Inspection on 19/07/05 for The Susan Hampshire House

This inspection was carried out on 19th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Susan Hampshire House 06/11/07

The Susan Hampshire House 22/11/06

The Susan Hampshire House 21/03/06

The Susan Hampshire House 10/11/04

The Susan Hampshire House 17/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Susan Hampshire House 103 Station Road Yate South Glos BS37 5AE Lead Inspector Sam Fox Unannounced 19 July 2005 09:00 th 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. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Susan Hampshire House Address 103 Station Road Yate South Glos BS37 5AE 01454 327690 01275 372151 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) Freeways Trust Ltd Mr Jeremy Venton Care Home only 16 Category(ies) of LD Learning disability for 16 registration, with number LD(E) Learning dis - over 65 for 16 of places The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 16 persons with learning difficulties aged 19 years and over Date of last inspection 10-Nov-2004 Announced Brief Description of the Service: Susan Hampshire House is operated by Freeways Trust and registered to provide personal care and accomodation for up to 16 people who have a learning disability. Three of the beds are set aside to provide respite care. The home itself is residential in style and blends in well with the local community. It is situated opposite Yate town shopping centre and there are a number of shopping, leisure and community resources. Public transport is available. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and was conducted over two visits. The first day was spent examining care plans and looking at progress towards previous recommendations and requirements. The premises was also inspected to ensure that it is being well maintained and clean. The second visit was specifically with residents to find put if they were happy with the service they were receiving. Evidence was gathered through discussion with staff and residents, observations and examination of records. There is currently an ongoing issue about the registration category of the home and this matter is being dealt with as a separate issue. What the service does well: What has improved since the last inspection? In the last few months two residents have moved on to more appropriate settings. This has led to reduced pressure on staff, who were finding it increasingly hard to meet their needs and a more relaxed atmosphere. It has also meant that more time can be spent with residents doing what they want The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 6 to do. Additional one to one support has been gained for one resident who has been depressed and this appears to have considerably improved their quality of life. All requirements made at the last visit were met, apart from one relating to quality assurance. This was not discussed and will be carried forward to the next 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 Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 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 The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 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) 2,4,5 Information about the home is well written, this enables prospective new residents to make an informed choice about their future care. EVIDENCE: It was noted at the last inspection that the home had an updated Statement of Purpose. It was not viewed during this visit, as there have been few changes. The home, however, are applying to vary their registration to accommodate one person with dementia. Once achieved, then the document would need to be reviewed to reflect this change. Freeways have developed a service user guide, which also doubles as a contract, that is written using symbols and pictures. This is good practice. Signed copies of these were found for two of the newest residents. It was apparent through discussion with staff, observation and examination of records that these two residents fit with the culture of the home. One said they had been able to visit first and met everyone before moving in. It was noted that one resident, admitted because of an emergency, had limited records and there were no pre-admissions assessments or care plans. He has been living at the home for over a month and action now needs to be taken by the manager to develop more information as this is very limited. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 9 Susan Hampshire House is atypical in that it accommodates residents with a diverse range of abilities and ages. At present this mix appears to work. The manager must however continue to ensure compatibility and monitor that the home can meet changing needs. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.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, 7,9,10 Care plans are well written and enable staff to provide consistent and individualised support EVIDENCE: The majority of residents are placed by South Gloucestershire who devise a care plan that is updated regularly after formal annual reviews. These are supplemented by the home with guidelines for support needed within the house, for example, with bathing and with morning and evening routines. These are written to good detail and provide evidence that the home considers emotional and social welfare as well as physical needs. The home operates a keyworker system whereby each resident has a named member of staff who co-ordinates the service they receive. A number of residents knew who their key worker was and what they could expect from them. One member of staff displayed a clear understanding of what his role was in this respect. This indicates that the system is working well within the home. All keyworkers write monthly reports about progress, which also include provision to check health care needs. These were spot checked and found to be The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 11 up to date and well written. They provide a good tool in the home to regularly monitor the service provided. It was noted that there is restricted access of visitors for one resident – the home must write guidelines for this so that all staff are consistent in their approach. This should also include provision for monitoring the situation. Each resident has risk assessments which are related to individual need – these indicated that residents are encouraged to take risks as apart of independent lifestyles. Some, however, were not detailed and it was not clear why they were in place. It is recommended that these be reviewed. All records are kept secure in a locked office and staff displayed a good understanding of the need to keep information in confidence. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.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) 12, 13,14,15 & 16 There are good support systems in place to enable residents to lead active lifestyles and to maintain links and friendships outside of the home. EVIDENCE: There was numerous evidence to indicate that residents are supported and encouraged by staff to lead active lifestyles. Levels of assistance vary, some residents require more assistance than others to go out. Members of staff said that they try and ensure that they have a good community presence and that they get on well with their neighbours. Some residents have jobs and some attend a local resource activity centre. This is due to close temporarily which is causing some anxiety for residents. Staff, however explained that alternative arrangements will be found for them. On the second visit a number of residents spoke animatedly about what they liked to do both during the week and during their leisure time. It was apparent that they enjoy what they do and that they are encouraged to pursue various hobbies and interests. Some of them also spoke about family members who go The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 13 to see them and of special relationships they had with residents living in other care homes. It was evident that staff sensitively support them to maintain positive links with people from outside of Hampshire House. Two members of staff said that they were pleased because there was now more time to support residents to go out. There have been issues that have arisen periodically about personal intimate relationships and discussions with staff indicated that they have provided the appropriate support and guidance. Residents were observed carrying out household chores and varying support is given to them according to their abilities. They explained they actively take part in cooking the meals and cleaning their rooms. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 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) 18,19 There are detailed personal care guidelines which means that residents receive sensitive support in a way that they want. EVIDENCE: A number of residents accommodated require significant support with their personal care needs. There was good detail in files about what individual preferences were and each resident has a bathing protocol. The information was well maintained and demonstrated that the home affords residents respect when helping them with their personal care. It was noted that there was no manual handling risk assessments – a number of residents are assisted by the use of hoists and as such should have their own manual handling risk assessments which identify the appropriate equipment for them. Records provided evidence that residents continue to be supported to see the relevant health professionals and that the home regularly seeks the opinion and support of specialists such as dieticians and occupational therapists. In addition to this there are good systems in place to ensure that residents are encouraged to have annual checks ups. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 15 It was noted that insulin was being stored in the main fridge to which residents have unlimited access. This is unsafe practice. As a temporary measure it was put in a locked box. By the time of the second visit the home had obtained a suitable lockable fridge which is now being kept in a separate room. One person takes insulin, which requires adjustment according to their blood sugar levels. There are guidelines in place for the home to make these adjustments, which have been approved by the Doctor and local district nurse team. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 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 Staff have created an open and trusting atmosphere within the home and they can be confident that they will be listened to. EVIDENCE: Freeways have an established complaints procedure – this is included in the service user guide in a simplified format for residents. There is a complaints logbook which is left in a communal area for residents to make comments in. During this inspection it was noted that there was a complaint made by the relative of someone, who uses the home for respite care, about their clothes which had been ruined in the laundry. The manager should record this type of complaint, with actions taken to ensure such a situation does not happen again. It was difficult to establish whether the home had replaced these clothes – there would be an expectation that they would do so. Each resident has a “reactive strategy” which details circumstances that may cause them upset and actions to be taken to reduce the likelihood of this. Those seen at the time of this visit were written to a good standard and written in a sensitive and respectful manner. There are established procedures in place for he protection of vulnerable adults and staff have received training about this. Residents spoke openly about the service they received and it was apparent that there is an open atmosphere within the home. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 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, 25,26,27,29,30 The home is comfortably furnished and well maintained. There is specialist equipment available so that residents can maximise their independence. Action needs to be taken to service the fire doors for improved fire safety. EVIDENCE: Susan Hampshire House is situated in a residential area and blends in well with the local environment. It benefits from a large patio area at the back which was found to be well maintained and is enjoyed by residents during the summer months. Opportunity was taken to view the premises. It was found to be clean, comfortably furnished and homely in appearance. The house has ramped access and there are a number of aids and adaptations throughout, including grab rails, specialised bathing facilities and raised toilet seats. All residents’ bedrooms were clean and continue to reflect individuals’ tastes and preferences. Two bedroom carpets have been replaced which has reduced the unpleasant odours which were identified at the last visit. One new resident had his room re-decorated to his own personal tastes. This is good practice. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 18 Some areas of the kitchen were not found to be cleaned to a suitable standard and these were pointed out to the assistant manager. Action needs to be taken to make improvements in this respect. It was noted that the laundry door was being propped open. This is a fire door and should be kept closed at all times. Discussion with staff indicated that some residents liked to prop the lounge doors open, it is recommended that consideration be given to installing magnetic door closers. In addition to this one fire door was found to be sticking and another did not close properly. These require servicing. At the time of this was visit one resident was carrying out their household chores and cleaning their room. It is good practise to encourage residents to take responsibility for their environment. It was noted, however, that the cleaning cupboard was left open. The assistant manager was asked to remind residents to lock these doors after them. This is especially important as the home accommodates one person who displays confusion. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,36 Residents’ benefit from receiving support from competent staff who know their roles and work well as a team. EVIDENCE: All members of staff spoken with said that staffing levels have improved within the last six months. This, coupled with the fact that two residents with high dependency levels have recently left, has led to a more relaxed atmosphere within the home. It was apparent that they now have more time to spend with residents and that all are benefiting from this. There were positive comments from staff about the improvements in their conditions of service and the fact that Freeways now use a pool of bank staff. This has improved morale and led to more consistency within working practice. Two members of staff confirmed that they received formal supervision at regular intervals and this was further evidenced through records. They said they found this a useful way in which to discuss concerns. Opportunity was taken to spot check two staff files. These provided evidence that the home completes the relevant checks on individuals prior to offering them employment, including seeking references and CRB checks. Records held The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 20 in relation to all staffing issues were found to be well organised and easy to follow. There are regular team meetings and minutes of these evidenced that this provides a forum for additional training and discussion of work practice. One, relatively new, member of staff, described her induction and said that this had given her the confidence to carry out her duties. Freeways have a formal induction during which time training is supplied about first aid, food handling and protection of vulnerable adults. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 21 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) 37,40,41,42 Residents can be confident that their interests will be protected by a competent and well-organised management team who run the home well. EVIDENCE: Members of staff spoke positively about the support they received from the management team and it was clear that they felt listened to. The fire logbook provided evidence that the home is making the appropriate tests and checks of the system. Residents have the opportunity to take part in regular fire drills. The assistant manager was advised that they need to develop risk assessments in relation to household tasks. This would enable them to more clearly evidence that they are meeting with requirements of the Health and Safety at Work Act. The Susan Hampshire House Version 1.30 Page 22 D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc It was noted that the home has food hazard analysis and that they are recording fridge and freezer temperatures. The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 23 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 x 2 3 x 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x 3 3 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Susan Hampshire House Score 2 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x 3 2 3 x D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 24 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. 3. 4. 5. 6. 7. 8. Standard 6 7 18 22 30 24 42 39 Regulation 15 12(2) 13(5) 22 23 (2)(d) 23 (4) 12 24 Requirement Develop care plan for resident admitted as an ememrgency. Develop guidelines for any restrictions on visitors for the home. Develop manual handling risk assessments Ensure all complaints are logged and that satisfactory outcomes are sought Review and improve cleaning routines in the kitchen Ensure fire doors are not propped open and that they are serviced regularly Develop workplace risk assessments Develop a quality assurance system Timescale for action 14\8\05 14\8\05 30\8\05 30\8\05 30\8\05 14\8\05 30\9\05 30\11\05 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. Refer to Standard 9 24 Good Practice Recommendations Review risk assessments relating to individuals Consider installing magnetic fire closers D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 25 The Susan Hampshire House The Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 26 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos. BS32 4RG 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 Susan Hampshire House D56_D05_S3399_susanhampshire_V234199_190705_Stage4.doc Version 1.30 Page 27 - 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!