Inspection on 22/11/06 for The Susan Hampshire House

This inspection was carried out on 22nd November 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 6 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 21/03/06

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 Key Unannounced Inspection 22nd November 2006 13:10 The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 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.V310672.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 16 persons with learning difficulties aged 18 years and over 21st March 2006 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 cost of placement is between £576.30 – £961.30, the price dependent upon assessed need. Prospective residents can be provided with information about the home and this will detail the services and facilities available. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. Evidence was gathered from a number of different sources: - Information taken from resident and relative survey forms - Directly speaking with residents - Case tracking a number of residents - Speaking with care staff - A tour of the premises - Examination of some of the homes records - Observations of staff practices and interaction with the residents. The home manager was present during the inspection and assisted in the inspection process. The manager had produced a pre inspection questionnaire for this inspection and had sent it to the commission at the end of August. This would have been a valuable document for the inspector to use however unfortunately the document has not been seen at the commission or by the inspector. The overall analysis is that the home is a good place in which to live and to work. Feedback from residents, relatives, professionals and staff provides evidence about the good quality of care and happiness of residents and staff. What the service does well: Fifteen surveys from relatives provided good evidence of a high quality of care. Written points within those responses provided a fully positive and comprehensive comment on key areas of care important to residents, which was endorsed by four health care professionals. There was evidence that staff focus on the individual needs of residents and create a homely place for residents to live. Staff spoken with enjoy their work and talk about good staff teamwork and of an open supportive relationship with the manager and senior staff, which includes good supervision. Thorough risk assessment protects residents. Staff had done well to gain their NVQ qualifications and continue with training including mandatory training. The responsible individual provides the manager and staff with good support and clear and helpful reports. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A statement of purpose and service user guide, which is clear and includes all points within the national minimum standards would provide information needed by residents, people important to them and other professionals. Resident’s wishes and needs were assessed to ensure the home could meet their expectations. However ensuring pre admission assessment is available soon enough would protect residents. Residents have contracts including fees, which provides protection and a further review of ‘extras’ would ensure understanding about all charges. EVIDENCE: Residents have an up dated statement of purpose, which includes details of staff qualifications; a further review was needed to ensure it clearly covers all points set out in the national minimum standards. This would include in the service user guide, details of extra charges made on top of fees. ‘Extras’ were not included in the resident contract. Examples of additional charges communicated at the inspection included: Chiropody at £5.50 and a contribution to use of the home transport and holidays was £8.50. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 9 Two Resident’s files case tracked showed they had up to date contracts. Two residents surveys, completed for the inspection raised points, which may have a bearing on this. One resident said, “At first I didn’t want to come here but now I have got used to living here”. A second resident said they did not receive enough information before they went to the home. Nine relatives responding to the pre inspection survey indicated they had not had access to the inspection report, which should form a part of the service user guide. Further work is needed to ensure all key information is provided. Good assessment records were seen to ensure residents needs can be evaluated and that the home has key information relating to residents. It was noted however that the home did not have a formal care management single assessment for a prospective resident due to move into the home at the end of the week. The home knew the resident well but it is a requirement that home’s have a full assessment prior to admission. This ensures managers have all necessary information and can make informed decisions about suitability of placement and that all key information is available to protect residents. The manager understood this and during the inspection was heard to be addressing it with the placing agency. It was understood that the assessment would be sent to the home immediately. The admission process and policy procedures must be reviewed to check they are robust and ensures the home has necessary information, when needed. The care file for a resident recently admitted was organised with a photo of the resident on the front. It was clear that an extensive and carefully planned long admission process had been followed. Detailed recording and a lot of thought and work had been put into ensuring the admission process was satisfactory. The manager had ensured that the process included small steps to help the resident feel secure and positive about their major life change. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 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): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good care planning and risk assessment ensures residents are listened to and helps residents to make choices and have independent lifestyles. EVIDENCE: Residents were fully involved in their care planning and supported to make decisions about their lives. Care plans seen, including those case tracked provided evidence of good and detailed recording. They showed that residents were making personal decisions and in one case changing their minds. Another resident wanted equipment to help them sleep at night, which had been responded to. Resident’s sexuality was also considered to support diversity. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 11 Survey responses from residents showed that one resident felt they usually make decisions and nine were able to make decisions, which indicates that residents are very much involved in considering their individual needs and choices. Residents were asked about whether staff listen to their needs and eight said always, two said usually and one said sometimes, which provides a generally very positive guide to the way residents feel staff support them. The last inspection required that all resident risk assessments should be reviewed and that other areas of risk should be included in the review including manual handling. The risk assessments were seen and all had been reviewed comprehensively and protocols had been produced for four identified procedures. Risk assessments were also seen concerning use of a hoist. The manager had provided a general risk assessment for each resident and specific assessments where needed, based on the information within the general assessment to ensure clarity of information for staff and residents. The manager had taken positive steps to ensure staff understood risk assessment, which had been a central theme for a staff meeting and all staff had also received specific risk assessment training. The manager had undertaken additional training for managers. One identified resident was spoken with in the presence of the manager in their new bedroom and commented to the inspector that they were not too happy that they had moved to a new bedroom. It will be necessary for the manager and staff to monitor and make a record of how this resident feels and take action if needed. The next inspection will need to focus on the section of resident contracts concerning rooms occupied and the terms and conditions of occupancy, since this was not reviewed at this inspection. If the identified resident continues to be unhappy it should form a complaint and be communicated to the commission. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 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 the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s lives are fulfilled through good opportunities and a lifestyle of their choice. EVIDENCE: Two residents enjoy going out on their own and the other residents were happy to be supported by staff. Residents enjoy a range of activities and there was evidence of involvement within the local community. One resident said they go to a day centre, where they do activities of their individual choice. Some residents enjoy going to different churches, which indicates diversity. Some residents also enjoy their local pub. The home is fortunate to be located opposite to shops and residents take full advantage of this, they also enjoy visiting the local café. The home has a minibus and residents like to go out a lot, however one resident said there were not always enough drivers to take them out. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 13 Residents have monthly house meetings and the notes for the meeting on 29/10/06 were read. Notes of house meetings showed that residents were involved in making decisions and there had been discussion including Halloween, a Christmas fair and holidays. There was also evidence of discussion about a new resident moving into the home. This showed that residents were included in decision making. One member of staff, talking about what was good about Susan Hampshire House said it was home from home and very welcoming, with a good rapport between residents and staff. The inspector had also observed this. Although not recorded, the manager said that equal opportunities and diversity was a part of the homes culture and that staff talk with residents on their own and in small groups. The staff team also reflects cultural diversity. Relatives made a significant response in returning surveys before the inspection and all fifteen were very positive about the care of residents. Staff have had training about diet and promote healthy eating amongst residents. One resident needed specific support with their diet. Residents spoken with said that the food was good and that they have choice. A member of staff sits down with residents to discuss menus. There were plans to include food from different cultures, which would also give opportunity to explore those cultures and diversity. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 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 the following standard(s): 18,19,20,21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that their needs will be met because the home has good care planning processes in place. They will be well cared for. Sensitive work to ensure residents can have their last wishes known would support residents. EVIDENCE: Residents survey responses were nearly all very positive in the way staff work with and listen to residents. Relatives also gave high praise for the general care provided. Four healthcare professionals, all gave positive responses. One said “A very caring environment” and “management and key workers have shown a commitment to supporting residents for as long as they can”. Key workers have a key role in ensuring residents are given personal support in the way they prefer and that their physical and emotional health needs are met. Two residents spoken with knew who their key worker was and said that they listen to the residents. One said the key worker does a monthly report. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 15 Care files case tracked for two residents showed key reviews had taken place as well as monthly reviews, produced by key workers. A review, completed in October 2006, had been countersigned by the resident. One resident said they like all the people at the home, all are friendly. The medication system was reviewed with the deputy manager, who was responsible for medication at the home. She said they were well supported by their local pharmacist. The medication was checked for the two residents case tracked and was correct. The medication cupboard was clean and tidy and fridge temperatures were kept, when the fridge was being used for medicine. A homely remedies protocol was seen. The sensitive task of discussing resident’s last wishes should be undertaken with residents and staff may need training to consider their approach with this and other aspects of the standard. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 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 the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A review of the complaints policy and procedure and how it is communicated will protect residents. Comprehensive reinforcement training for staff in the protection of vulnerable adults would safeguard residents from harm. EVIDENCE: House meetings are held two weekly, where residents can raise issues with staff. The provider has a ‘Focus group’, especially established for residents to say how they feel about their life in the care home and raise points to help improve Freeways practice and promote positive developments. No resident had joined the ‘Focus group’ and hopefully encouragement can be given. The manager gathers information from residents at Susan Hampshire House and passes it on for the Focus group meeting. One resident spoken with was concerned about some pipes in their room, which needed to be boxed, redecoration and a new carpet. A representative from Freeways had also noted this. The inspector viewed the bedroom and the visible pipe work, and the work was clearly outstanding. The manager had listened to the resident and had taken action to seek a remedy, but since this was not effective, the resident chose to write to Freeways about it. The resident was clearly unhappy about the issue, raising it with the inspector, and it should have been recorded as a complaint. The complaints process, policy and procedure must be reviewed to ensure that points of concern can be investigated within agreed timescales and that The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 17 residents know what to expect if they wish to raise something. Complaints are a valuable way of improving resident’s lives and ensuring a culture of openness. The complaints book was reviewed and was out of date and there was no written evidence that staff had read and understood the complaints policy and procedure. Staff received reinforcement training in the protection of vulnerable adults (POVA) in October 2005, which was of one hour duration. POVA is also a part of staff induction and LDAF training, however all staff must have more comprehensive training to ensure they can protect residents. The South Gloucester POVA policy was seen to be available for staff however a copy of ‘No Secrets’ was not available and this should be obtained. No complaints or allegations had been sent to the commission for investigation since the last inspection. One member of staff provided an appropriate response about the steps to take if they were concerned about abuse. Another member of staff said that they had received POVA training at another facility and that the ‘whistle blowing’ policy was in a file in the office and easily available for staff. Of fifteen survey responses from relatives, six indicated that they were not aware of the homes complaints procedure. One relative made the point that “I don’t know the complaints procedure because I have never had to use it”. The manager must ensure the procedure is communicated to relatives. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is homely and equipped to meet their needs, however the heating system must function properly so that all residents feel comfortable. EVIDENCE: Residents enjoy a good environment, which is homely and appreciated by residents. Three residents spoken with were very content with the environment, which was clean and tidy. Points raised at the last inspection had been addressed, without the need of a requirement. Unfortunately a difficulty with the home heating system continues and a requirement will be made since there could be a risk to residents. At the last inspection, the main boiler for the home was not functioning and a portable heater was noticed. Since then, the other boiler had been replaced but the main boiler was not functioning at this inspection. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 19 The manager said he could make some adjustments, which should help. The inspector felt a little cool, although not cold and considered this issue with two residents who both disagreed and said it was a little warm for them. The inspector observed a member of staff checking an older resident, and turned on a portable electric fan heater. Another resident said it was a little cool but that a fan heater can be put on if needed. The provider said in their regulation 26 reports that they were considering a suitable resolution to the problem. The home has a loop system for the benefit of hearing aid users but it was not currently needed. Sensory equipment fitted in the main bathroom was said to be appreciated by residents. Bathrooms had a number of homely items like plants, which help to ensure they were not institutional in appearance. One resident’s bedroom needed pipes to be boxed in, decoration and a new carpet. The downstairs bathroom had a new assisted WC, which was important to some residents. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 20 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): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents will be cared for by a stable staff team, qualified, skilled and competent, to meet their needs. EVIDENCE: The home continues to maintain a qualified staff team and in addition to the qualified managers, nine staff hold NVQ level 3 and two staff were undertaking it. The deputy manager had done well to complete her NVQ level 4 in management in July of this year and her skills will be valued in supporting development of the home; she had responsibility for medication, staff supervision and care plans. Staffing was considered satisfactory on the day of inspection and the home does not use agency staff, ensuring consistency. Survey responses to the question of staffing levels showed that thirteen relatives were satisfied, one said “usually” and one said “ just occasionally, usually due to illness staff numbers become depleted, which causes stress to those on duty – the relative said it did not worry them and was on rare occasions. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 21 Two staff files were case tracked and showed good recruitment practice. Residents were involved in staff selection. Supervision notes were read for two staff, which confirmed that staff had six weekly supervision and an annual appraisal. The supervision notes, produced by two different managers were seen, they were very well recorded, raised issues of importance and were positive in feedback for staff. One member of staff spoken with said they find the manager very easy to talk to and that their ideas were listened to and taken up and an example of recycling was given. A member of staff said that it had been difficult to provide one to one time with residents in the past but that it was now much easier to give residents time they need. They also said that staff turnover was low, which was good in terms of consistency of care. A member of staff spoken with said that all staff had received LDAF training, which was very good and that “I really enjoy my shifts and everyone works as part of a team” and for my own improvement, “I would like to do more as a key worker”. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 22 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): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective management ensures the home is run in the best interests residents. Development of quality assurance and self-monitoring will ensure residents views underpin improvements for their benefit. Resident’s health and safety had been promoted by a review of work place risk assessments. EVIDENCE: The home was well run and a confident and competent deputy supported the experienced manager. A significant number of surveys were submitted prior to the inspection from residents, relatives and professionals and gave a strong message of good standards of care being provided. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 23 Reports of the monthly Regulation 26 unannounced visits to the home, which were unannounced, had been copied to the commission and were read before the inspection. They were very well presented, and easy to read, covering key aspects for the home, and felt to represent excellent practice. The reports gave evidence of key tasks, which had been completed such as: a new format for key worker reviews; manual handling and training in the use of a hoist; review of general work place risk assessments; a quality improvement in that a speech and language therapist had attended a team meeting on 26/09/06 to provide staff with training about dementia. A report also said that a boiler was still not functioning and a major concern to the provider. The manager said the provider was taking action to deal with the matter. These reports showed the provider was very much in touch with the home and it was good to hear that the manager felt well supported by the provider and visiting responsible individual. A great deal of work remains for the manager, concerning quality assurance. The manager should bear in mind the national minimum standards when establishing the systems and approaches needed. The manager had been proactive in sending out a survey to families and a member of staff was delegated to support the task. The outstanding response to surveys completed by relatives before the inspection show excellent engagement with relatives and huge praise for the work of staff at the home. Relatives made so many positive comments that it was difficult to set them all down and so the inspector has summarised the comments as follows: • • • • • • • • • • • • • • • their son/daughter likes it there and is able to tell the relative what happens satisfied with the care and the manager is excellent efficient and caring staff are well chosen a nice atmosphere and they are welcomed if I wasn’t happy I wouldn’t let my son/daughter go to SHH my son/daughter is gaining in confidence they go for respite and love it we go to events and they make us so welcome they take their son/daughter to anything they go to the staff are excellent the food is excellent always happy and well cared for and staff try to make it like home senior staff are excellent and all staff are caring always very pleased with the care and attention and friendliness son/daughter very happy to stay there and I am very satisfied with the care The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 24 Since the last inspection, the home had properly sent the commission four Regulation 37 incident reports about four different residents. However a phone call from the home to the commission on 01/11/06 reporting a readmission to hospital of a resident needed a Regulation 37 report and the manager said he would provide this. Work place risk assessments had been reviewed since the last inspection. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 25 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 2 2 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 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 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 3 X 2 X X 3 X The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? yes 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 YA1 Regulation 4; 5 Requirement Timescale for action 30/03/07 2 YA2 14.b 3 YA22 22.3 4 YA23 13.6 The registered person shall ensure a review of the statement of purpose and service user guide to ensure it fully covers all points within the national minimum standard and ensure the documentation is communicated. (This is also to ensure that charges for ‘extras’ and details about occupancy of bedrooms are clearly set down) The registered person shall 28/02/07 ensure a review of the admission process to ensure the home has a copy of a prospective resident’s full assessment prior to admission. (This is to ensure the manager has enough time to consider any issues.) The registered person shall 30/03/07 ensure a review is completed of the complaints policy and procedure to ensure the process of responding to complaints is communicated to staff, residents and people important to them. The registered person shall 30/03/07 provide staff with training in the protection of vulnerable adults. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 27 5 YA24 23(2)(p) 6 YA39 24 The registered person shall ensure heating is suitable for residents, in all parts of the home they have access to. (This concerns a difficulty with a boiler, which the provider is responding to) The registered person shall ensure the development of a quality assurance system. (Previous timescale of 30/11/05 and 28/07/06 not met) 30/03/07 30/04/07 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 YA21 Good Practice Recommendations In taking account of residents wishes, make a record of residents last wishes. The Susan Hampshire House DS0000003399.V310672.R01.S.doc Version 5.2 Page 28 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.V310672.R01.S.doc Version 5.2 Page 29 - 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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