Inspection on 09/01/07 for South Highnam

This inspection was carried out on 9th 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 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

South Highnam 05/10/05

South Highnam 12/08/05

South Highnam 14/10/04

South Highnam 03/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 South Highnam Park Avenue Hartlepool TS26 0DZ Lead Inspector Lesley Anne Moore Unannounced Inspection 9th January 2007 09:30 South Highnam DS0000021748.V324640.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 South Highnam DS0000021748.V324640.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. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Highnam Address Park Avenue Hartlepool TS26 0DZ 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) 01429 864848 londonroad@tiscali.co.uk Milbury Care Services Limited Carole Stephenson Care Home 8 Category(ies) of Learning disability (8) registration, with number of places South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: South Highnam is a large detached property located in a pleasant residential area of Hartlepool. Accommodation consists of eight single bedrooms all with individual washing facilities, and pleasant communal living and dining areas. The home is fully accessible to wheelchair users with the provision of level access and door openings of a suitable width. The house is situated in its own grounds with a car parking area to the front of the property. The large garden to the rear provides a private area for service users to enjoy. Service users have access to local amenities, transport and relevant support services. The home is registered to provide care and accommodation for up to 8 people who have a learning disability. The current fees charged are between £912.92 to £1076 per week plus a contribution from an individual’s disability living allowance of £8 or £25 for travel in the company vehicle depending on level of disability, and do not include additional charges for personal items or holidays. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 9 January and lasted approximately 5 hours. The Registered Manager provided some information on the pre-inspection questionnaire. 10 relatives/visitors comment cards were completed and returned. The inspection focussed on key standard outcomes for service users and to check whether the recommendations made at the previous inspection had been implemented; in particular to confirm that improvements had been made to the interior décor where damage had been caused through wheelchair contact, that ceiling cracks had been repaired in the downstairs bathroom, that the lounge carpet had been refurbished/replaced, and that the kitchen work surfaces had been repaired or replaced; to meet with the service users and talk to them about their experiences of living in the home; to meet with the staff and to look at the home’s records. The Inspector was given a tour of the premises. There were 7 service users at the time, the remaining service user was attending a day centre. There was a relaxed and homely atmosphere, service users appeared happy, well cared for, and were carrying out their normal daily activities. Two service users were baking with a member of staff, others were relaxing in the lounge area. It was noted that recommendations made at the previous inspection relating to repair of the kitchen work surface and repair of a cracked ceiling in the downstairs bathroom are yet to be implemented. What the service does well: Service users are encouraged to make choices about their life style and given the opportunity to develop their social, educational and life skills. Each service user has a personal activity programme according to their ability and needs. Individual records have been developed with the service user both in text and pictorial format including personal photographs that give a detailed description of the service user’s life, personal and health care needs, family and friend support, and future life goals. South Highnam DS0000021748.V324640.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. South Highnam DS0000021748.V324640.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 South Highnam DS0000021748.V324640.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): 1, 2, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives receive appropriate information about the home including an assessment of the service users needs prior to admission. EVIDENCE: The home is seen to provide adequate information within the Statement of Purpose and Service User Guide to prospective service users in a pictorial format including a visit to the home where possible. The Inspector looked at the records of a service user who recently came to live at South Highnam. The home’s own assessment documents were available providing a preliminary assessment of daily living activities, and also the original assessments from the social work team. The Service User Guide within each individual file contained a statement of terms and conditions in pictorial format and had recently been updated with the service user’s current fees. Original signed contracts were also available and stored safely in the Manager’s office. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are involved in decisions about their lives and play an active role in planning the care and support they need. There are procedures in place to ensure that service users are informed of their rights to confidentiality. EVIDENCE: Care plans are developed following person centred planning principles whereby each service user has a care plan that is written with him/her, presented in a format that service users can understand the information it contains, and is easily accessible. The care plans consider all areas of the service user’s life including personal and social care needs, health needs, behaviour management and risk assessments. A comprehensive risk assessment is undertaken for each activity with documented evidence of regular review by staff. A section dedicated to personal goals ‘Planning and dreaming about the future’ considers the future aspirations of service users. There is evidence of regular review of South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 10 the care plan with the service user by the key worker, care manager, Registered Manager and where agreed their family. A separate 24-hour file acts as a working tool and provides a record of the care needs and activities that the service user has been engaged in over a 24-hour period. Amongst other records the file contains a daily record, mood chart, bathing chart, activities chart, details of visits by family, and bedroom management chart setting out a schedule for cleaning/tidying the service user’s own room. Each file contains a statement written in consultation with the service user setting out the service user’s rights to confidentiality and their agreement of when staff may share the personal information that is written in the file. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 11 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 and 17.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home understands the importance of enabling the service users to achieve their goals, follow personal interests and leisure activities, and be integrated into community life. EVIDENCE: The Manager discussed the various activities that service users are engaged in to include educational, social and employment. A programme of weekly activities is written in consultation with each service user and kept in the service user’s individual file. A number of service users attend local Day Centres and colleges to develop their independent life skills. Service users are encouraged to take part in the various activities that take place in the home. During the inspection several service users were baking cakes. There is also an active social programme run in the home to include regular outings to the ‘Hourglass’, a disco catering for people with similar disabilities, escorted holidays where possible and visits to local pubs and the nearby park. Several South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 12 of the service users spoke enthusiastically of their weekly visits to local organised events for people with similar disabilities The staff encourage a good relationship with the local community and neighbours. Individual records are held securely. Each file contains a statement agreed with the service user as to where they wish their personal records are to be kept. The aims and objectives of the home reinforce the importance of treating service users with respect and dignity in all aspects of their life. There is a varied menu on offer and service users are given choice if they have particular likes or dislikes. The staff support those service users who have difficulty with eating and give assistance where appropriate. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 13 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff support and help service users to be independent and responsible for their own personal care and hygiene where possible. EVIDENCE: The care plan provides a detailed pictorial summary of the health and personal care needs written in consultation with the service user. Personal photographs are inserted to support the care plans showing service users engaged in personal care activities. Service users are supported where possible to be independent and responsible for their own personal care. Where this is not possible the staff acknowledge that the delivery of personal care is highly individual and the staff work hard to preserve the service user’s privacy and dignity. This includes giving the service user choice about who delivers their personal care and if the service user requests ensuring that care is delivered by a staff member of the same sex. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 14 Service users have access to local health care and are encouraged to be independent and attend regular appointments. Where this is not possible home visits are arranged to meet the needs of the individual service user. Of those service user’s who are visited by community health staff, documented records are maintained and kept in the home describing the care received. The home has a medication policy in place to allow for the safe receipt, storage, administration and disposal of medicines and includes administration of Controlled Drugs. However, it was noted when examining the medicines of 2 individual service users that there was over stocking of some medicines. The home needs to review its policies and procedures in relation to stock levels. There are no service users who self-medicate at the present time. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 15 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to express their concerns and have access to an effective complaints procedure that is up to date, clearly written and accessible. The policies and procedures regarding protection of individuals are of a high quality and are regularly reviewed and updated. EVIDENCE: There is a clear and accessible complaints procedure available to anyone associated with the service to raise a concern. The Service User Guide includes a pictorial summary titled ‘What to do if you don’t like something’. The Manager reported that there had been no complaints since the previous key inspection. Comments received on the relatives/visitors comment card include ‘I am involved and kept informed as and when any concerns/problems arise, No complaints from me at all’, Another, ‘In my opinion both the service user and all other residents are happy whenever I see and meet them wherever they are.’ There was evidence available to support the training that staff members have received in relation to protection of vulnerable adults both during the induction programme and on an on-going basis. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 16 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, 25, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and homely environment, which encourages independence. EVIDENCE: Recommendations made at the previous inspection relating to repainting of damaged walls from wheelchair contact and refurbishment of the lounge carpet have largely been met. The lounge area has recently been redecorated and newly carpeted to provide a pleasant area in which service users can relax. The programme of redecoration to the downstairs bedrooms, bathroom and corridor access continues. The suite to the downstairs bathroom has been replaced in parts and the Manager explained that the ceiling cracks were to be repaired as part of the redecoration programme. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 17 Service users bedrooms are individualised giving the opportunity for choice to be exercised in the colour of décor and fixtures and fittings. There is also the opportunity for a limited number of personal possessions and furnishings to be brought in. It was noted that there is an absence of window restrictors on the windows to the ground floor. Whilst this is unlikely to pose a risk to service users, a risk assessment looking at the health and safety of the current arrangement would satisfy the service that it is doing everything possible to reduce the likelihood of any risk. During the visit it was noted that the flooring in the upstairs bathroom is stained. The Manager confirmed that the flooring is to shortly be replaced. Also, the carpet immediately outside the bathroom door was particularly worn. The home should consider repairing or replacing this carpet. Service users have access to a range of specialist lifting and handling equipment suited to their individual needs. The home is clean, tidy and generally free from odours. However, it was noted that there was an offensive odour in one of the upstairs bedrooms that was also apparent on the landing area outside the service user’s door. The Manager had taken the appropriate action, however, it was suggested that the home should consider what other action could be taken to remove the odour. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff are employed to support the care needs of the individual service users. EVIDENCE: Discussion with the Manager, examination of the duty roster and observation during the inspection visit demonstrates appropriate number of staff and skill mix on duty at all times to meet the needs of the service users. Service users and their relatives report that staff working with them are very skilled in their role and are able to meet their needs, e.g. ‘in all honesty Carole and her team are wonderful with all the service users, they are professional but a very caring team,’ ‘I am very impressed with the care and attention given to all residents and finally, ‘My brother, the service user, is very happy here, well cared for’. There is a comprehensive staff training programme in place that is focussed on improving outcomes for service users, e.g. the National Vocational Qualifications in care (NVQ’s), behaviour management, infection control, South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 19 person centred planning, report writing, protection of vulnerable adults and autism. 3 staff files were examined, 2 of who were newly appointed and gave evidence of effective recruitment procedures. Newly appointed staff complete a comprehensive in-house induction programme to introduce them to the service. The Manager described how staff are supervised and supported in their roles through a programme of regular appraisal. Notes are kept in staff files of these meetings and used as a working tool to plan future personal development around the needs of the service. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager provides direction and leadership to a service that is committed to ensuring quality of life for its service users. EVIDENCE: The current Manager has been with the home 2 years now and describes a period of working hard to get to know the service and to gradually consider changes for the benefit of the service users. She demonstrates good leadership, is committed to providing a high quality service and supports her staff to deliver the best possible care to service users. She is not afraid to take risks in the best interests of the service users; she describes how her staff team are personally involved in updating the décor in service users rooms. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 21 Comments received from relatives include ‘I never thought that the service user could be so happy and she is in a very loving environment’ and ‘I am particularly impressed with the current Home Manager, Carole Stephenson’. The Manager spoke of the importance of involving and keeping the service users up to date with new developments in the home and planned changes. She explained that the service does hold regular residents’ meetings to obtain service users views but the staff find it more suited to individual needs if these sessions are held on a one to one basis with the key worker. Detailed health and safety policies safeguard the interests of service users, staff and visitors to the home, and are available for inspection to include evidence of regular servicing of fire equipment, gas and electrical appliances. The Inspector had received notification of incidents relating to events affecting the health and well being of service users, e.g. illness in the home, admission of a service user to hospital, but the Manager was able to confirm the procedures in place to safeguard individuals’ from harm or risk to themselves. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 3 5 3 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 3 25 3 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 3 South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations The Registered Manager should undertake a risk assessment of the potential risks to the service users of an absence of window restrictors on the ground floor. Any unnecessary risks to health and safety should be identified and eliminated. The Registered Manager should ensure that the redecoration programme is completed to include the cracks to the ceiling in the downstairs bathroom, the adjoining corridor access, and service users rooms on the ground floor. The Registered Manager should make arrangements to repair or replace the worn kitchen work surfaces The Registered Manager should ensure that the flooring to the upstairs bathroom is replaced, and that the worn carpet immediately outside the door is either repaired or replaced. DS0000021748.V324640.R01.S.doc Version 5.2 Page 24 2. YA24 3. 4. YA24 YA24 South Highnam 5. 6. 7. YA42 YA30 YA20 The Registered Manager should review the procedures in place to ensure that the boiler door in the kitchen is kept locked at all times. The home should consider replacing the flooring in the service user’s room in which there was an offensive odour with a surface that can be cleaned more effectively. A review of the medication policy in relation to stock control should be undertaken to ensure that over stocking is prevented. South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 South Highnam DS0000021748.V324640.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!