Inspection on 06/11/07 for The Susan Hampshire House

This inspection was carried out on 6th November 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Susan Hampshire House 22/11/06

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 Paula Cordell Key Unannounced Inspection 6 and 8th November 2007 09:45 th The Susan Hampshire House DS0000003399.V351417.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.V351417.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.V351417.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 susanhampshirehouse@freeways.trust.co.uk 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.V351417.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 22nd November 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 - £892, 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.V351417.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit as part of a key inspection. The purpose of the visit was to follow up the requirements from the Key inspection in November 2006. In addition to monitoring the quality of the care provided to the sixteen people living at Susan Hampshire House. There have been no additional visits between November 2006 and this visit. There have been no complaints received about the service. There were no vacancies in the home. The home has an established group of people that stay at Susan Hampshire Home for respite. Three of the sixteen beds are respite beds. The inspection methods used included record checks, case tracking, a tour of the home and discussion with the manager, the deputy, staff on duty, and the people who use the service. The home has been sending information in respect of regulation 37 notices of events affecting the well being of the people who use the service. These were used as a focus for the site visit, along with the annual quality assurance selfassessment completed by the home and comments from people who use the service (6), relatives (4) and visiting professionals (4). The visit was conducted over a period of two days for a total of nine hours and ended with structured feedback. What the service does well: There was evidence that staff focus on the individual needs of people who use the service and create a homely place for people to live. There is a commitment to provide a wide range of leisure and occupation. Individuals living in the home benefit from a consistent staff team. 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. There is a good commitment to ensure that a competent and a trained workforce support the individuals living in the home. The majority of the staff team have obtained a National Vocational Qualification. There is a good rolling programme of mandatory training. The responsible individual provides the manager and staff with good support and clear and helpful reports. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 6 Surveys from people who use the service, relatives and professionals provided good evidence of a high quality of care. 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 summary of this inspection report can be made available in other formats on request. The Susan Hampshire House DS0000003399.V351417.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.V351417.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. JUDGEMENT – we looked at outcomes for the following standard(s): 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, provides information needed by people who use the service, relatives and other professionals. People’s wishes and needs were assessed to ensure the home could meet their expectations. However once a person moves to the home they must be confident that a full care plan is drawn up based on the home’s assessment and the placing authority’s care plan. People receiving a care service have contracts including fees and extras, which provides protection. EVIDENCE: The home was in the process of updating the statement of purpose and the service user guide. This has been expanded to include all the points in the National Minimum Standards and bring together all the home’s documentation, which included a statement of purpose, service user guide and a home’s brochure. ‘Extras’ which are not included in the fees are now included in the service user guide and the statement of purpose. Examples of additional charges communicated during the visit included: Chiropody, aromatherapy and a contribution to the home’s transport and holidays. The latter was discussed The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 9 in detail and it was not the cost of the holiday but the transport to and from the holiday. Individuals are expected to cover the cost of the holiday accommodation and spending money. This should be made clearer. There were two rates for the contribution to the home’s vehicle depending on the rate of the individual’s Disability Living Allowance. From the conversations it was not clear what service those contributing more could expect in addition to the basic rate. One person who rarely uses the transport does not contribute and one person’s parents have financial control and they do not contribute. It is strongly recommended that the present system of funding of the home’s vehicle is reviewed to ensure it is equitable and based on usage. Three people’s care files case tracked showed they had up to date contracts and the individual or their representative had signed them. The home has included in the contract the fees and extra charges made on top of fees. From completed surveys it was evident that individuals had sufficient information prior to moving to the home. One person stated, “They had not chosen the home, but were more than happy with the choice that was made for them, stating it was home from home”. Good assessment records were seen to ensure people’s care needs are assessed prior to moving to the home as seen at the last visit. However, in November it was noted that the home did not have a formal care management single assessment for a prospective person planning to move to the home. The home has demonstrated compliance to this requirement. Since the last visit a person has moved to the home and whilst it was noted that the formal care plan had been obtained. However, this had not generated a care plan drawn up by the home. The manager stated that this is not usually completed until the six monthly review. The National Minimum Standards clearly states that the home must generate a formal care plan within five days of the person moving to the home detailing the support needs of the individual. From conversations with the manager and the staff it was evident that the home would ensure that the assessment process was tailored to the individual. With a variety of visits to the home being made prior to making a decision including an overnight stay to enable the individual, people living in the home and the staff to get to know each other. From conversations with the manager some of the individuals have been known to the service prior to admission as they stayed for respite. The manager stated that individuals are consulted on the admission of new people moving into the home to ensure compatibility with the existing group. The manager stated that this is true of individuals receiving a respite service and that it is imperative that those staying for only a short time get on with the people whose home it is. Information relating to the assessment process is clearly documented in the home’s statement of purpose. The Susan Hampshire House DS0000003399.V351417.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. 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. Individuals can be assured that their care needs and aspirations are being met. The outcome for individuals is that they are supported in the way they choose, however, the documentation is lacking on how this support is delivered in the form of a plan of care that is measurable. There is good communication in the team to ensure that a consistent approach is delivered, this would be enhanced if this was documented. EVIDENCE: A random selection of care files were seen. The home operates a system where the care review forms part of the care plan. The review covers a wide range of areas including personal care, social, emotional, physical and psychological care needs. At each six monthly review ideas are generated for the person to pursue over the forthcoming months. The key worker then formally reviews these goals and aspirations monthly. Many of the goals that were set were broad statements for example independence, swimming, maintaining health with no guidance to staff. It would be difficult to fully review these goals, as The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 11 they were not clear, measurable or broken into small achievable steps. For example independence could be interpreted in so many ways or how many times should an individual go swimming. Other areas of concern was that where an individual had an area of need for example diabetes or mobility there was no clear guidelines to support the individual and ensure a consistent approach. The manager stated that this is verbally communicated to the team, through team meetings, supervisions and staff induction. Whilst it is evident that there has been a consistent team at Susan Hampshire House each person must have a clear plan of care detailing their support needs. People living at Susan Hampshire House were fully involved in their care planning and supported to make decisions about their lives. This was confirmed in the surveys from relatives, professionals and the individuals living in the home. Individuals were asked via the surveys if staff listen to them and treated them well, six out of six said always. Relative questionnaires were equally as positive. One returned survey stated, “Great care and attention is paid to all the individuals living in the home” another stated, “Staff are caring and understanding of the individuals”. Risk assessments were seen and covered a wide range of areas. It was evident that these did not curtail independence. Individuals were evidently encouraged to lead full and active lifestyles based on choice. One person who has recently been admitted to the home did not have any risk assessments. The manager stated that these would be formalised at the six monthly review. The home must ensure that where a risk is identified this is clearly documented within a timely manner. It was evident that that the person has fallen and a risk assessment must be developed. Risk assessments included the use of equipment for manual handling. The manager has attended a Manual Handling assessor’s course and all staff attend periodic updates in manual handling. The home operates a key worker system. This was confirmed in conversations with staff and people who use the service. The key worker completes a monthly report on what activities have been undertaken, contact with relatives, a review of any health care appointments and documentation on the progress to the goals and aspirations that have been discussed at the six monthly reviews. This is good practice and demonstrates a commitment to meeting the care needs of the individuals and their aspirations. Whilst there was limited evidence of a formal care plan it was evident that the outcome for individuals was that their care needs were being met. The Susan Hampshire House DS0000003399.V351417.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. 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. Individuals lead active and social lifestyles based on choice. Good contact is maintained with friends and family. Individuals are very much part of the running of the home and there is an inclusive atmosphere. Individuals have available to them a healthy diet. EVIDENCE: Completed surveys from individuals living in the home provided evidence that they are supported to make decisions on how they spend their time throughout the day, in the evenings and weekends. Three of the surveys stated that this was not the case at their day centre. The manager was aware of this and was working with the day centre to alleviate concerns. The manager stated that the centre is planning to close which has heightened concerns for the individuals. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 13 Individuals are evidently offered a wide range of activities both in the home and the community. Some of the individuals attend a day centre, some attend college and some have employment in the local community. It was evident that the activities were tailored to the individual. Some of the individuals attend clubs and local places of worship. It was evident from talking with the manager and staff, that individual’s diverse and cultural needs would be met. Some of the individuals are members of the local golf club and a club specifically for people with a learning disability, which is organised fortnightly. One person was keen to share photographs of their annual holiday. It was evident that they had enjoyed their time away. Another person was planning to go away the weekend after this visit and was observed making plans with the staff on the transport arrangements. From conversations it was evident that all individuals were supported to have an annual holiday if they wanted and could choose the destination and who they went with. Social activities were many and organised at frequent intervals. Individuals described how they have been supported to go on trips to places of interest, football matches, the theatre, meals out and pub trips, the examples were numerous. Some of the individuals stated that regular entertainment is brought into the home for special occasions to assist with celebrating with birthdays and other festivities. From the conversations it was evident that this was seen in a positive light. People who use the service have monthly house meetings as confirmed in conversations with the individuals and staff. Notes of the meetings demonstrated that a wide range of topics were discussed demonstrating that individuals are involved in making decisions and very much part of Susan Hampshire House. Some of the individuals living in Susan Hampshire House have attended a course to enable them to be part of the recruitment process for new staff. Again demonstrating that individuals are involved in the running of the home. Relative surveys confirmed that there was good communication from the home and that they were involved and made to feel welcome. The home has a visitor’s policy and a record of visitors to the home. Individuals are supported to maintain and renew contact with relatives. One of the individuals has been successfully supported by staff in the home to trace relatives where contact has been lost. This is good practice. Menus and conversations with individuals and staff provided evidence that there is a wholesome, healthy and varied menu available. Individuals spoken with stated that the food was good and that there were always two choices. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 14 From the conversations it was evident that the individuals were involved in the menu planning. Professional advice had been sought regarding menu planning for individuals that have eating issues. From the conversations it was evident that special diets are catered for as well as individual preferences. The opportunity was taken to participate in the lunchtime meal. Support was given sensitively and it was evident that meal times were social time. Conversations were inclusive of staff and the people living in the home. A good rapport was noted. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals can be assured that their personal and health care needs are being met. Individuals are protected by the home’s medication practices, however individuals could be at risk where this is not stored securely. EVIDENCE: Health care monitoring was good; it was evident that the home was responsive to the needs of the individuals living in the home. Good records were maintained demonstrating how individuals were supported to attend appointments and the outcome. The manager stated that the plan is for all individuals to have a health action plan, this would enhance the care planning system and clearly state how individuals are being supported. This will be followed up at the next inspection. Health care professional surveys received prior to the inspection gave positive feedback about the support being given to the individuals and the commitment The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 16 of the staff and the manager to meeting individual needs. The surveys provided evidence that individuals are treated with dignity and respect and that their privacy is maintained. As already mentioned the key worker has a responsibility to review the individual’s health and personal care on a monthly basis and for co-ordinating appointments. The medication system was reviewed with the assistant manager who has the responsibility for the medication in the home. It was evident that there was a good system in the home and the assistant manager could account for all medication entering and leaving the home. However, a concern would be that whilst the assistant manager could complete an audit of stock it was not clear whether other staff could have the same efficiency. It is suggested that for “as and when required” medication that a stock recording sheet is developed. This is presently already in use for the home’s stock of paracetamol. This would mean that staff would not have to go through the previous medication recording sheets to determine how many have been administered and take this away from the amount that is in stock. Records were clear relating to medication and signed by staff that had been assessed as competent to administer. Each person had a profile of the medication that they were taking including a current photograph of the person. It was noted that excess medication stock was stored in an unlocked cupboard under the sink. The home is required to ensure that all medication is held secure. The manager has agreed to keep the door locked as an interim arrangement until this cupboard can be made more secure. The home has suitable storage for the medication that is required to be kept in the fridge. Staff competence is checked with records maintained as part of the induction process. Only staff assessed as competent can administer medication. The manager stated that the home is responding to a recommendation to record the last wishes of individuals in relation to death and dying. Information was seen on one individuals file. The manager stated that this will be an ongoing process. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals and their representatives can be confident that individuals are protected from abuse and their concerns are listened to. EVIDENCE: Completed surveys from people receiving a service and their representatives confirmed that they knew how to complain. The manager stated that the process for raising complaints is frequently discussed at house meetings with the people who receive a care service. Freeways Trust have a service user representative group and one of the individuals from Susan Hampshire House attends again another forum to raise concerns. At the last inspection it was noted that a person had raised a concern about their bedroom and this had not been actioned within an appropriate timescale and recorded in the home’s record of complaints. This has now been addressed. The manager stated that concerns are listened to and responded to within the agreed timescales. The complaints policy is included in the statement of purpose and the service user guide. An opportunity was taken to view the home’s record of complaints. A clear record was maintained with the action taken and the outcome. Complaints in the main related to relationships within the home and no different from those you would normally find when a group of people live together. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 18 The organisation has a policy on protecting individuals from abuse as seen at previous inspections. This has been made accessible to individuals living in the home and includes pictures and is written in plain English. In addition a copy of South Gloucestershire’s safeguarding policy was available. The home has a Whistle Blowing Policy as seen at the last visit. Staff were aware of the policy and how to respond to concerns with clear reporting to the manager or the senior Freeways manager for the service. At the last inspection it was noted that some staff have not attended a formal training session in protection of vulnerable adults from abuse (POVA) other than an hour training with the provider. Other staff had not attended an update or a refresher course. The manager was able to demonstrate that all staff are now attending this training with the local council as part of a rolling programme and the majority of staff have now attended. The manager stated abuse is also covered as part of the organisational induction and as part of the Learning Disability Award Framework that all new staff complete. This training is completed within the first six months of commencing employment with Freeways. Finances were checked and found to be correct for a random selection of people receiving a care service. Individuals have their own bank accounts and these are kept in the home. The manager stated that when individuals require money from their bank accounts then a signature is obtained from Freeways Head office. This person is the appointee for those individuals living in the home who do not have an external appointee. A receipt supported all expenditure and two staff or the individual had signed for the expenditure. The member of staff responsible for the finances stated that money belonging to the individuals is subject to monthly audits by the financial department based at Freeways Headquarters and external auditors visit occasionally (the frequency was unknown). The manager stated that training has been given to the majority of staff working in the home on supporting individuals that challenge. The manager stated that they are a trainer in this particular topic for Freeways and attend annual updates with an accredited trainer to enable them to officially deliver this training. The manager stated that all staff will receive an update in January 2008 and those that have not attended in the past will attend a more intense course. From discussions it was evident that the training was based on positive interventions and focused on the individual. Care files provided evidence that individuals have a positive strategy to support them if they become angry or upset. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Susan Hampshire House is purpose built and is suitable for the people that presently live there. Great attention has been paid to make it homely and appealing both for the people living there and their visitors. High standards of cleanliness are in place. EVIDENCE: Susan Hampshire Home is purpose built and in keeping with the local neighbourhood. It is situated opposite Yate Shopping Centre and has many local amenities, which include places of worship, sport facilities, pubs, shops and good transport links. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 20 Four people stated that they were happy with the environment of the home, one person receiving respite stated that they did not want to leave, another stated that they were really pleased with their bedroom and liked spending time there watching television. All bedrooms are single with many having ensuite facilities (a toilet and sink). There are four bathrooms and toilets situated throughout the home. All bedrooms seen were personalised and decorated and furnished to a high standard and reflected the interest of the individuals. The home provides respite care to individuals living in the community and separate facilities are available for these individuals including a small kitchen and lounge. However, from conversations with staff, the manager and those receiving respite it was evident that they enjoyed spending time in the communal areas of the main home. During the last visit it was noted that the temperature in the home was a little cool in certain areas of the home. Again this was noted and discussed with staff and people living in the home. No consensus was reached. However, the manager did adjust the heating. It was noted that one of the older people living in the home was seated by a portable heater and was covered in a blanket to ensure that they were not cold due to being immobile. It was evident that staff were responsive to the needs of the individuals. The manager stated that a new boiler has been installed and this has improved the situation. This was in response to a requirement from the last inspection that in addition had been noted through the monthly provider visits in respect of regulation 26. The home has a loop system for the benefit of the hearing impaired but the manager stated that this is not currently used. In addition bedrooms had a light that would let the person know that the fire alarm was ringing. This is good practice. Sensory equipment had been fitted in the bathrooms and was said to be appreciated by the people living in the home. The home was purpose built and is accessible to those that may be disabled including handrails throughout, a lift to the second floor and a variety of manual handling aids including hoists and bathing aids. It was evident that the staff and the people living in the home have paid great attention to making all parts of their home homely with ornaments, plants and domestic style furniture. All areas were clean and free from odour. The home has responded to all environmental requirements from the last visit, which included boxing in some pipe work, replacing a carpet and decorating in one of the bedrooms. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 21 There is an enclosed outside garden with seating and mature shrubs. The home has a number of pets including a cat, two kittens, fish and guinea pigs. Individuals said they were actively involved in looking after the animals. The staff and the individuals living in the home are responsible for keeping the home tidy. Staff support individuals as part of their weekly life skills day to clean their bedrooms and change their bedding. In addition individuals were observed helping with the washing up, generally clearing the kitchen and dining area and doing their laundry. It was evident that individuals felt valued and part of the home. The home has recently achieved a five star rating from the Environmental Health Officer. A good standard of cleanliness was observed in the kitchen with safety measures being taken to ensure that individuals are protected. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 22 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. 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. Individuals benefit from a competent and stable staff team. There are good support mechanisms in place for staff to ensure they are meeting the care needs of the individuals living at Susan Hampshire House. EVIDENCE: From talking with staff it was evident they enjoyed working at Susan Hampshire House, that they felt supported in their roles and had built good relationships with the people they support. Staff were knowledgeable about the needs of the people living in the home. The home has an established team, which offers consistency to the people living at Susan Hampshire House. It is rare to find a home that has a full staff team with no vacant posts. From talking with the manager and staff it was evident that the home has a core bank of relief staff that support during the occasional sickness and holidays. The updated statement of purpose states that there should be a minimum of four staff working during the day with one waking and one sleeping in member The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 23 of staff to cover the nights. Staff stated that majority of the time this level of staffing is in place. The rota seen confirmed this. There was one day when this was not achieved due to staff sickness and the home was unable to cover. From conversations with staff it was evident that individual team members had a clear role within the team whether that was a key worker role or responsible for a particular area. Staff were very involved in this visit where it was clearly their responsibility for example finances or medication. Staff Recruitment information was seen and demonstrated that a thorough process had been undertaken. It was noted that one newly appointed member of staff’s reference had not included the last employer. The manager stated that “the employer refused and stated that the individual was not leaving”. They had gone on to obtain two references however good practice would be for the home to record the telephone conversation. All staff had been subject to a criminal record disclosure. These are held at Freeways Trust. There was a good rolling programme of training including annual updates in first aid, manual handling and fire training. Other training seen included dementia, epilepsy, specific training on a communication aid used in the home, supporting individuals that challenge and diabetes training. It was evident that training would link with the needs of the people living at Susan Hampshire Home. The home has exceeded the government target of achieving 50 of the workforce having a National Vocational Award. The assistant manager has recently completed a NVQ at level 4 in management. In addition all new staff complete the Learning Disability Award Framework as part of their induction. This was confirmed in staff records. Staff stated that they felt supported in their role with regular team meetings, supervisions and appraisals. Documentation was seen supporting this. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 24 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. 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. Individuals benefit from a well managed and inclusive service. Good health and safety systems are in place. EVIDENCE: Mr Jeremy Venton is the registered manager. He has worked for the organisation supporting individuals with a learning disability for many years. He has managed Susan Hampshire home since it opened eight years ago along with the assistant manager. Evidence was provided that Mr Venton continues to attend training enhancing his skills and experience. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 25 Reports of the monthly visits in respect of regulation 26 had been copied to the Commission for Social Care Inspection and were read prior to this visit. They were well presented and gave a good insight into the service covering key aspects of the running of the home. It was evident that the provider had a key role in reviewing the quality of the service provided. In response to a requirement at the last inspection the manager has developed a quality assurance audit, which includes sending surveys to relatives, and people who use the service. This will be followed up at the next visit to the home. In addition the home has a business plan, which highlights actions for the home to improve the service. The home completed the Annual Quality Assurance Assessment as part of this inspection process. The AQAA offers the provider an opportunity to say where the service is doing well and what could improve. The manager has identified some key areas that the home could improve and these will be followed up at the next inspection. Areas included more involvement for individuals living in the home, development of the health action plans and ensure manual handling training is offered six monthly on the use of the hoist this list was not exhaustive. It was evident that this would only enhance the service further and build on the existing good practice within the home. Health and safety in the home was paramount from talking with the manager. A member of the team has the responsibility to co-ordinate health and safety within the home. Good standards of documentation were in place including fire records, fire risk assessments, general risk assessments and policies and procedures. The risk assessments would benefit from an annual review and the manager was aware and this was on the agenda to discuss with staff. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 26 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 2 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 X 3 X 3 X X 3 X The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 27 NO 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. Standard YA1 Regulation 5 (2) Requirement The manager to forward to the Commission for Inspection of Social Care a copy of the Statement of Purpose. Ensuring that individuals living in the home and their relatives have a copy. The registered person shall ensure a review of the admission process to ensure that newly admitted individuals have a care plan detailing their care needs, which is generated by the single Care Management Assessment/Care Plan. To expand on the present care planning processes to clearly describe how the person’s care needs are to be met. For goals to clear and measurable. Timescale for action 08/12/07 2. YA2 15 (1) 08/12/07 3. YA6 15 (1) 08/03/08 The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 28 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 YA5 Good Practice Recommendations For the home to review the contribution towards the home’s transport to ensure that it is equitable and based on usage. The Susan Hampshire House DS0000003399.V351417.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V351417.R01.S.doc Version 5.2 Page 30 - 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!