Inspection on 21/06/05 for Searchlight Workshops - Francis House

This inspection was carried out on 21st June 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Searchlight Workshops - Francis... 08/02/07

Searchlight Workshops - Francis... 03/03/06

Searchlight Workshops - Francis... 28/01/05

Searchlight Workshops - Francis... 25/11/04

Searchlight Workshops - Francis... 17/06/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Searchlight Workshops - Francis House Claremont Road Mount Pleasant Newhaven BN9 0NQ Lead Inspector Jennie Williams Unannounced 21 June 2005 10.30 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. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Searchlight Workshops- Francis House Address Claremont Road Mount Pleasant Newhaven East Sussex BN9 0NQ 01273 514007 01273 611289 enquiries@search-light.org.uk Searchlight Workshops 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) Ms Annette Shepheard Care Home 6 Category(ies) of Learning disability (LD) 6 registration, with number Physical disability (PD) 6 of places Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That service users accommodated are aged eighteen (18) to sixty-five (65) on admission. 2. That service users must have a physical disability or learning disability. 3. The maximum number of service users to be accommodated is six (6). Date of last inspection 28 January 2005 Brief Description of the Service: Francis House is a home within the Searchlight Workshops organisation that is registered for six places for younger adults, of either gender, who have a physical disability or a learning disability. There is no nursing care offered at this establishment. The home is situated on the top of a hill on the outskirts of Newhaven. The home has access to a mini bus. There are local amenities and access to bus routes at the bottom of the hill. There are three registered establishments at this one site within the organisation of Searchlight Workshops. There is also a workshop on the site available to residents and others within the community. A variety of crafts/activities are offered at the workshop. A social club is ran on site and this opens a couple of evenings a week. All rooms are for single occupancy and are located over two floors. Residents must be able to mobilise independently to access the first floor. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Francis House will be referred to as ‘residents’. This unannounced inspection took place over five hours on the 21 June 2005. A tour of the home was not required, as the Inspector had previously inspected the home. Individual rooms were spot-checked. Care plans were spotchecked. Residents and staff were spoken with throughout the inspection process. There were six residents residing at the home on the day of the inspection. Two trustees were undertaking their unannounced visit on the day of the inspection. 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. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 6 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 Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 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 standard(s) 1, 2, 3 & 4 The home has information available to prospective residents and their representatives to make an informed decision if the home is suitable for their needs. All prospective residents are assessed prior to moving into the home EVIDENCE: The home has a Statement of Purpose and Service User Guide that is available upon request and provides prospective residents and their representative information on the services and care provided at the home. The manager undertakes all pre assessments of prospective residents. A copy of social services assessment is obtained wherever possible. There has been no new admissions since the last inspection. The location of the room will be taken into consideration when assessing any prospective resident, as people must be able to mobilise independently between floors. Prospective residents are able to visit the home prior to moving in if they wish. The manager has been advised to ensure that another pre assessment is undertaken if a resident has spent a period of time in hospital. This is to ensure that the needs of the individual have not greatly changed and can still be met by the home. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 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 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 & 10 Some needs are at risk of not being met due to lack of documentation in the care plans. Residents’ routine and lifestyle is their own choice. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: A new care plan format is being developed between the three homes located on the one site. This has taken longer to finalise than anticipated. Care plans were only spot-checked on this occasion as it was confirmed that no care plan has been transferred onto the new format. Additional information has been provided to the old format as required. It remains an outstanding requirement that care plans cover all aspects of care and reflect actual current practice. Residents confirmed that staff discuss their care needs with them and are involved in the reviewing process. Residents spoken with confirmed that their routine of life is their own choice. Staff encourage residents to make their own decisions. Some comments from residents were ‘couldn’t fault the care’ to ‘the staff are tops’. It was confirmed that all residents at Francis House are now provided with their own bank accounts, as required at the last inspection. One resident has a solicitor as their Power of Attorney. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 9 Residents are now encouraged to be more involved in the running of the home. Residents now undertake their own shopping on a rota basis and do the preparing and cooking of meals. Residents spoken with confirmed that they are enjoying being involved in this process. Residents appeared proud of gaining further independence. The home has undertaken appropriate risk assessments for all residents and activities they may participate in. All personal information is kept securely at the home. Residents have access to their records if they wish. Information given in confidence is not share with families/friends against the residents’ wishes. It was discussed with the manager the importance of care notes reflecting information on the disability and health needs of an individual to monitor progress being made. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 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 standard(s) 11, 12, 13, 14, 15, 16 & 17 Residents are provided with opportunities for personal development and to be involved in the local community if they wish. Residents have opportunities to engage in appropriate leisure activities. EVIDENCE: There is a workshop and social club located on the same site as Francis House. Residents of the home are able to use these facilities if they choose. People that live outside of the home environment may also use these facilities. There is a bus available at the home to transport residents. Wheelchairs can be accommodated in the bus. Feedback from residents regarding the use of the social club was discussed with management. One resident felt it could be ‘put to better use’. It was recommended that management undertake a formal survey on the provision of activities/entertainment provided at the social club. Residents have opportunities for personal development. No one had chosen to undertake any courses recently. One resident has been provided with appropriate support and is currently looking at suitable measures to allow them to move out of the home environment and live independently. There were no residents working in paid jobs outside of the home environment. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 11 Two residents work at the reception for Searchlight Workshops. One resident does volunteer work. Individuals are encouraged to continue their activities they are engaged in prior to entering the home. Residents are encouraged to participate within the local community. It was confirmed that most residents went to a polling booth to vote in the elections this year. Visitors are welcomed to the home. Residents confirmed that there are more opportunities for activities being offered and are provided with more opportunities to be out of the home environment. One resident informed the Inspector that they went independently on a holiday to Canada to visit a long lost relative. This was thoroughly enjoyed. Residents now develop their own menus. Residents are now involved in doing the grocery shopping with the assistance of a staff member. Residents stated they enjoy developing the menu and preparing and cooking the meals for each other. These tasks are done on a rota basis. Residents choose where they eat. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 12 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 & 20 Residents’ routines of daily activities are flexible. Residents are safe guarded by the procedures in place for medication administration. EVIDENCE: Residents spoken with confirmed that they choose their own daily routines. Residents were observed to move freely within and outside of the home environment. Residents spoken to confirmed that they felt their privacy and dignity is respected. Changes in residents health are monitored and advice is sought whenever required. One resident was provided with transport to attend an appointment with a health professional on the day of the inspection. Procedures for the administration of medication have improved as required at the last inspection. Medication was observed to being signed for at the time of administration. It is recommended that MAR charts demonstrate when prescribed creams are no longer required. Risk assessments are completed for those residents who self-medicate. Systems have been developed and are commencing to be implemented to ensure medication is accurately recorded and administered. A monthly internal audit will be undertaken on medications. It was confirmed that the first audit will be undertaken at the end of the month. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 13 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 & 23 People involved with the home are provided with suitable information to allow them to make a complaint. Staff are provided with sufficient information to inform them of the correct procedures if an allegation of abuse is made. EVIDENCE: There is a complaints procedure available at the home. Residents spoken to confirmed that they know who to speak to if they needed to make a complaint. There is a record kept of complaints. There have been no complaints made to the CSCI since the last inspection. There had been one complaint made to the home since the last inspection. Management needs to ensure that the action taken to deal with complaints is documented. There are policies and procedures in place for dealing with allegations of abuse. The manager has undertaken a one-day course on Adult Protection that was provided by an external body. The manager found that the course was ‘a waste of time’ and is obtaining information on an additional course to attend. Adult protection information is included in the induction process for all new staff. There have been no allegations of abuse made since the last inspection. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 14 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 & 30 The location of the home provides opportunities for residents and visitors to access local amenities and transport. Residents live in an environment that suits their needs. EVIDENCE: The home is situated on the top of a hill on the outskirts of Newhaven. The home has access to a mini bus. There are local amenities and access to bus routes at the bottom of the hill. All rooms are for single occupancy and are located over two floors. Residents must be able to mobilise independently to access the first floor. Residents spoken to confirmed that they were happy with their individual room. Rooms that were spot-checked were seen to be personalised to reflect the individual’s choice and personality. The home was free from offensive odours on the day of the inspection. There is a rota for cleaning duties that residents are involved in. The cleaning of equipment in the kitchens could be improved. The oven and microwave were observed to be in need of cleaning. It was confirmed to the Inspector that the oven was scheduled to be cleaned the following day. Some residents spoken with confirmed that they enjoyed being involved in the cleaning routine. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 15 There were no paper towels provided in the upstairs bathroom for people to dry their hands. This had been removed due to the paper blocking the toilet. It was discussed with the manager that hand-drying provisions must be made available. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 & 35 Residents’ needs are being met with the numbers and skill mix of staff working at the home. Staff are suitably trained to meet the needs of the individuals currently residing at the home. EVIDENCE: Resident spoken to were very complimentary about the staff working at the home. All residents felt that their needs were being met with the skill mix and staffing numbers at the home. There have been no new staff employed since the last inspection. There was evidence that the home is working towards the 50 ratio of NVQ level 2 trained staff working at the home. Staff are provided with updates for all mandatory training and are provided with opportunities to attend study days being offered by external agencies. The registered manager is also the health and safety officer for all three homes located at the one site. There is a training schedule implemented until 2008. A computer system used for recording training will highlight when a staff member is due for an update on any mandatory training. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 17 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, 39, 40 & 42 Residents are safe guarded by the systems in place to monitor the health, safety and welfare of residents. A developed and implemented quality assurance and quality monitoring programme would enable management to assess the suitably of services provided at the home and identify areas that can be improved. EVIDENCE: The manager is experienced and qualified to manage the home. She has achieved her NVQ level 4 in care and only has a couple of units to complete to achieve the Registered Manager Award. It was confirmed that there is still work being done within the organisation to develop an effective quality assurance and quality monitoring system. The Responsible Individual confirmed that this will be completed by mid-July. There are surveys kept at the entrance of the home for people to complete if they wish. Trustees of the organisation undertake monthly unannounced visits to the home to monitor practices and provides a report to the home and CSCI. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 18 The organisation has purchased a set of policies and procedures from a company and is currently in the process of personalising them to the home. The home must ensure these comply with Appendix 2 of the NMS. The Responsible Individual confirmed that this would be completed by the end of July. The manager is also the designated health and safety officer. It was confirmed that all relevant checks are undertaken and up to date. Staff receive all mandatory training relating to health and safety. Hot water taps sampled demonstrated that water is being delivered around the recommended temperature. Pre set valves have been placed on hot water outlets that were delivering water at excessive temperatures, as required from the last inspection. A record is kept of any accident/incident that occurs. The Inspector noted that it would be difficult for residents to distinguish between hot and cold taps. It was confirmed that this had already been addressed with the maintenance man. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 19 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 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x x x 2 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 x 2 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Searchlight Workshops - Francis House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 2 x 3 x H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 20 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 YA6 Regulation 15 Requirement That care plans cover all areas as stated in Standard 2 of the NMS. That care plans reflect actual current practice. (Timescale 31.03.05 not met) That care notes reflect information on the disability and health needs of an individual. (Timescale 31.03.05 not met) That the action taken to deal with complaints be documented. That hand drying provisions are provided in the upstairs bathroom. That an effective regular quality assurance and quality monitoring system is developed and implemented.(Timescales 30.08.04 and 31.03.05 not met) That policies and procedures are reviewed on an annual basis and comply with Appendix 2 of the NMS. (Timescale 31.03.05 not met) Timescale for action 31.07.05 2. YA6 17 31.07.05 3. 4. 5. YA22 YA30 YA39 22 16.2(j) 24 31.07.05 30.06.05 31.08.05 6. YA40 Appendix 2 31.08.05 Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 21 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. 2. 3. 4. Refer to Standard YA2 YA14 YA20 YA32 Good Practice Recommendations That an additional pre assessment is undertaken if a resident has spent a period of time in hospital. That management undertake a formal survey on the provision of activities/entertainment at the social club. That MAR charts demonstrate when prescribed creams are no longer required. That the home continues to work towards the 50 ratio of care staff NVQ level 2 trained. Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 22 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 Searchlight Workshops - Francis House H59-H10 S59172 Francis House V218862 210605 stage 4.doc Version 1.30 Page 23 - 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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