Inspection on 01/09/05 for Sefton Park Residential Care Home

This inspection was carried out on 1st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sefton Park Residential Care Home 01/11/07

Sefton Park Residential Care Home 21/11/06

Sefton Park Residential Care Home 12/01/06

Sefton Park Residential Care Home 24/03/05

Sefton Park Residential Care Home 17/07/04

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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

CARE HOME ADULTS 18-65 Sefton Park Residential Care Home 10 Royal Crescent Weston-super-Mare North Somerset BS23 2AX Lead Inspector Nicola Hill Announced 1 September 2005 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. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sefton Park Residential Care Home Address 10 Royal Crescent Weston-super-Mare North Somerset BS23 2AX 01934 626371 01934 626371 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) Mercia Care Homes Limited TBA Care Home - Personal Care Only 28 Category(ies) of 1. People with past and present drug registration, with number dependency. of places 2. People with past and present alcohol dependency. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24 March 2005 Brief Description of the Service: Sefton Park provides a residential therapeutic program for up to 24 people aged 18-64 years who have alcohol or drug dependency issues. The home is an attractive spacious property situated near the seafront within walking distance of the town centre. The home provides a variety of well furnished communal areas; there are eight double bedrooms (all en suite) and ten single rooms. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection at Sefton Park Lodge took place with the acting managers, Sue Hewlett and Irene Rendell. Due to a recent increase in the number of people leaving the programme before completion, the inspection focused on the admission processes to the home from the perspective of both the staff at the home and residents. The inspection lasted approximately 8 hours and involved the acting managers, three new members of the staff team and five residents currently following the rehabilitation programme. At the time of the inspection there were 20 residents at Sefton Park. Residents completed 14 comment cards in order to canvass their views of the service for the inspection. What the service does well: What has improved since the last inspection? The home has been successful in recruiting a new manager who is due to start at Sefton Park on 5th September 2005. The establishment is registered with BACP. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 6 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. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 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 standard(s) 1,2,4 The statement of purpose and service user guide provide sufficient information about the service to enable prospective service users to make an informed decision about admission. The admission procedure must be monitored. EVIDENCE: The statement of purpose and service user guide will require updating when the new manager starts at the home. The information contained in both of these documents is sufficiently detailed to inform prospective service users about the programme run at the home and the expectations of service users joining the programme. There is also an accessible website. The inspector discussed with the Residents at the home their decision to join the rehabilitation programme at Sefton Park. The responses from the residents indicated that they had attended the home for a pre-admission assessment, which was valuable as it enabled them to explore the content of the programme and meet with residents currently following the programme. It is noted that none of the residents had seen the pre-admission information, and their decision to apply to Sefton Park was based on recommendation by either ex-residents or referring agencies. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 9 The admissions process at Sefton Park was reviewed with the acting managers, who were able to demonstrate that they had reflected on current practices in respect of the increased number of early discharges. Following analysis of the early discharges, further guidance on the admission processes has been put in place. The intention is to reduce the number of people leaving and to maintain the stability and continuity of the programme for the other residents. The guidelines are that: • • • • There will be no admissions on a Friday as the counselling support available to new residents is limited at weekends. New residents will be admitted singly i.e. only one on a day. One-to-one interviews to replace telephone interviews wherever possible for prospective service users who are within the penal system. No residents will be admitted directly from prison. These measures will be monitored for effectiveness and may be reviewed by the new manager. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 Service user’s views are sought and acted on when they contribute to the day-to-day running of the home. The expectations of the programme limit the individual choices available to the residents. EVIDENCE: The discussions with residents indicated that regular weekly meetings were held for all residents to attend. The house meetings are held for residents to raise issues relating to the day-to-day running of the home for example, minor repairs. Within the group, residents also raise and discuss issues of importance to them and benefit from the peer group support. The comment cards given to residents indicated that some would like to have more involvement in the decision-making within the home. This was discussed with residents in respect of planning leisure time at weekends. The programme is planned with certain restrictions of personal freedom to ensure that residents focus on their rehabilitation. The group therefore has to reach a consensus on how to spend their leisure time; this is not always possible with the result that no activities take place. It was acknowledged by the house leader that the diversity amongst the group made it difficult to keep everybody happy. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 11 The acting managers discussed with the inspector the possibility of residents taking over responsibility for self-medication. This should be subject to a risk assessment, but will allow the home to support people toward a more independent lifestyle. The documentation held at Sefton Park concerning service users is stored safely. Paper records are stored in locked cabinets and computerised records have password protection. In order to comply with the Freedom of Information Act the home allow all residents to see their records. It was suggested that a memorandum of understanding between Sefton Park and referring agencies be drawn up so that they are aware that any information sent to Sefton Park may be seen by residents. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,16,17 Links with the local community are good and support the residents with social and educational opportunities through AA and NA. The meals in this home are good offering choice and variety; the home is able to cater for any special dietary needs. EVIDENCE: Sefton Park is situated close to the local shops and facilities. The extent to which service users can access the community is dependant on the stage they are at in the programme. Service users are supported to go out into the community and participate in therapeutic activities, AA or NA in order to relate to the support networks available to them on discharge. Residents spoken with found this acceptable and were happy that this represented an opportunity to them to use the wider community as peer support. Limited recreational facilities are provided, however, some service users reflected on the fact they would have preferred more recreation whilst others felt that detracted from the work they were there to do. All the residents Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 13 participate in the therapeutic duties that contribute to the day-to-day running of the home. The therapeutic duties also enable residents to take responsibility, participate and contribute to the community of the home. The residents stated that meals were good with sufficient choice available to them, several of the residents commented that they had gained weight since arriving at Sefton Park. Three of them assist in the kitchen with the meal preparation and clearing away. There is a part-time chef who currently works split shifts in order to cover the main lunchtime and evening meal periods. This means that the chef is not always available to receive food orders and a degree of flexibility in the number of hours allocated per week could be implemented. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 The systems for administration of medication are clear with comprehensive arrangements in place to ensure service users medication needs are met. EVIDENCE: The health care needs of residents are assessed prior to admission. The home will not admit people with a diagnosed mental health condition, as they are unable to provide any specialist support. For example, a person recently admitted to the home who did not exhibit any mental health problems on assessment, or prior to admission, appeared to have problems, which the counselling team did not feel able to address. This person was given a therapeutic discharge, with follow-up arranged for a psychiatric assessment through their probation officer. The day-to-day health care needs are met by local primary health care practices; residents are allocated a GP by NHS direct. The local dental practice will register residents from Sefton Park. Staff administer the medication system at the home; currently no residents administer their own medication. When residents come to the end of the programme it may be appropriate for them to self-administer medication following a risk assessment. The home will need to include control measures Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 15 such as issuing small amounts medication at a time or spot checking stock numbers. These will reduce any potential risks and fulfil the homes duty of care towards the resident. If this system is to be introduced at Sefton Park then a lockable cabinet must be available to the residents. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The complaints procedure in this home is good with information readily available to residents. EVIDENCE: There have been no complaints made by residents or visitors to the home. The North Somerset Council Protection of Vulnerable Adults policy is in the process of being revised and it is advised that staff training be requested to take place at Sefton Park when this policy revision is completed. The home currently has a copy of the No Secrets procedures, however, it would be useful for the home to produce a short bullet point procedure, which staff can easily follow. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 17 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 The residents at Sefton Park have a safe environment that requires regular maintaining to keep it in good order. When planning the best way to use available space, reference to relevant health and safety legislation must be included. EVIDENCE: The building is subject to heavy use and the organisation employ a part-time handyman in order to maintain a good standard of decoration. The residents clean the home as part of the therapeutic duties. The office space at the home is a very limited. The intention is to revamp the space and create storage space within the sleep in area. Currently the office is not planned to provide an ergonomically friendly environment. The staff need designated workstations planned to meet individual need, these need to be risk assessed as required by the health and safety legislation. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 18 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) 34, 35, 36 The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. EVIDENCE: Since the last inspection Sefton Park has employed three new staff. The inspector spoke with the staff about their recruitment and induction to the home. The recruitment process followed an established procedure, however, it was noted that CRB checks were outstanding as were references for one member of staff. There is a recruitment checklist that had not been completed for all the new staff. There is an induction checklist that was an introduction to the home and the health and safety systems such as the fire safety procedures. The administrative and counselling staff members also received induction into their specific roles. The new member of the counselling staff team also confirmed that she received internal and external supervision. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 19 Staff training had been recently undertaken in respect of fire training and first aid. If training takes place within Sefton Park, then residents could possibly also access the training course. The staff rota indicated that there were a minimum of two counsellors and ancillary staff at work during office hours and a support worker on duty in the evenings and weekends. The counsellors also participate in an on-call rota and the inspector was able to review how often counsellors were called and the nature of the incidents. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39 The staff team have a very good understanding of the residents support needs through a programme of rehabilitation; this is evident from the positive comments from service users. EVIDENCE: The new manager has been appointed to Sefton Park and will take a post week commencing 5th September 2005. The residents spoke highly of the staff team and the ethos of the home. The residents were able to identify the leadership at the home and stated that all the staff were approachable and would listen to them. As part of the quality assurance process residents complete exit questionnaires when they have completed treatment. The comments from ex-residents were very positive and shown to prospective and current residents in order to support them through the rehabilitation process. There is also an area on the website for ex-resident’s comments. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 21 The areas particularly identified as being excellent were the counselling received and the professionalism of the staff team. The occupancy/referral statistics are in the process of being audited in order to provide information about the target market for the future business development. In respect of the implementation of health and safety at Sefton Park it is recommended that one file be used to record the fire safety checks and that checks are undertaken as per Avon Fire Brigade recommendation. All users of visual display screen equipment must have a risk assessment, which identifies how the equipment can be used safely. There were no other areas of health and safety of concern identified by the inspector. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 22 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 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x x 3 x x 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sefton Park Residential Care Home Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x x 2 x D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 23 Are there any outstanding requirements from the last inspection? No 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 42 Regulation 23 Timescale for action The implementation of the health 1/10/05 and safety at the home must include risk assessments of all users of visual display screen equipment. Sufficient office space should be provided in order that staff can work safely. Two references must be obtained 1/9/05 and CRB checks must be completed before staff commence employment. Requirement 2. 34 19 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. Refer to Standard 42 23 2 Good Practice Recommendations Fire safety records should be collated into a single file which is easily audited. A bullet point adult protection procedure should be produced which includes contact information for relevant agencies. The admissions process must be closely monitored to ensure that potential service users understand the programme and fit the criteria for admission. Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier, Taunton TA1 4AL 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 Sefton Park Residential Care Home D53_D02 S50772 Sefton Park V240635 010905 Stage 4.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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