CARE HOME ADULTS 18-65
15 Sussex Road 15 Sussex Road Southport Merseyside PR9 0SS Lead Inspector
Paul Kenyon Unannounced 28 September and 4 October 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. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service 15 Sussex Road Address 15 Sussex Road Southport Merseyside PR9 0SS 01704 537344 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) Speciality Care (Rest Homes) Ltd Samantha Faria PC - Care Home Only 3 Category(ies) of LD - Learning Disablity - 3 registration, with number of places 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 3 LD. 2. The service should, at all times, employ a suitably qualified and experienced manager that is registered with the CSCI. Date of last inspection 29th November 2004 Brief Description of the Service: 15 Sussex Road is a small residential care home that offers support to up to three service users with learning disabilities. The home is owned by Arden College who are a subsidiary of Craegmoor Ltd. The home does not currently have a manager registered with the Commission for Social Care Inspection, however, Samantha Faria, who is currently acting as Manager has applied to the Commission For Social Care Inspection and is undergoing the registration process.The home is a domestic dwelling located in Southport. The home is close to local shops and transport links. Southport town centre is approximately ½ a mile away.The home is on two floors with one bedroom on the ground floor and two on the upper floor. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was undertaken over two days and took three hours in total. The first part of the inspection was unannounced and involved discussions with residents and staff as well as a tour of the premises. The second part of the inspection was announced and focussed on the examination of personnel and training records and other documents. What the service does well:
The nature of the disability of residents is such that it is not always possible to get a direct response about their views of living at 15 Sussex Road. Comments were made during discussions yet these were limited to ‘I am alright’; ‘I like it here’ and ‘yes’. It was considered that a better view of the support offered would be possible through the informal observations of residents and their interactions with staff. The service has now developed a coherent system of care planning. The plans are based on essential lifestyle plans that outline those features that are important to residents as well as the relationships that need to be fostered. All care plans are reviewed and are presented in appropriate formats. The service is good at providing community opportunities for residents on an individual basis. It is also good at striving to identify activities that are appropriate to the individual even though some opportunities have not worked out as planned. The service provides a stable staff team for service users and it was clear through observations that interaction between residents and staff are positive, informal and constructive. This is important given that staff remain a key point of contact for residents. Staff are good at respecting the wishes of residents to interact as a group or pursue their own activities. The service is good at ensuring that residents remain as independent as it is safe to do so. This was evident by one resident being able to access a local college facility independently. The stable staff team means that staff were recruited some time ago. Personnel records for these individuals showed that appropriate checks had been completed. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better:
The service needs to consider whether the information is gives to residents about what it can offer to them is appropriate and whether residents can generally understand it. The service needs to provide evidence that it is looking for other ways of holding residents’ finances and needs to steer away from the current institutionalised method whereby the organisation holds finances. The service needs to ensure that individual and general risk assessments are dated and reviewed regularly Staff need to receive medication awareness training to enable the improved medication system to be made more robust. The service needs to make sure that staff are given the information to allow them to contact the Commission
15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 7 for Social Care Inspection if any aspect of care practice causes them concern. Training in abuse awareness must be extended to all staff. The maintenance requisition system must be more responsive to the Manager’s request to remove a coded lock given that it could compromise the safe evacuation of the building in the event of a fire. The service needs to extend mandatory training for all staff to ensure that they are aware of health and safety issues. 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. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 8 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 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 9 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. Standard 2 is not applicable at present given that all three residents have lived at Sussex Road for some time. Information about the aims and objectives of the service do not take the needs of residents into account with the result that residents are unable to determine whether the service meets their needs. EVIDENCE: A statement of purpose is on display in the hallway. This contains details of the home as well as the aims and objectives of the service. In its current format the statement of purpose can be readily understood by staff and relatives but not necessarily by residents. There was no evidence that the aims and objectives of the service had been explained to residents on an ongoing basis. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 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) 6,7 and 9 Care plans are available to residents, presented in an appropriate format with regular review. Residents have not been given the opportunity to be provided with financial assistance independent of the organisation. Residents are not fully supported to take risks. EVIDENCE: Care plans are present in the form of essential lifestyle plans. Two residents have agreed to have these placed on display in their bedrooms. The other individual has not agreed yet the plan is still available to her and staff in another private area. Separate evidence was available suggesting that these care plans are reviewed every six months. One of the reviews includes relatives in the process and this was evidenced through the same records. Care plans are presented in a format that strives to ensure that residents are aware of their own goals and aspirations and include photographs outlining those aspects of daily living that are important to them. The finances of two individuals are retained by Arden College. Monies are available on request but only within the times when the college is open. The Inspector takes the vulnerability of residents in financial affairs into account
15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 11 yet there was no evidence that the organisation had looked into possible alternatives to the current system. Risk assessments are in place for each resident. They provide a detailed account of potential hazards that residents face either within the home or when pursuing leisure activities. Risk assessments have only been dated in some cases and again only some have been reviewed. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 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 Residents are supported to access the local community taking individual preferences into account. EVIDENCE: All residents have specific interests that are recorded within their care plans. During the day of the inspection, one individual was out supported by a member of staff involved in some voluntary work in a local shop. Residents were asked during the inspection by staff whether they wished to come on an outing but refused. This wish was respected although the individual changed their mind later. All residents attend educational or work placements on a part time basis with the exception of one person. Past placements have not worked out although a new opportunity has been identified and it is hoped that this will become a permanent feature of the person’s daily life in future. One individual independently attends a local college. This person is able to go to and from the placement with no staff support and risk assessments have been devised to ensure that this is done safely. The home’s is located in a residential area of Southport and is local amenities are within easy reach. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 Residents benefit from a medication system that is safe and much improved although staff must be provided with medication awareness training to sustain this. EVIDENCE: No residents self-administer medication at present. All medication is securely stored. Medication records are signed after administration and these is now done consistently. The Manager has provided a written reminder to staff ensuring this. Policies and procedures are now in place and photographs of each resident accompany each medication file. Staff confirmed that they had not received medication awareness training. This training must be provided and is raised as a requirement. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 14 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) Residents are not fully protected from abuse. EVIDENCE: The Local Authority protection procedure is available. The Manager has sort to remind staff of its whereabouts and has encouraged the staff team to read them. Two members of staff were asked about protection issues during the inspection. Both were aware of action to take if an allegation was made to them. A whistle blowing procedure is available yet outlines that staff can refer any concerns to senior management within the organisation. No reference is made to the Commission for Social Care Inspection as an external vehicle for the investigation of concerns. This is raised as a requirement in this report. 23 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 15 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 safety of staff and residents is not guaranteed by the security arrangements in the home. EVIDENCE: A coded lock has been placed on the front door of the home. This is designed to ensure the safety of residents. The Manager has questioned the safety of this and in particular the extent to which safe evacuation of the building would be compromised by the presence of the lock. After consultation with Fire Authorities, a decision has been made to remove this. This step was reinforced during the inspection with the availability of correspondence with the Fire Authorities as well as a requisition to maintenance staff to remove the lock. This was made in August 2005 and the lock still remains. It is required that this requisition is acted upon. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 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) 34 Residents are protected by the home’s recruitment policies . EVIDENCE: Personnel files were made available for inspection on the second day of the inspection. In total three files were examined in detail. The staff team remains stable with no staff having been recruited since the last inspection in 2004. All documentation was in place on the three files. This included proof of staff identity, proof that all staff had been subjected to Criminal Record Bureau checks as well as evidence of satisfactory references. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 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) 42 The health and safety of residents and staff is not fully promoted or protected. The general risks facing staff in their daily work have not been reviewed and mandatory training for staff is inconsistent. EVIDENCE: Fire records indicated that smoke detectors are tested on a weekly basis. In addition to this, fire drills are held on a regular basis. Records indicated that the reactions of both staff and residents are noted indicating whether any further work is needed to make these individuals more aware of the need to leave the premises in the event of a fire. Some staff have received statutory training in first aid, food hygiene, manual handling and health and safety. Records present during the inspection dated September 2005 reinforced this. Other staff have not received training in these subjects. The Manager reported that they had been offered it but it had not been attended. A memo advising the availability of staff and dated 3 October
15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 18 2005 was available. It is required that all staff receive mandatory training consistently. Risk assessments are available to staff outlining all the potential hazards they face when carrying out their duties. The review of these assessments was overdue having last been reviewed over twelve months ago. Accident records were noted to have been maintained appropriately with few accidents having occurred over the last few months. Information was in place during the inspection relation to reportable injuries (RIDDOR). These were available but there had been no need to use these. 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 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 2 N/A x x x Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 2 x 2 x
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 x x Standard No 31 32 33 34 35 36 Score x x x 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
15 Sussex Road Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x F53 F03 15 Sussex Rd S5269 V227106 28.09.05 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. 2. Standard 1 7 Regulation 4 20 Requirement The statement of purpose must be provided to residents in formats that meet their needs Evidence must be provided that the organisation has examined the options to provide residents with independence in their financial affairs Risk assessments must be consistently dated and reviewed Medication awareness training must be provided to all staff Abuse awareness training must be consistently provided to staff The whistle blowing procedure must include reference to the Commission for Social Care Inspection The requisition to remove the coded lock submitted to the organisation must be acted upon All staff must be consistently provided with statutory training General risk assessments must be reviewed at least annually Timescale for action 30 November 2005 30 November 2005 31 October 2005 30 November 2005 30 November 2005 31 October 2005 7 October 2005 30 November 2005 30 November 2005 3. 4. 5. 6. 9 20 23 23 13 13 13 21 7. 8. 9. 24 42 42 23 18 13 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 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. Refer to Standard Good Practice Recommendations 15 Sussex Road F53 F03 15 Sussex Rd S5269 V227106 28.09.05 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Burlington House, 2nd Floor, South Wing Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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