Inspection on 21/02/06 for The Sanctuary

This inspection was carried out on 21st February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Sanctuary 14/10/08

The Sanctuary 17/04/07

The Sanctuary 08/11/05

The Sanctuary 15/02/05

The Sanctuary 29/07/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 The Sanctuary 36 Ashburnham Road Hastings East Sussex TN35 5JL Lead Inspector Rebecca Shewan Unannounced Inspection 21st February 2006 10:30 The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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 The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Sanctuary Address 36 Ashburnham Road Hastings East Sussex TN35 5JL 01424 200353 01424 200352 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) Turning Point Limited Vacant Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of residents to be accommodated is seven (7) Residents will be aged between eighteen and sixty five on admission Date of last inspection 8th November 2005 Brief Description of the Service: The Sanctuary is situated within a two storey detached house in a quiet residential area of Hastings. The Sanctuary is a crisis centre and is part of the Turning Point Organisation, which has a number of mental health and drug and alcohol residential services. The home is close to the local shops and the town centre and seafront of Hastings. The home has a secluded rear garden with a patio and area of lawn. The home is registered to offer placements to up to seven service users with mental health needs, these placements act as a short term respite and are offered for periods of up to two weeks. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to take place in the CSCI inspection year of 2005/2006. To gain a complete overview of the standards assessed it will be necessary to read both inspection reports for this inspection year. This inspection took place during the morning and early afternoon of the twenty first February 2006. Before the inspection papers held by the Commission for Social Care Inspection were read. The inspection of the home took three hours. A partial tour of the home was undertaken and a Project Worker, Support Worker and two service users were spoken with. What the service does well: What has improved since the last inspection? What they could do better: There is a need for the home to make staff files available at all times for inspection. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 6 Policies and procedures are in need of updating and evidence of annual reviews must be apparent. 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 Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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 The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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 the following standard(s): 1,3 & 4 The home has a good staff team that are experienced and have the appropriate skills to meet resident’s needs. There are appropriate processes in place to provide potential new service user with the opportunity to visit the home on a trial basis. EVIDENCE: The home’s Statement of Purpose and Service Users Guide viewed were comprehensive in content, however the Project Worker said that these documents were currently out of date (due to staffing levels being incorrectly detailed) and were being amended at the present time. The Project Worker said that once new copies of these documents have been received these would be made available to all service users. The Project Worker said that potential residents would be declined if necessary, if it were deemed that the home could not meet their needs. Staff were observed to have the appropriate skills and experience to deliver the services and care, which the home offers. Due to the home offering crisis management/short term respite placements, Trial visits to the home are arranged in a manner that is respectful of current service users needs, along with those of the potential service user. The Project Worker said that trial visits are arranged as such that potential service users The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 9 may visit the home and have a chat with staff and service users. Potential new service users may also stay for a meal if they wish. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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 the following standard(s): 8 & 10 Good systems are in place to ensure that residents participate in all aspects of life in the home at a level of their choosing. Records are stored in a safe and secure manner. EVIDENCE: Service users spoken with said that they felt involved in all aspects of life in the home and that staff allowed them the freedom to maintain their independence and usual daily routines. The home has a comprehensive Confidentiality Policy in place. Staff are trained in confidentiality matters during Induction training. Service users and staff records are stored in accordance with the Data Protection Act 1998. Service users may have access to their records upon request. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Service users are encouraged to maintain their usual level of leisure activities in a manner that is appropriate to aiding their recovery. EVIDENCE: As the home is centred around service user recovery activities are not arranged in house. The home structures service users leisure activities in accordance with service users wishes and service users are encouraged to maintain their usual leisure activities, unless it is detrimental to their recovery. Feedback from both staff and service users confirmed this. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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 the following standard(s): 21 There is an appropriate Death & Dying policy in place. EVIDENCE: There is a Death and Dying policy in place, which is designed to inform staff of actions to be taken in the event of a death in the home. Both the Project Worker and Support Worker said that service users entering the home are often low in mood and may be at risk of self-harm or displaying suicidal tendencies. Service users are appropriately risk assessed prior to admission and if risk assessed in a high category service users would not be placed at the home. Service users recovery is paramount, therefore death and critical illness wishes are not discussed, as this may be detrimental to their recovery. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: These standards were fully assessed during the previous unannounced inspection. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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 the following standard(s): 25,26,27,28 & 29 The home is well maintained and suitable furnished, providing a safe and comfortable environment for service users. Service user’s bedrooms were comfortable and residents are encouraged to have their personal possessions around them. EVIDENCE: Service users spoken to said that the bedrooms provided were ‘comfortable and decorated nicely’. Service users are encouraged to bring in items of their personal possessions during their stay at the home. One service user said that ‘Sanctuary means safe haven and that’s exactly how I feel about this place.’ Furnishings, fittings and equipment are domestic in style. It was evident resident toilets and bathrooms were suitable in number and provided appropriate privacy. There is a designated smoking lounge in the home. Alternatively there is a seating space and a television provided in the homes kitchen/diner, which is a no smoking area. All communal areas are well decorated and provide a comfortable environment. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 15 The home does not currently have any aids or specialist equipment in place. The Project Worker said that the current service users are fully independent in their mobility, however should a service user require an aid or item of specialist equipment then the home would be able to obtain it. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35 & 36 A competent staff team meets the service users needs. There is a need for the home to make staff files available at all times for inspection. Staff are appropriately supervised and trained to do their jobs. The home has good systems and processes in place for staff training. EVIDENCE: Staff are sufficient in numbers and have the necessary skills to meet service user’s assessed needs. There are two staff on duty throughout a 24-hour period, with there being one waking and one sleep in staff member on duty overnight. The Support Worker said that there is a low turnover of staff at the home. Service users said that they like staff, that they are easy to approach and are always helpful. The staff induction-training package was viewed and this was found to be comprehensive in content. Staff spoken to said that comprehensive training is provided. Mandatory training is conducted in Fire Safety, Food & Hygiene, First Aid, Health & Safety, Medication and Protection of Vulnerable Adults (POVA). The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 17 Staff confirmed that regular staff meetings are held and minutes kept. These were made available to the inspector. Recruitment procedures could not be assessed during this inspection, as the homes manager, who had a day off on the day of the inspection, is the only person to have access to staff files. Therefore a requirement has been made. Staff said that they receive copies of the General Social Care Council code of conduct and have job descriptions. Both the Project Worker and Support Worker said that they are supervised regularly and that annual staff appraisals are held. Due to the restricted access to staff files, records confirming this could not be viewed. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,40,41 & 43 The home is operated in a service user focused manner. Policies and procedures are in need of updating and evidence of annual reviews must be apparent. EVIDENCE: The home’s current manager is in the process of obtaining CSCI registration. During the inspection it was evident that the staff of the home operate an open door policy. Staff are available to service users at any time during the 24-hour period, service users spoken to confirmed this. The policies and procedures that were viewed during the inspection were detailed in content, however it was evident that these were not dated or signed by the manager. It was also evident that hand written amendments had been made and there was no evidence of policies having been reviewed on annual basis. Therefore a recommendation has been made. The Support Worker said that the home’s policies and procedures were currently being updated and that The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 19 the current policies file utilised by the home will be updated once updated policies are available. Records were found to be stored in a safe and secure manner. Service users may have access to their records upon request. Suitable insurances policies and certificates were viewed and found to be on display where appropriate. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 20 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 X 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 3 26 3 27 3 28 3 29 3 30 X STAFFING Standard No Score 31 3 32 X 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 3 X 3 X 3 3 X 3 The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 21 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 YA34 Regulation 17 (2) (b) Requirement That staff recruitment files are accessible for inspection purposes. Timescale for action 20/03/06 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 YA41 Good Practice Recommendations That the home’s policies and procedures are updated to include a date of generation, are signed by the manager and there is evidence of them being annually reviewed. The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection East Sussex Area Office 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 The Sanctuary DS0000021263.V282169.R01.S.doc Version 5.1 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. 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. 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