Inspection on 13/07/05 for 114 Douglas Road

This inspection was carried out on 13th July 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

114 Douglas Road 25/03/09

114 Douglas Road 18/02/08

114 Douglas Road 24/08/06

114 Douglas Road 09/11/05

114 Douglas Road 06/10/04

114 Douglas Road 29/06/04

114 Douglas Road 25/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 114 Douglas Road Newcastle under Lyme Staffordshire ST5 9BJ Lead Inspector Wendy Snell Announced 13 July 2005 9:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 114 Douglas Road Address Newcastle under Lyme Staffordshire ST5 9BJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01782 711041 Staffordshire County Council, Social Care and Health Directorate Mrs Caroline Brenner CRH 13 Category(ies) of DE 3 registration, with number DE(E) 3 of places LD 13 LD(E) 6 MD 3 PD 4 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) 1 Learning disability 16-18yrs on admission. Date of last inspection 20th January 2005 Brief Description of the Service: The home in Douglas Road is a purpose built local authority respite care unit catering for up to 13 persons, originally only younger adults with a learning disability, but now the categories have been extended to also cater for both younger and older adults with Dementia, and younger adults with both Mental Health problems, and Physical Disabilities. It offers short stay respite accommodation to both male and female service users, and can accommodate couples in either of its upstairs rooms with double beds, or two who wish to share in a room that can have a second single bed installed. Like the doublebedded rooms this is upstairs, so like them would only be available to service users who can manage climbing stairs, as currently there is no passenger lift. The four ground floor bedrooms have been adapted to take wheelchair users.The home is conveniently situated to access a wide variety of community facilities, with the town of Newcastle approximately one mile away. A supermarket is within walking distance. It is located in its own extensive grounds with a safe bounded rear garden containing a patio and a fountain.Communal space on the ground floor comprises two dining rooms with kitchenettes, two sitting rooms, and a separate games and activities room housing a pool table. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on a Wednesday over six and a half hours. During the first half of the day the guests at Douglas Road were out at work and at day services. The inspector checked 3 guests care files and inspected paper work and spoke with staff during this time returning to the home later to speak with the guests. Three guests were spoken with, two were spoken with briefly and another one was very helpful and spoke in depth about the service at Douglas Road. What the service does well: What has improved since the last inspection? The manager has made sure that information about the recruitment of staff is stored in the home. The service user guide has also been reviewed to make it easier to use and the shower facilities have been adapted for easier use by guests with physical disabilities. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 6 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. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The home has clear assessments of service users’, which enable staff to support them appropriately. EVIDENCE: Guests are only admitted to this establishment through the Care Management procedure of the local authority. There were six guests having respite at the time of the inspection. Random samples of three care files were inspected. Assessment documentation was in place in all three files. One guest had been an emergency admission. The assessment documentation for this person was not completed on admission but had been completed within the last 9 months. The manager stated that the guest’s assessed needs had not changed during this time. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 Care planning is satisfactory however, the proposed changes will enhance this system further to clearly provide staff with the information they need to meet service user’s needs. Service users are supported to take responsible risks with the appropriate risk management strategies being in place. EVIDENCE: A sample of three guest’s files were inspected. As well as the care management assessment, information is also gathered from the carers and guest prior to their stay at Douglas Road. There was a range of useful information, which outlined each guest’s care needs. The wealth of information, however, did mean that it in some cases it was not always clear to see at a glance what the support needs of the guest’s were and the tasks that needed to be carried out by staff. It was also not clear how the support needs were reviewed after each stay. This was discussed with the manager and care manager. The care manager provided evidence that a new care planning system is in the process of being implemented which will both identify care needs and how they those needs are to be met by staff. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 10 All service users have a key and a link worker both members of staff are responsible for the admission and support of individual guests. A range of risk assessments were in place, which detailed how identified responsible risks are managed. There was evidence that staff had signed these documents when read. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 17 Service users are supported to take part in a variety of education and work activities. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: This is a respite facility and therefore guests who use this service are generally already engaged with education and work prior to their visits to Douglas Road. The staff spoken with demonstrated a good understanding of the activities or work their guests were involved in. One guest had spent the day working at a charity shop in town where he said he had ‘worked for quite a while’ and the other guests had been to their allocated day services. The manager and a staff member stated that they work closely with day services with the communication between the two services being generally good. There was evidence that guests staying at Douglas Road access local facilities such as local shops, supermarket and pubs. One guest demonstrated a good understanding of the local community and it’s facilities regularly catching the bus into Newcastle and ‘having a cup of tea’ in the local supermarket. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 12 Two cooks were spoken with both of whom demonstrated a good understanding of the needs of guests staying at Douglas Road. A system was in place which highlighted special dietary needs for each guest. The cooks stated that there is a choice of food for breakfast and supper, which guests can either prepare independently or with the support of staff. The cooks prepare hot meals at teatime after the guests have returned from work or day services as well as at the weekends. A guest said that he ‘makes tea and toast in the mornings and can help himself to food’ at other times. He said that the meals were good and that he had tried different foods since being at Douglas Road. In the kitchen there were good food management systems in place with the appropriate checks being carried out. The cupboards, fridge and freezers were well stocked with a good stock taking system in place. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 The health and medication needs of service users are well met with evidence of good communication with carers taking place on a regular basis. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 14 EVIDENCE: Service users retain their own G.P throughout the period on respite unless they are out of area; in these cases the local PCT allocates a G.P, if necessary. Three service user files were inspected and appropriate health information was in place. The manager stated that if guests have health appointments whilst having respite discussions take place with the guest and their carers as to who will support them for the appointment. Any input individuals have from specialist health services is continued while at the home or at the day services. Medication systems were checked. The medication is stored appropriately in a locked cabinet with senior staff being responsible for administration. Staff had either completed or were in the process of completing appropriate training. PRN protocols were in place for staff guidance as was a file, which contained information about possible side effects of medication stored within the home. The arrangement for accepting medication into the home from carers was discussed with the manager. It is recommended that all medication coming into the home is counted and recorded on admission. The manager should also consider seeking advice from a pharmacist regarding medicine storage and administration systems. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The home has a satisfactory complaints system and there is evidence that service users feel that their views are listened to and acted upon. EVIDENCE: Information about how and who to complain to was clearly available on a notice board in a communal dining area. The home has clear policies in place and staff demonstrated an awareness of what to do on receiving a complaint. A complaints and compliments book was in place, which showed that appropriate action was taken by staff on receiving a complaint. A service user said that he was aware that he could complain and who he could complain to. CSCI are not aware of any outstanding complaints about this home. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: An extensive programme of works has taken place and with parts of the home now offering a well-decorated and ‘homely’ environment for guests receiving respite. Rooms on the ground floor are accessible to people with physical disabilities. Douglas Road does not have a lift and therefore the first floor accommodation is inaccessible for guests unable to climb the stairs. There are adequate bathing and toilet facilities with the appropriate aids and adaptations being in place. The home, although purpose built does not look out of place within the local community and as such does not present as a care setting. A large lawned area surrounds the property with a furnished patio area at the rear of the building. The home is situated close to a local supermarket and within walking distance of a bus stop. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) This standard was not inspected at this visit, however there were more than adequate staffing on shift at the time of the visit. EVIDENCE: 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Although safe working practices are in place within this home the scheduling of service and inspection of utilities must be improved to safeguard both service users and staff. EVIDENCE: Staff spoken with stated that they had received core training in areas such as manual handling, food hygiene and fire safety. Appropriate service records were in place for hoists although gas service records indicated that a gas safety check had not been carried out since the 23/5/00 with this document there was a memo from Staffordshire County Council Property and Estates department stating that gas checks are to be carried out every five years. Gas safety regulations 1998 state that gas appliances, pipe work and flues in care homes are checked at least once a year. An electrical systems check had been carried out within the allowed time frame; however, this certificate stated that the results of the inspection had been unsatisfactory. At the time of writing this report the manager is in the process of seeking clarification from the Property and Estates department that this work was completed. Gas and electricity 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 19 maintenance must be addressed to ensure the safety of service users and staff. Fire records were checked which indicated that appropriate fire checks and drills take place. A member of staff confirmed that she had taken part in a fire drill and was knowledgeable about the fire procedures. Appropriate accident recording was in place. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x x x 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 114 Douglas Road Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 21 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 42 Regulation 23(2c) Requirement A gas appliance and systems check must be carried out afterwhich a check must be made annually. The manager must provide clarification that the works outlined on the last electricity check have been completed and the electrical systems are satisfactory. Timescale for action Immediate 2. 42 23(2c) Immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 20 20 Good Practice Recommendations All medication handed to staff should be counted and recorded on admission Advise from a pharmacist should be sought regarding medication systems. 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 114 Douglas Road E51-E09 s.28866 Douglas Road AI 13.07.05 v.237087 Stage 4.doc Version 1.40 Page 23 - 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. 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