Inspection on 21/03/06 for The Susan Hampshire House

This inspection was carried out on 21st March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Susan Hampshire House 06/11/07

The Susan Hampshire House 22/11/06

The Susan Hampshire House 19/07/05

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 Peter Still Unannounced Inspection 21st March 2006 09:00 The Susan Hampshire House DS0000003399.V283933.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 Susan Hampshire House DS0000003399.V283933.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 Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 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 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) Freeways Trust Limited Mr Jeremy Venton Care Home 16 Category(ies) of Dementia (0), Learning disability (16), Learning registration, with number disability over 65 years of age (16) of places The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 16 persons with learning difficulties aged 18 years and over 19th July 2005 Date of last inspection Brief Description of the Service: Susan Hampshire House is operated by Freeways Trust and registered to provide personal care and accommodation 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 DS0000003399.V283933.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five hours. Case tracking was undertaken and three residents were seen and two residents spoken with. Two relatives gave praise for the care and commitment of staff and a visiting professional said their agency was pleased with the work of the home and that agreements reached had been met. Two staff from the Freeways Trust, completing a financial audit were spoken with briefly. A number of files and records were examined and a tour of the building and outside area was undertaken. The home presented as a relaxed and comfortable environment for residents who were content with their care and busy with their daily lives. Most residents were out at the time of the inspection, involved with their daytime activity. A minor variation to the registration detail of the home was being responded to separately. What the service does well: A very pleasing and homely environment was provided for residents and commented upon by staff about being very happy at the home and of the quality of care provided. One resident said that nothing could be better. Staff were approachable and clearly committed to their work. The Respite service at the home was said to be working well for its clients and had a positive affect for the permanent resident group. The different clients using the Respite service gave permanent residents opportunities to socialise with other people and the differing needs of people helped staff to be aware of their practice and be proactive in improving their approaches. Some residents enjoy contact with local churches and this involvement had also helped residents to be a part of their community. Staff were successful in their aim to ensure that all residents at the home enjoy interests and social experiences away from the home. A member of staff with special responsibility for activity ensures activity and stimulation is maintained as a priority for residents. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 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 Susan Hampshire House DS0000003399.V283933.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 Susan Hampshire House DS0000003399.V283933.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): 2, 5 Key documentation prior to admission was in place to ensure suitability and understanding of care needs. The home must provide a written contract of residency for the protection of residents. EVIDENCE: Three files were case tracked and evidence of appropriate pre admission documentation was seen. No permanent residents had been admitted since the last inspection. Staff have been finding ways of involving residents in decisions about people who wish to use the respite facility and who comes into their home and possibilities for enhancing this were discussed. Compatibility was a key issue of consideration. The previous inspection noted that the Statement of Purpose would need to be updated once the minor changes to the home’s registration had been completed. The home was awaiting a response from the Commission about this and will complete the update when it is finalised. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Residents were fully included with their care planning. Residents were supported to make decisions and choices to enjoy fulfilling lives. Residents were supported to take risks as part of an independent lifestyle. It was evident that some residents did not have risk assessments for all key risk areas and this must be addressed to protect residents from harm. EVIDENCE: Two residents spoken with talked about their involvement in care planning and knew whom their key worker was. One resident was spoken with in some depth and was clear that the process was helpful and that a record was maintained with their input. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 Page 10 Care files case tracked showed that good recording was being maintained. This included a daily Report book, which was up to date however through constant use pages were falling out. The manager was aware of this and had already put in place a new reporting system with documentation, which was about to become operational. The manager considered that residents and staff were being well supported by the local CLDT. Residents lead busy lives. Often on Saturdays residents make choices about where they want to go in the home’s mini bus and what they wish to do. Key workers have a significant role to ensure the wishes of residents were met, including holidays through the year, birthdays/anniversaries. One resident visits the large shopping complex opposite the home on a regular basis and is well known. Residents discuss and agree the home’s menu and also make their own decisions about the decoration of their bedrooms and furniture. Residents enjoy using buses and trains, which adds an extra dimension. Residents were supported to take risks and it was clear that residents enjoy much variety and activity in their lives however risk assessments were lacking and this must be resolved swiftly. It was recognised that this will be a significant area of work for the staff team since each resident will need to be reviewed and the possible risks areas thought through carefully. The home has the valuable support of an administrative person, who may be able to help with the task. One resident was just beginning the process of gaining confidence to go to the shopping complex on their own and careful stages were being considered to support the resident. One resident has mobility difficulties and a member of staff spoke of the way they help to increase independence as well as maintaining the residents confidence. One resident spoke knowledgeably about their horse riding activity and of their paid job, where they were clearly valued. The Susan Hampshire House DS0000003399.V283933.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): 12, 13, 17 Activity was carefully and well organised to ensure quality experiences for residents. Staff support residents to make choices and decisions to encourage their involvement with their local community. A healthy diet was provided and dietary needs were catered for. EVIDENCE: A member of staff holds responsibility for monitoring and ensuring suitable activity is offered to residents. New ideas were introduced and activity was tailored to individual’s needs and wishes. The member of staff should be praised for their valuable contribution. An example of the thought being given to the needs of residents concerned a theatre trip where the lighting was not suitable. A new karaoke machine had been recently purchased, an entertainer visits and a band visits occasionally. Staff were using innovative ways to encourage residents to use a very pleasant lounge in the home. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 Page 12 The manager had responded to points raised by people living close to the home, addressing issues. An annual summer fete is held. Friday night was the night residents enjoyed visiting their local pub, where residents are known and valued as individuals. A healthy menu was seen and one resident said they enjoyed the food. Some residents had dietary needs, which were recorded within their care plans. Two bowls of fresh fruit were seen with a good variety of food and interesting colour to catch the eye. The lounge in the respite unit also had its own bowl of fruit available and the resident said he/she liked to use that space from time to time and enjoyed the fruit. The main kitchen was clean, tidy and well organised. At the time of the inspection it was being thoroughly cleaned. One resident said he/she cooked with staff sometimes. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 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 the following standard(s): 18, 20 Staff understood resident’s needs so they are supported in the way they wish however their safety would be assure if manual handling risk assessments were completed. The administration of medication practice protects residents. EVIDENCE: Staff talk to residents to find out how they wish to be provided with care. The last inspection required that manual handling risk assessments must be provided for residents and remains outstanding. It is essential that this task is completed swiftly and the particular set of risk assessments for those residents who need such support must be an early priority. The home has had difficulty in gaining training for staff on the use of a hoist, which had been provided by the professional agency; it was made clear to the manager that a demonstration of its use did not constitute training. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 Page 14 This is of concern since staff must be confident with training to use the equipment. One resident particularly needs this facility and without the hoist two staff are involved in moving the person, which may not be safe. The manager had just completed a weeks training on moving and handling but the training did not cover hoists. The manager must assess the safety of the current practice with the resident and must ensure training to enable use of the hoist is provided swiftly. If it is considered there is a risk with current practice, the district nurse and OT must be told and asked for guidance on what must be done. No resident currently handled his or her own medication. Staff received training from the pharmacy on the administration of medication. One member of staff spoke of their medication training at the home, which included 8 observations and 16 with senior staff oversight. A check of two residents showed that the medication was signed and up to date. Insulin was stored in a dedicated fridge and temperature records were maintained. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Staff ensure residents were listened to and their wishes and needs acted upon. Staff, who had received training concerning adult protection, help residents to be safe. EVIDENCE: Residents meetings were held every two weeks. The provider holds annual focus groups including residents and a director recently visited the home to provide feedback, though no notes were available. Staff have a key aim of ensuring constant communication with residents to ensure views are known and issues acted upon, key workers also have a role in meeting this objective. All staff have been provided with adult protection training, through their LDAF training and one member of staff spoken with said they had undertaken the training with three other staff in January 2006. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 A comfortable and well-decorated home, with good furnishings meets resident’s needs. A damaged door must be attended to. The cleanliness of the home was generally good. EVIDENCE: It was considered that staff must work very hard to maintain the home in such good order. There was excellent use of colour, furniture, ornaments and sensory equipment to create a very warm and inviting environment; beautiful blue glass in a WC catches the sun. The main bathroom had sensory lights. Quality furniture and plants were positioned tastefully throughout the home. Staining to the rear of some WC’s needs to be removed. A problem with cisterns, covered by tiles may have caused the stain and tiles had been broken in two bathrooms. The main boiler of two, for the home was not working and the Trust was considering the best way to resolve the problem. The home was sufficiently warm on the cold day of the inspection, though one portable heater was noticed. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 Page 17 The top door hinge to bedroom 2 had failed so that the door could not be closed easily as the door had moved out to its frame and this must be attended to. These issues should be responded to soon so that they do not detract from the overall quality found in the home. Communal rooms have a Loop system, and other alerting equipment was in place to help keep residents safe. A significant task had been completed to produce workplace risk assessments. The home was clean and tidy. Resident’s bedrooms were very personalised and one resident showed the inspector their room, which they kept clean. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35, 36 Good recruitment practice protects residents. The standard concerning staff training was exceeded, which ensures trained staff cared for residents. Good staff supervision supports staff in the work with residents. EVIDENCE: Two staff files were seen and provided evidence of good recruitment practice including CRB checks for the staff. One member of staff spoke of a good level of induction and training. No new permanent staff had been employed since the last inspection and no agency staff were being used. Some staff increase their hours when needed. This was considered to be a positive indicator for the home. The home has a policy of involving residents in the interview process for new staff. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 Page 19 The Trust decided to ensure staff were trained to NVQ level 3 and the current position showed that 7 staff have the award; 2 staff were completing their training; 4 other staff had completed LDAF training and of these 2 were waiting to commence their NVQ training. The manager holds NVQ level 4 and the deputy was completing the award. One member of staff spoke of their good progress with training. The staff team should be praised for their commitment to training and for their success in gaining awards. Supervision was at 6 weekly intervals and included an annual appraisal, which was seen for two staff and was comprehensive. One member of staff said supervision was positive and the feedback helpful, also that senior staff were supportive with their guidance and the staff team showed respect for each other; at the monthly team meetings managers listen to the views of all staff. This was considered to be a very positive reflection of the staff structure and support provided. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Quality assurance needs to be introduced for the home so that residents can be sure their views underpin self-monitoring, review and development of care and practice at the home. EVIDENCE: No formal quality assurance document was available for inspection and needs to be developed. Regulation 26 visits by the provider were taking place and found to be very supportive. One member of staff knew the name of the director who had been visiting and said that he spoke with staff and was easy to talk to. The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 Page 21 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 X 2 3 3 X 4 X 5 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 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 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X 3 X X X 2 X X X X The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 Page 22 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 Standard YA18 YA39 YA9 Regulation 13(5) 24 13(4)(c) Requirement Timescale for action 28/04/06 4 YA5 5(1)(b)(c) Develop manual handling risk assessments. (Previous timescale of 30/08/05 not met) Develop a quality assurance 28/07/06 system (Previous timescale of 30/11/05 not met) Complete a review of risk 02/06/06 assessments for all residents and identify risk areas where other assessments are needed. A contract of terms and 02/06/06 conditions for residency including fees must be provided for residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Susan Hampshire House DS0000003399.V283933.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bristol North LO 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 DS0000003399.V283933.R01.S.doc Version 5.1 Page 24 - 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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