1-125892604 cri crime reduction initiatives 1-230561489 st thomas fund 20120530

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Review ofcompliance

CRI (Crime Reduction Initiatives)

St Thomas Fund

Region: South East

Location address:58 Cromwell Road

Brighton

Sussex

BN3 3ES

Type of service: Residential substance misuse treatmentand/or rehabilitation service

Date of Publication: May 2012

Overview of the service: St Thomas Fund is part of the CrimeReduction Initiatives (CRI) which is ahealth and social care charity. It workswith individuals affected by drugs,alcohol, crime, homelessness, domesticabuse, and anti-social behaviour.

The project at 58 Cromwell Road is asupported living house whichaccommodates a maximum of 7


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residents. They are supported by staffto undertake a residential andtherapeutic programme to enable themto regain control of their lives and totackle their problems.


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Our current overall judgement

St Thomas Fund was meeting all the essential standards of qualityand safety inspected.

The summary below describes why we carried out this review, what we found and anyaction required.

Why we carried out this review

We carried out this review as part of our routine schedule of planned reviews.

How we carried out this review

We reviewed all the information we hold about this provider.

What people told us

During our visit we spoke with people who lived at the service and staff members.

The people we spoke with told us they felt safe living at the home and felt supported by the

staff team.

Staff we spoke with knew the people living at the home well and had a good understandingof their support needs.

What we found about the standards we reviewed and how well StThomas Fund was meeting them

Outcome 01: People should be treated with respect, involved in discussions abouttheir care and treatment and able to influence how the service is run

We found that people were respected and their independence maintained at St ThomasFund home.

People's views and experiences were taken into account in the way the service wasprovided and delivered in relation to their support and treatment.

Overall, we found that St Thomas Fund home was meeting this essential standard.

Outcome 04: People should get safe and appropriate care that meets their needsand supports their rights

We found that service users had their support and welfare needs met.

for the essential standards of quality and safetySummary of our findings


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People had treatment and support that met their needs and protected their rights whilstadhering to the rules and regulations of the home.


Outcome 07: People should be protected from abuse and staff should respect their

human rights

We found people living at St Thomas Fund home were protected from the risks of harmbecause staff received safeguarding training. Staff knew how to recognise abuse and howto act in the event of any concerns.

People who used the service were protected from the risk of abuse, because the providerhad taken reasonable steps to identify the possibility of abuse and prevent abuse fromhappening.


Outcome 13: There should be enough members of staff to keep people safe andmeet their health and welfare needs

We found that the concerns raised by staff around staffing levels had already beenacknowledged by management and that there was evidence that concerns were beingaddressed.

We felt confident that the services manager had acknowledged the need for more staff atthe home and was actively seeking to increase staff numbers. Although there was

sufficient staff at during weekdays the services manager recognised that providing anadditional staff member would increase the stability of the team.

We found that there were sufficient numbers of staff employed at St Thomas Fund homewith the exception of weekends where a skeleton team was in operation.

We found that service users had their support needs met and that the staff team had theknowledge to meet each person's identified needs.


Outcome 16: The service should have quality checking systems to manage risksand assure the health, welfare and safety of people who receive care

We found that a quality assurance system was in place at St Thomas Fund home thatenabled the services manager to regularly assess and monitor the quality of the servicethat people received.

The views of people living at the home and staff had also been sought to improve thequality of care delivery.

The provider had a system in place to identify, assess and manage risks to the health,safety and welfare of people using the service.


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Other information

Please see previous reports for more information about previous reviews.


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What we found

for each essential standard of qualityand safety we reviewed


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Outcome 01:Respecting and involving people who use services

What the outcome says

This is what people who use services should expect.

People who use services:* Understand the care, treatment and support choices available to them.* Can express their views, so far as they are able to do so, and are involved in makingdecisions about their care, treatment and support.* Have their privacy, dignity and independence respected.* Have their views and experiences taken into account in the way the service is providedand delivered.

What we found

Our judgement

The provider is compliant with Outcome 01: Respecting and involving people who useservices

Our findings

What people who use the service experienced and told usWe found that independence and individuality were promoted within the home. Peopleliving at St Thomas Fund home told us they were supported and enabled to do thingsfor themselves.

One service user told us 'there is a supportive staff team here..staff support me withissues with social services'.

Another service user told us 'we get a choice of what we want to eat and then cook itourselves'.

Other evidenceCare plans had been developed for each service user living at the home. The careplans we looked at provided appropriate and detailed information to staff on serviceuser's support needs. The care plans also showed evidence of people setting their ownindividual goals to achieve.

We saw that each service user had their personal belongings in their rooms and their

own furniture and decorative effects.


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During our visit we observed staff talking to people and supporting people in aprofessional manner. We saw that, where required, support was offered and providedin a way that ensured that people's rights to privacy and dignity were respected.

During the inspection, we observed a service user who was talking to a staff memberabout leaving the service. The staff member spoke with him in a respectful and

professional way. She provided him with advice around risks and consequences andcurrent (drug) issues on the street to help the service user make an informed decision.

We saw that care plans were signed by service users. We saw a section in the careplans on 'things I would like to change' to enable the service users to make decisionsabout the goals they wanted to achieve.

In the care plans we looked at we saw a key worker agenda signed by service usersand a medication storage form signed by service users. The service users we spokewith said they were fully involved in decisions made about their care plans.

Our judgementWe found that people were respected and their independence maintained at St ThomasFund home.

People's views and experiences were taken into account in the way the service wasprovided and delivered in relation to their support and treatment.



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Outcome 04:Care and welfare of people who use services



People who use services:* Experience effective, safe and appropriate care, treatment and support that meets theirneeds and protects their rights.

What we found

Our judgement

The provider is compliant with Outcome 04: Care and welfare of people who useservices

Our findings

What people who use the service experienced and told usService users we spoke with told us about the staff at the home and how they likedthings done.

One service user told us 'I feel healthier since being in here and have started eatingagain. There is a supportive staff team here'

Another service user told us 'I can talk with staff about my care plan'.

Other evidenceCare records we saw confirmed that people living at St Thomas Fund home were

registered with a local GP and had access to healthcare professionals as necessary.There was a key worker scheme in operation at the home.

During our visit we looked at the care plans for some of the people living at the home.The plans were up-to-date and contained evidence of regular review. They providedinformation to staff on how people preferred things to be done.

The care plans had risk managements plans and substance misuse assessments thatrelated to specific and identified risks to people's safety. The care plans containeddetails of actions to be taken by staff and service users to minimise the identified risks.

The care plans we saw demonstrated evidence of people's individual needs to includeindividual goal setting, support networks and significant events sheets. We saw


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evidence of up-to-date daily evaluation sheets being used.

We saw service user signatures on care plans and updated reviews were observed,with the review due date clearly documented on the care plans. One care plan welooked at was over due for a review.

We were told that service users attended daily group and therapeutic sessions andcompleted assignments during their residential programme. The home also providedgroup sessions for people not residing at the service.

Our judgementWe found that service users had their support and welfare needs met.

People had treatment and support that met their needs and protected their rights whilstadhering to the rules and regulations of the home.



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Outcome 07:Safeguarding people who use services from abuse



People who use services:* Are protected from abuse, or the risk of abuse, and their human rights are respected andupheld.

What we found

Our judgement

The provider is compliant with Outcome 07: Safeguarding people who use servicesfrom abuse

Our findings

What people who use the service experienced and told usThe staff we spoke to said that they had undertaken recent safeguarding training. Theytold us if they witnessed abuse they would speak with the services manager or contactexternal agencies.

One staff member told us 'I have completed recent safeguarding training and havecompleted fire warden training also'.

Another staff member told us 'I completed safeguarding training recently. If I witnessedabuse I would go to a manager and alert other agencies as needed'.

A service user told us 'I feel safe living here'.

Other evidenceThe services manager at the home confirmed that St Thomas Fund home operated inaccordance with the Pan Sussex Multi Agency Policy & Procedures for SafeguardingAdults at Risk.

We saw evidence of internal safeguarding policies and procedures used by the home.The internal safeguarding policy was updated in March 2012. We saw examples ofother policies to include a Mental Capacity Act policy and joint working protocolsregarding safeguarding the needs of children.

We also saw evidence of a 'Whistleblowing' procedure in place at the home. We


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advised the services manager that the policy needed to inform employees of externalagencies they could contact to discuss whistleblowing concerns.

The services manager told us that the home ensured, as far as is practicable, thatpeople were safeguarded from all forms of abuse. During our visit we were told therewere no safeguarding investigations taking place within the home. We were told that

the home attended the Multi-Agency Risk Assessment Conference (MARAC) whenrequired to discuss high risk cases of domestic abuse between relevant externalagencies.

The services manager told us that staff attended safeguarding training regularly toincrease their knowledge of safeguarding practices and procedures.

The services manager told us that she attended a local manager's safeguarding 'hub'.This enabled them to identify risks and undertake prevention work with service userswithin their specialist service sector.

The services manager told us that quarterly management meetings were held todiscuss safeguarding issues. We were told that the Deputy Director for the CrimeReduction Initiatives (CRI) was the safeguarding lead for the organisation and that shewas very supportive and there was good communication around safeguarding issues.

We saw evidence in team meeting minutes of regular safeguarding discussions held.

We were told that safeguarding issues were discussed by staff members at shifthandover times and an electronic handover of safeguarding issues was also inoperation within the home.

The services manager told us that the home worked closely with the community policeteam and had developed a good working relationship with them. This enabled thehome to support service users where safeguarding issues arose. This often led toappropriate negotiation of bail conditions; planned arrests, use of plain clothes policeofficers to support a balanced and measured safeguarding process.

Our judgementWe found people living at St Thomas Fund home were protected from the risks of harmbecause staff received safeguarding training. Staff knew how to recognise abuse andhow to act in the event of any concerns.

People who used the service were protected from the risk of abuse, because theprovider had taken reasonable steps to identify the possibility of abuse and preventabuse from happening.



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Outcome 13:Staffing



People who use services:* Are safe and their health and welfare needs are met by sufficient numbers of appropriatestaff.

What we found

Our judgement

The provider is compliant with Outcome 13: Staffing

Our findings

What people who use the service experienced and told usAs part of our inspection we looked at staffing levels at St Thomas Fund home.

We spoke with service users to obtain their views on staffing levels in the home. Oneservice user told us 'every now and again they are short staffed'.

We also spoke with members of staff during our inspection about their experience ofworking at St Thomas Fund home.

One staff member told us 'I feel there is an environment of open communication now. Ican talk to management about issues and concerns'.

Another staff member told us 'I have a concern with regard to lone working atweekends. I have discussed this with management and they have listened to myconcerns. Another staff member is needed particularly at weekends'.

Another staff member told us 'It has been short staffed here, however it doesn't feel likewe are short staffed, as any issues are addressed quickly by management'.

Other evidenceWe were unable to speak with the registered manager for the service as she wastemporarily absent from post.

We discussed staffing arrangements at St Thomas Fund home with the services


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manager. We were told that interim management of the service was being provided bythe services manager who was available at the service several days per week andcontactable by telephone. In addition a senior project officer was providing an interimmanagement role and worked between three locations and attended the service on adaily basis. She was also available at short notice to attend the service when needed.

The services manager confirmed that the staff team consisted of two project workers,one sessional worker and a volunteer working on a shift from 9am to 5pm. At nightthere was one permanent night worker working at the home. At weekends there wasone project worker or sessional worker at the home. This was confirmed when welooked at duty rotas.

The services manager told us that having interim management had been unsettling forstaff. Staff had been supported by weekly staff meetings being held. Staff supervisionswere also undertaken. The services manager was confident that the staff team wassufficiently experienced and competent to meet the demands of the service.

The services manager told us that there was one staff vacancy which they were due toadvertise for. The services manager told us that the service could benefit from anadditional staff member at weekends and a change in how the existing staff team wasutilised. She was satisfied that the current staff team was competent to manage allissues arising, however staffing changes needed to take place to better meet the needsof the service.

The services manager told us she was developing a staff action plan. This action planwould include the need to refocus existing resources within the three local homes runby the Crime Reduction Initiatives (CRI). At the time of the inspection we were told that

this had been agreed in principle by management at CRI. The services managerforwarded an action plan to us on future staffing arrangements and we were satisfiedwith the proposed action being taken.

The services manager told us that an additional project worker was required atweekends as this had been identified as a time when crises can occur. Also serviceusers required more structure at weekends to reduce the risk of such crises occurring.

We were told by the services manager that the service could manage with the currentstaff team, but that it was currently 'fire fighting' situations. With the changes proposedin the action plan the service would be more stable.

We observed staff to be working and interacting with service users in a calm andresponsive way during our inspection. We observed that staff dealt with a crisis duringout inspection in a calm, responsive and professional manner.

Our judgementWe found that the concerns raised by staff around staffing levels had already beenacknowledged by management and that there was evidence that concerns were beingaddressed.

We felt confident that the services manager had acknowledged the need for more staff

at the home and was actively seeking to increase staff numbers. Although there wassufficient staff at during weekdays the services manager recognised that providing an


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additional staff member would increase the stability of the team.

We found that there were sufficient numbers of staff employed at St Thomas Fundhome with the exception of weekends where a skeleton team was in operation.

We found that service users had their support needs met and that the staff team had

the knowledge to meet each person's identified needs.



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Outcome 16:Assessing and monitoring the quality of service provision



People who use services:* Benefit from safe quality care, treatment and support, due to effective decision makingand the management of risks to their health, welfare and safety.

What we found

Our judgement

The provider is compliant with Outcome 16: Assessing and monitoring the quality ofservice provision

Our findings

What people who use the service experienced and told usDuring our visit to St Thomas Fund home we asked people their views about the homeand whether they were happy living there. We also looked at service user consultationdocuments for more information.

One service user told us 'there is a supportive staff team here'.

Another service user told us 'staff sometimes have different views on policies which canbe confusing'.

Other evidence

During our visit to St Thomas Fund home, we observed people who lived at the servicebeing spoken with and supported in a friendly and professional manner.

We observed that service users were able to express their views and make suggestionsby talking directly to the staff where possible. We observed a suggestion box in thelounge where service users were encouraged to provide suggestions to improve theservice.

We saw that a service user consultation had taken place in January 2012. A staff teamand service user training day had recently taken place to find out what people wantedfrom their residential and therapeutic programme. Feedback had been sought from

current and previous service users and people who attended the structured dayprogramme.


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In response to comments raised at the consultations, changes had been implementedat the home. As a result of the consultation a creative group and reflective learningsessions had been introduced. Another example involved working closely with ThePrinces Trust and Jobcentre to promote job opportunities for service users.

We were told by the services manager that monthly care plan audits were completed on

care plans. We were told that due to the absence of the registered manager this audithad recently not been completed.

We saw that Incident Notification Forms were being used in the home and thatincidents were communicated to regional managers to ensure lessons were learned.We saw clear evidence of risk issues being addressed at weekly team meetings. Wewere also told that work practice risk assessment forms were completed and sixmonthly reviews undertaken to address issues arising.

We saw that a Brighton and Hove City Council Supporting People contract review hadtaken place on16th March 2012. The previous safeguarding rating of 'C' had been re-assessed as a 'B' due to staff increasing their safeguarding awareness by attending asafeguarding hub. This review evidenced that the home had an 'A' rating for involvingservice users in decisions about the home and the service provision.

We saw written evidence that an internal unannounced inspection had been completedin August 2011. Recommendations had been made regarding health and safety issuesand an action had been set up for the registered manager to complete. We were toldthat some of the actions had been completed. Some actions were awaiting completiondue to the absence of the manager.

We saw that the home's policies and procedures were updated centrally on the intranetand that employees could access these at all times. The policies that we saw were up-to-date. We were told that policy changes were communicated to staff via emails andemployee consultations were also held as required.

We saw evidence of a clear complaints policy within the home and evidence that thiswas being followed appropriately by the management team.

The services manager told us that an unannounced internal health and safety audit hadtaken place in February 2012 and was due to be completed again in May 2012. Theservices manager acknowledged that the health and safety policy was not up-to-date

and said that she had already started working on this. She expected to have itcompleted within two weeks of the date of the inspection.

The services manager told us that an internet based governance tool was beingintroduced to enable effective auditing and action planning. The computer systemwould create triggers for managers to action any issues that needed to be addressed.The services manager told us that the audit tool should be fully operational within athree months period after audit information had been transferred onto the system.

We saw that there was a fire safety policy at the home and the Sussex Fire Brigadecompleted a fire inspection in August 2011. A 'eurofire protection' assessment wascompleted in March 2012 where no issues were identified.


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The services manager told us that the Crime Reduction Initiatives (CRI) had recentlybought the lease for the building and a new maintenance plan was due to bedeveloped. We observed that a new kitchen had recently been fitted at the home.

Our judgementWe found that a quality assurance system was in place at St Thomas Fund home that

enabled the services manager to regularly assess and monitor the quality of the servicethat people received.

The views of people living at the home and staff had also been sought to improve thequality of care delivery.

The provider had a system in place to identify, assess and manage risks to the health,safety and welfare of people using the service.



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What is a review of compliance?

By law, providers of certain adult social care and health care services have a legal

responsibility to make sure they are meeting essential standards of quality and safety.These are the standards everyone should be able to expect when they receive care.

The Care Quality Commission (CQC) has written guidance about what people who useservices should experience when providers are meeting essential standards, calledGuidance about compliance: Essential standards of quality and safety.

CQC licenses services if they meet essential standards and will constantly monitorwhether they continue to do so. We formally review services when we receive informationthat is of concern and as a result decide we need to check whether a service is still

meeting one or more of the essential standards. We also formally review them at leastevery two years to check whether a service is meeting all of the essential standards ineach of their locations. Our reviews include checking all available information andintelligence we hold about a provider. We may seek further information by contactingpeople who use services, public representative groups and organisations such as otherregulators. We may also ask for further information from the provider and carry out a visitwith direct observations of care.

Where we judge that providers are not meeting essential standards, we may setcompliance actions or take enforcement action:

Compliance actions: These are actions a provider must take so that they achievecompliance with the essential standards. We ask them to send us a report that says whatthey will do to make sure they comply. We monitor the implementation of action plans inthese reports and, if necessary, take further action to make sure that essential standardsare met.

Enforcement action: These are actions we take using the criminal and/or civil proceduresin the Health and Social Care Act 2008 and relevant regulations. These enforcementpowers are set out in the law and mean that we can take swift, targeted action whereservices are failing people.


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Information for the reader

Document purpose Review of compliance report

Author Care Quality Commission

Audience The general public

Further copies from 03000 616161 / www.cqc.org.uk

Copyright Copyright (2010) Care Quality Commission(CQC). This publication may be reproduced inwhole or in part, free of charge, in any formator medium provided that it is not used forcommercial gain. This consent is subject tothe material being reproduced accurately andon proviso that it is not used in a derogatorymanner or misleading context. The material

should be acknowledged as CQC copyright,with the title and date of publication of thedocument specified.

Care Quality Commission

Website www.cqc.org.uk

Telephone 03000 616161

Email address [email protected]

Postal address Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

1-125892604 cri crime reduction initiatives 1-230561489 st thomas fund 20120530

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