Inspection on 24/08/06 for 114 Douglas Road

This inspection was carried out on 24th August 2006.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

114 Douglas Road 25/03/09

114 Douglas Road 18/02/08

114 Douglas Road 09/11/05

114 Douglas Road 13/07/05

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 Key Unannounced Inspection 24 August 2006 09:00 114 Douglas Road DS0000028866.V305139.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 114 Douglas Road DS0000028866.V305139.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. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 114 Douglas Road Address Newcastle under Lyme Staffordshire ST5 9BJ 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) 01782 711041 Staffordshire County Council, Social Care and Health Directorate Mrs Caroline Brenner Care Home 13 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (3), Learning disability (13), Learning disability of places over 65 years of age (6), Mental disorder, excluding learning disability or dementia (3), Physical disability (4) 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 learning disability 16-18 yrs on admission Date of last inspection 9th November 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. The service user charges are £19.21 per night. 114 Douglas Road DS0000028866.V305139.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 inspection, which took place on a Thursday afternoon from 1.30pm to 7.30pm. Before the inspection the Commission for Social Care inspection (CSCI) sent out questionnaires to the manager, service users and relatives. The manager and five service users completed and returned the questionnaires prior to the inspection. The views received are reflected in the report. During this time four guests, two care managers, one support worker, and the acting manager were spoken with. Three guests files were inspected as were training records and other documentation related to health and safety and management of the home. What the service does well: What has improved since the last inspection? There were no identified areas for improvement at the last inspection. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 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 DS0000028866.V305139.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 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home has clear assessments of guests’ needs, which enables the staff to support them appropriately. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Three guests’ care files were inspected as part of the case tracking process. Comprehensive care management assessment documentation was in place for all service users. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Guests are able to make decisions about their lives and the assistance they need whilst having a short stay at Douglas Road. Quality in this area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was evidence in the three files examined that guests have a care plan which covers aspects of personal and social support and healthcare needs. The assistant manager stated that the plans are updated at each visit and all changes to care needs are recorded. Examination of care plans confirmed this. There was also information regarding risk both in the form of a risk assessment and also recorded within the care management assessment document. It was noted that one risk assessment whilst clearly identifying risk was not robust in relation to the management strategy to manage the risk. The need to review risk assessments to ensure management strategies are in place was discussed with the temporary manager. Five guests completed, or were assisted to complete Commission for Social Care Inspection (CSCI) surveys. Three surveys stated that they were always 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 10 able to make decisions at Douglas Road and two guests said they were sometimes consulted. Four guests were spoken with. The views expressed about decision making were positive. One guest said ‘staff ask what I think’. It was observed that guests are free to spend time in private or to spend time with other guests. The space within the home facilitates this choice. There is a small kitchenette area where guests, who are able, can make snacks and drinks. Staff were observed talking with guests about their day and to establish their views. It was noted that guests participate in a guests meeting every Monday evening. The minutes of these meetings confirm that guests are asked to express opinions about the menu and the following weeks activities. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 16 & 17 Service user’s education and dietary needs are met during their short stay visits, however the social and community needs of a number of guests are not being met. Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service EVIDENCE: Guests who receive short stays at Douglas Road generally continue with their education and occupation arrangements during this period. At the time of the inspection guests confirmed that they had spent most of the day at their particular day services or training placement. As the home is a short stay provision there is not always contact with or by the relatives of guests during their short stay. However, staff demonstrated a good understanding of the family networks of the guests and care files indicated that there is regular contact and exchanges of information. One relative completed a CSCI survey, which stated that they are made to feel welcome at Douglas 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 12 Road. The assistant manager stated that Douglas Road also has regular carers meetings. Five guests completed CSCI surveys. One guest survey raised some concerns about the lack of activities within the local community. The reports sheets for three guests were examined to see what outings or activities had taken place during this visit and three previous visits. There was only one entry of an outing recorded in one service user’s notes. This outing had been to the local supermarket. Four guests were spoken with. One guest said that she had been to a local supermarket during her stay. The other guests spoken with had not been out. The guests said that they cannot go out if there are not enough staff to go with them. It was also noted that in the guests meeting minutes that each week guests request to do things in the local community such as a trip to the pub, go shopping etc. However staff spoken with stated that these requests are often not met because of staffing numbers. This issue was discussed with the temporary manager. Dependency levels and staffing numbers must be reviewed to ensure that service users do have access to the local community. Meals were discussed with guests. One guest said that a choice of food is available. Another said ‘the dinners are lovely’. One guest spoke about how he is able to make his own breakfast, supper and drinks in the guest’s kitchenette. The guests were asked if they were aware of that evenings meal. The guests spoken with were unaware of what was on the menu for that evening. It was noted that there was a written menu attached to a notice board in the kitchenette. It is recommended that Douglas Road review the way in which guests are made aware of daily menus. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users receive personal support in the way that they prefer and require and their medication needs are met by appropriately trained staff. Quality in this area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Guests records demonstrate that the staff are very thorough in eliciting information from guests, relatives and professionals about personal support needs. Feedback from a relatives during this inspection confirmed that there is good liaison between staff and relatives, particularly in respect of guests who have limited communication, about preferred routines or methods of support. Five guests completed CSCI questionnaires all the views expressed about staff support were complimentary and positive. Four guests were spoken with about the support they receive the guests felt that the staff supported them appropriately. The staff demonstrated a good understand of each guest’s needs and were aware of how to seek additional help if needed. Healthcare needs were recorded. However as this is a short stay facility the carers generally meet the healthcare needs of the guests. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 14 Medication systems were examined. Medication is stored in a metal wall mounted cabinet, which is locked at all times with only senior staff having access to theses keys. A senior support worker explained the protocol within the home for accepting guest’s medication on admission. Two guest’s medication and accompanying medication administration records were checked and found to be in order. The senior support worker stated that all staff who administer medication have been trained. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has appropriate systems in place for dealing with complaints and safeguarding adults. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Douglas Road is managed by Staffordshire County Council Social Care and Health Directorate who have robust vulnerable adult and safeguarding procedures in place. The assistant manager stated that there has been no adult protection referrals made since the last inspection. One senior support worker and one support worker were spoken with about their training. Both staff stated that they had received vulnerable adults training. Three staff files were also looked at which also confirmed that staff training in safeguarding has taken place. The guests spoken with stated that they feel safe at Douglas Road. The home has a complaints procedure. The pre inspection questionnaire completed by an assistant manager stated that there have been no complaints made in the last 12 months. Five guests completed CSCI surveys all stated that they or their carers were aware of the complaints procedure and how to complain. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The standard of the environment within this home is good, providing service users with a clean, safe, attractive and homely place to live. Quality in this area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home, although purpose-built, has been suitably decorated and furnished to present as ‘homely’. All of the bedrooms, although not personalised because this is a respite facility, were decorated and furnished to a high standard. There is a pleasant enclosed back garden with seating areas for guests and staff. The home was well maintained and clean. The feedback from guests’ surveys was positive in relation to the cleanliness of the home. One survey stated that ‘the cleanliness at Douglas Road cannot be faulted. I am very impressed’. The rotas indicate that there are three part time domestic staff. These staff members are responsible for general cleaning and hygiene within the home. There is a separate laundry area, which is situated off the ground floor corridor. A member of staff said that the domestic staff do the bulk of the laundry but that all care staff help as and when required. Guests are 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 17 encouraged to take their laundry to the laundry area, however some guests need support with this task. Appropriate gloves, hand wash and aprons were in place. The staff member spoken with demonstrated a good understanding of the issues of cross contamination and infection control. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Douglas Road has an appropriately vetted, trained, supervised and competent staff team who are able to meet service users needs. Quality in this area is good. This judgement has been made using available evidence including a visit to this service EVIDENCE: Records within the home indicate that there is a positive emphasis amongst the staff group on training and development. Two members of staff were spoken with about their training needs both staff members felt that they received appropriate training. Three staff files were examined. There was evidence that training certificates were in place for some courses. However, the staff files that were examined were disorganised and the information was not easily accessible. It is recommended that the structure of staff files be reviewed. It was noted that staff would benefit from dementia training to meet service user’s changing needs. This was discussed with the temporary manager at the time of the inspection. It is strongly recommended that all staff receive dementia awareness training. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 19 The pre inspection questionnaire completed by an assistant manager states that more than 50 of the care staff have achieved NVQ2. This exceeds the guidance set out in the National Minimum Standards. Staff records revealed that a comprehensive induction system is in place for new starters. It was also noted that there is a further induction system in place for care workers who are promoted to the next level of responsibility. This is good practice. Discussions with staff members confirmed that regular staff meetings and staff supervision takes place. This was also evidenced in staff meeting minutes and supervision records. Three staff files were looked at to examine the home’s recruitment and vetting processes. The staffing files were not ordered and recruitment and vetting information was not easily accessible. It is recommended that the filing system be reviewed to aid ease of reference. All files contained the correct information in relation to safe recruitment and selection. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Service users who have a short stay at Douglas Road benefit from a well run home with effective systems. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: At the time of the inspection another registered manager from a Staffordshire County Council care home was managing Douglas Road. This is a temporary arrangement to cover whilst the registered manager is on sick leave. The temporary manager has many years experience having worked in the care sector since 1991. She also has seven years experience of managing learning disability care homes. The staff stated that the management style within the home was inclusive and that the manager had an ‘open door’ style and was very approachable. Quality assurance was discussed with the temporary manager and whilst it was evident that there are quality assurance systems in place, which include 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 21 internal quality audits and service user interviews, it was not clear how the results feedback into future changes to the service via the annual development plan. It is recommended that quality assurance be reviewed to ensure that the views of guests are included in changes to the service. The fire records indicate that service user’s health and safety is protected by satisfactory fire drills. There was an up-to-date fire risk assessment. Gas and electricity supplies had been serviced. The home has an appropriate number of first aid boxes. The temporary manager confirmed that there is always a staff member on shift who is qualified in first aid. The home employs a part time handyman who is responsible for fire system checks and for ensuring the water temperature is within safety limits. There was also evidence that hoisting equipment is regularly serviced. The home had up to date insurance cover. 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x 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 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 2 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 114 Douglas Road DS0000028866.V305139.R01.S.doc Version 5.2 Page 23 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 2 Standard YA9 YA13 Regulation 13(4)© 12(3) Requirement Risk assessments must have clear and robust management of risk strategies to guide staff. Dependency levels and staffing numbers must be reviewed to ensure that service users do have access to the local community. Timescale for action 15/09/06 30/09/06 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 YA35 YA39 YA17 YA34 Good Practice Recommendations It is strongly recommended that all staff receive dementia awareness training. Quality assurance systems should be reviewed to ensure that guests’ views influence future development plans for the home. The home should consider reviewing the way in which guest’s are made aware of daily menus The staff files should be ordered and structured to ensure information is easily accessible. DS0000028866.V305139.R01.S.doc Version 5.2 Page 24 114 Douglas Road Commission for Social Care Inspection Stafford Office 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 DS0000028866.V305139.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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