an application form, two references, a previous Criminal Record Bureau Check (CRB) dated 2004 and a Protection of Vulnerable Adult (POVA) check dated 2006, there was no evidence of a recent CRB, however one must have been undertaken as this is the only way information can be got from the POVA list. In discussion with the manager Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 23 they explained that this file had been viewed at a previous inspection and they had requested another CRB for this staff member but could not explain why it was not on file. In discussion with three staff, two reported that they had undertaken training as part of their induction. There was evidence of training certificates in staff files. Training includes, health & safety, fire safety, administration of medication, first aid and safeguarding vulnerable adults. In discussion with a counsellor they confirmed that they had undertaken training in additional training in motivational interviewing and principles of cognitive behavioural therapy. There was evidence on file that staff have induction training however the manager needs to ensure that induction training is accredited by the skills for care council and obtain the appropriate materials. In discussion with two project workers they confirmed that they had been shadowed over several shifts on the commencement of their employment. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the house is based on openness and respect. The house has effective quality assurance systems developed by a competent manager. EVIDENCE: In discussion with the manager they reported that they have commenced and are half way through the National Vocational Qualification (NVQ) training at level 4 and hope to complete this before the end of 2007. An NVQ assessor visits the manager monthly to assess their progress. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 25 The manager has displayed the CSCI registration certificate and has obtained public liability insurance. The manager has ensured that each resident’s has a written contract and terms and conditions of the placement. At the last inspection the person responsible for the running of the house was an acting manager who has since become the registered manager of the service. With regards to quality assurance the manager has developed questionnaires, which are given out two monthly. The information is then sent to the organizations head office to be viewed and compiled into resident feedback. In discussion with the manager they reported that a director from the organiastion visits the house regularly to undertake audits and completes a regulation 26 form which are filed at the house. Each resident has goals, which they have to achieve as part of their recovery and the ultimate goal is to overcome their addiction. One resident had just completed their programme and was leaving the project the following day. The inspector attended their graduation ceremony at which all residents are present to give recognition to the person who has achieved their goals. The following statements were provided by three residents in the questionnaire sent out prior to the inspection visit: “On the whole Francis House is good in all areas”. “ I have enjoyed my stay at Francis House” “ So far I am very pleased with the rehabilitation I am getting”. The house does not have an annual programme of renewal work however a maintenance person has been employed to do minor repairs and redecoration to the house. There was evidence of a fire risk assessment undertaken by the manager. In discussion with a project worker and a counsellor they demonstrated that they knew the fire procedures. There was evidence that fire equipment is checked and weekly fire alarm/systems tests are done. It was noted however that in the graduation room, the fire exit had been blocked by two chairs. There was a notice on the window reminding people not to block the entrance but this had not been adhered to. Regular fire evacuations are undertaken to ensure that the residents are aware of the fire procedures. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 26 Staff, have had first aid training and first aid boxes are strategically placed around the house. There was evidence that portable electrical appliances are checked annually. And that heating systems are regularly serviced and maintained. Substances that are considered harmful to health (COSHH) are stored appropriately following use. The residents are responsible for the cleaning of the house and sign a document to say that they aware of the hazards and will use products safely. The manager ensures compliance with Health & Safety legislation by example, training, supervision and team meetings. All accidents are recorded and CSCI are informed of incidents, which adversely affects an individual. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 27 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 Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Stanard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 (1) Timescale for action You are required to obtain care 30/04/07 management assessments prior to admission for any resident who is fully or partially funded. (This was a requirement was outstanding from the previous inspection dated 28/02/2006.) You are required to ensure that staff responsible for the drawing up of care plans, gather accurate information from the needs assessment to protect residents’ welfare. You are required to ensure that staff, responsible for the administration of medication sign the MAR sheets or put a relevant code to demonstrate that the medication has or has not been taken as prescribed. You are required to fit a lock to the ladies toilet cubicle, which has no lock. You are required ensure the flooring in the urinals is hygienic . All beds must be sound and fit DS0000011915.V320154.R01.S.doc Requirement 2. YA6 12 (1) (a) (b) 30/04/07 3. YA20 13 (2) 30/04/07 4. 5. 6. YA23 YA23 YA23 23 (2) (b) 23 (2) (b) 23 (2) (c) 30/04/07 31/08/07 30/04/07 Page 29 Francis House Version 5.2 for purpose 7. YA23 23 (2) (b) (d) You must ensure all rooms are suitable for their purpose. The double room which was vacant at the time of the visit must be well furnished and in a good decorative state. You are required to replace the bath panels on both Jacuzzi baths. You are required to repair or replace the broken window in the resident’s bedroom as discussed in the main body of the report. If repaired then the paintwork will need to be repaired as it is flaking off. You are required to replace the cracked tiles in bathroom detailed in the report. You must ensure that all service users have adequate storage facilities for their clothing and other belongings in line with the standards. (This requirement has been outstanding from two previous inspections. The last inspection dated 28/02/06.) You are required to ensure that health and safety procedures are carried out in respect of putting up warning signs to inform people of wet floors. 31/05/07 8. 9. YA23 YA23 23 (2) (c) 23 (2) (b) 31/08/07 30/04/07 10. 11. YA23 YA26 23 (2) (b) 16 (2) (c) 30/04/07 30/04/07 12. YA42 12 (1) (a) 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000011915.V320154.R01.S.doc Version 5.2 Page 30 Francis House 1. 2. 3. YA24 YA23 YA23 4. 5. YA35 YA42 The house would benefit from the purchase of a new commercial cooker. The house would benefit from the introduction of feminine items in the vanity room such as dried flower arrangements or plants to give it a warmer feeling. The house would benefit from outside furniture being cleaned, sanded down and re-varnishing to provide a pleasant seating area in which residents can enjoy the garden. Staff and residents would benefit if the house had an induction programme which is accredited by the skills for care induction standards. Project workers & counsellors should ensure that residents do not block fire exits in meeting rooms. Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Francis House DS0000011915.V320154.R01.S.doc Version 5.2 Page 32 - 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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