Inspection on 29/06/04 for 114 Douglas Road

Care Homes For Adults (18 ­ 65)114 Douglas RoadNewcastle under Lyme Staffordshire ST5 9BJUnannounced Inspection29 June 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment 114 Douglas Road Address Newcastle under Lyme, Staffordshire, ST5 9BJ Email address Tel No: 01782 711041 Fax No:Name of registered provider(s)/company (if applicable) Staffordshire County Council Name of registered manager (if applicable) Mrs Caroline Brenner Type of registration Care Home No. of places registered (if applicable) 13Category(ies) of registration, with (number of places) Dementia (3), Dementia - over 65 years of age (3), Learning disability (13), Learning disability over 65 years of age (6), Mental disorder, excluding learning disability or dementia (3), Physical disability (4) Registration number E090000433 Date first registered Date of latest registration certificate 16 May 2003 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspection 7 May 2004 no YES 25/02/04 If Yes refer to Part C114 Douglas RoadPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 329 June 2004 11am Ms Wendy JonesID Code078252Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionDenis Curry114 Douglas RoadPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers Agreement Wendy Jones Darryl Davies 6 September 2004 Signature Wendy Jones Signature Signature Darryl DaviesLead Inspector Second Inspector Locality Manager DatePublic reports It should be noted that all CSCI inspection reports are public documents.114 Douglas RoadPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of 114 Douglas Road. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.114 Douglas RoadPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 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 double-bedded 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. 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 comprised, two dining rooms with kitchenettes, two sitting rooms, and a separate games and activities room housing a pool table. A quiet room is also available, whilst upstairs there are three open areas that can be used communally, one has two easy chairs and a water dispenser, another has a small snooker table, a third is not furnished. The communal room designated as the smoking area is on the ground floor.114 Douglas RoadPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Information for this inspection was provided from discussion with staff, a guest and management; from inspection of the physical environment, care records, and other documentation pertinent to the inspection process. At the time of this visit the home was providing accommodation for 9 guests. Work men were undertaken planned work to improve the physical environment and to address issues identified at previous inspections. Choice of Home (Standards 1­5) The 1 standard assessed was partially met The home has produced a Statement of Purpose, and a service user guide. The service must ensure bedroom sizes are included in the Statement of Purpose, and a copy of the updated version supplied to the Commission. The service user guide should be reviewed to ensure that it is up to date, and further efforts should be made to ensure that guests are introduced to the service users guide. Individual Needs and Choices (Standards 6­10) 1 of the 3 standards assessed was fully met. Those care plans seen, had been developed taking into account the changing principles associated with learning disability services. One care assessment indicated that a guest exhibited difficult to manage behaviour at times, the homes admission records, indicated that this guest exhibited Challenging Behaviour, but no risk assessment was evident. Lifestyle (Standards 11­17) All of the 3 standards assessed were met Guests continue to attend work placements, day services etc while staying at Douglas Road for their period of respite.. Activities available to guests included, social outings, shopping trips, pub meals, video nights, the games room provided guests with opportunities to play pool, have fun on computer games, relax listening to music. Menu planning and food choice was satisfactory.Personal and Healthcare Support (Standards 18­21) 114 Douglas RoadPage 6 The one standard assessed was met The health care arrangements in the home satisfactorily met the needs of guests. Concerns, Complaints and Protection (Standards 22­23) Both of the 2 standards assessed were met Complaints procedures were available to service users, the service also has procedures in place for staff to follow is abuse is suspected. Environment (Standards 24­30) 5 of the 7 standards assessed were met or exceeded. Measurement of bedrooms indicated a number below the minimum standards expected for single bedrooms and those allocated for wheelchair users. Bedrooms had door locks fitted, further consideration should be given to supporting clients to have keys to their bedroom doors and bedside cabinets. Work to further improve the physical environment and to address outstanding issues from previous inspections was being undertaken at the time of the inspection. Staffing (Standards 31­36) All of the three standards assessed was met Staffing levels were adequate for the number and dependency of guests. Recruitment practice was satisfactory. It was recommended that a regular pattern of staff supervision is established. Conduct and management of the home (Standards 37­43) of the standards assessed were met Staff, guests and carers meetings were held regularly. Records relating to fire and health and safety were satisfactorily maintained. It was recommended that the person in charge is involved in a fire drill.114 Douglas RoadPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 3 4 5 6 YA4 YA29 YA25 Devise a policy on the use of alcohol and substances by users, visitors, and staff. Communication facilities for service users should be regularly reviewed and upgraded to keep up with advances in the technology. Room sizes must conform with national minimum standards for the category of service user being accommodated. Consider the provision of keys to bedroom locks when fitted and provide a front door key to guests where assessed as being appropriate. Consider publishing the results of service user surveys when in use. Consider devising a policy on smoking, use of alcohol and substances by users, visitors and staff.114 Douglas RoadPage 8 CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)114 Douglas RoadPage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 4 schedule 1 YA1 Provide a copy of a completed statement of purpose to the commission. Review the Service users guide to ensure it contains relevant information of the staff team, contains service users views, up to date inspection comments. Supply details of relevant insurance cover for the home. 28/07/0426YA128/08/04317YA4129/07/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 3 YA1 YA6, YA36 Make further efforts to ensure that guests are familiar with the purpose and contents of the Service User Guide. Ensure that where identified needs of guests could present a potential risk that risk assessments are carried out. Establish a regular pattern of staff supervision.114 Douglas RoadPage 10 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection 114 Douglas Road YES YES NA YES YES YES NO NA YES NO YES NO YES YES NA NA NA YES YES YES 1 X X NO NO YES YES 22 X 29/06/04 11AM Page 11 Duration of inspection (hrs)3.15The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.114 Douglas RoadPage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 2 Key findings/Evidence Standard met? The home has produced a Statement of Purpose, and a Service user guide. The main elements required were included in the Statement of Purpose, bedroom sizes must be included. The service user guide information regarding staffing was not up to date, the information regarding Inspection noted to be in the bedside cabinet of all bedrooms seen. Some of the information regarding the inspections of the home did was not up to date, and the service user interviewed did not know what the document was. The Service User Guide should be reviewed to ensure that it is up to date, and further efforts should be made to ensure that service users are introduced to the service users guide.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met?114 Douglas RoadPage 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met?Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met?Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met?114 Douglas RoadPage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? Those service user plans seen, had been developed taking into account the changing principles associated with learning disability services. There was evidence that service users and relatives or carers had been involved with providing information from which care plans had been developed and a program of how these needs were to be met. At each period of respite care, an admissions sheet is completed, any changes to the care needs of the guest are recorded. One care assessment indicated that a service user exhibited difficult to manage behaviour at times, the homes admission records, indicated that this guest exhibited Challenging Behaviour, but no risk assessment was evident, this was discussed with the senior staff in charge. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The format used by the home to assess service users needs, is based upon Valued Lifestyles, and accepted principles of Learning Disability services. The evidence from the guest spoken to indicated that guests were encouraged to make their own decisions and choices.114 Douglas RoadPage 15 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met?Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? General and individual risk assessments were in evidence from the sample of records seen with the exception of an assessment discussed in standard 6 of this report.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met?114 Douglas RoadPage 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met?Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Guests continue to attend work placements, day services etc while staying at Douglas Road for their period of respite. On the day of the inspection, 6 guests were at day services, 1 was spending the day at a specialist rural centre, 1 guest had been taken for a trip to the shops in town, and one service users had chosen to go out for a walk.114 Douglas RoadPage 17 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met?Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Leisure activities currently engaged in by service users at the home include social outings, shopping trips, pub meals, video nights, the games room provided guests with opportunities to play pool, have fun on computer games, relax listening to music.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met?Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met?114 Douglas RoadPage 18 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Food stores were satisfactory, records of fridge freezer temperatures appropriately maintained, hot food temperature records were not evident after the 25 June 2004. Menus seen offered a choice of hot meal of snack type meal, most guests who attended day services had meals provided there, records of the day service menus were seen in the kitchen. Guests known dietary preferences were recorded in care records and copied in the kitchen. Two service users who did not have work placement or day service to attend chose sandwiches for their lunch during this visit, preferring their main meal in the evening.114 Douglas RoadPage 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met?Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) XX3 Key findings/Evidence Standard met? It was understood, that except in cases of emergency, service users would continue with whatever regime of health care, and health related appointments that had been arranged in the community. In an emergency the homes procedure requires that the emergency services are contacted or advice sought from a doctors co-operative service if a health issue occurs after the normal surgery hours.114 Douglas RoadPage 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met?Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met?114 Douglas RoadPage 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 3 Key findings/Evidence Standard met? The complaints procedure was displayed in the home and included in the service users guide, no complaints have been made to the Commission relating to this service. One guest spoken to during this unannounced inspection visit was highly satisfied by the service she received, and felt confident that if she had any concerns she could address them with the staff and management of the home. She was particularly complimentary about her allocated support worker.114 Douglas RoadPage 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? This standard was not inspected in detail, the service has appropriate procedures in place, and the evidence from previous inspections indicated that staff had received training and guidance, in the recognition of and indicators of abuse.114 Douglas RoadPage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Since the last inspection work has commenced at the home to address some environmental issues, a full schedule of works included, replacement of light switches near wash basins in bedrooms, provision of additional electrical and arial points, boxing in of pipe work, improvement of in the first floor bathrooms, new ceiling on the ground floor corridor, new laundry door, fitting of bedroom door locks, replacement of corridor lighting, essential additional fire precaution work, provision of a loop system. Due to the amount of work required the contractors had been allocated an office and work shop space in the south side dining room, as a temporary measure the south side lounge had been changed into a lounge dining room. Risk assessments had been completed and discussed at staff meetings.114 Douglas RoadPage 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO YES NO 12 X 1 1 8 41 3 X 12 Key findings/Evidence Standard met? A sample of bedroom sizes were measured during this visit, the smallest measured 9.1sq metres, there were four bedrooms under or equivalent to the minimum required size of 9.3 sq metres,.four rooms on the first floor, exceeded the minimum requirements for single bedrooms. Two bedrooms on the first floor had double bed, but did not met the spatial requirements for double bedrooms. Bedrooms on the ground floor, nominated for persons with physical disabilities or who have mobility difficulties or are wheelchair dependent, measured 10.18, 10 28, 10.15 and 14.99 sq metres. Only one met the standard for persons who are wheelchair dependent.114 Douglas RoadPage 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 2 Key findings/Evidence Standard met? In the bedrooms seen all had wardrobes, chests of drawers, bedside cabinet with lockable facility, a bed, and a chair. In each guests care records it was evident that guests were asked what furniture they would like in their bedroom, a note of their stated preference was noted. Since the last inspection all bedrooms have been fitted with door locks, that can be overridden by staff in the event of an emergency. One guest spoken to had not got a bedroom door key she was not aware that she could have one, in addition the bedside lockable cabinet was locked but she had not been given a key. This issue was discussed with staff and the senior in charge. The impression of the inspector was that staff expect the guests to request keys, it was recommended that all guests are given the choice, of a bedroom door key, and a cabinet key at the time of admission, or during the pre admission discussion. Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The service provides two unassisted bathrooms on the first floor, two single toilets, and two bedrooms have en-suite bathrooms, with WCs, on the ground floor, a large assisted bathroom, with specialist equipment available to service users, and two single wcs with adaptations. Contractors were working in the ground floor bathing and toilet areas during the inspection, the schedule of work seen indicated that work was to be undertaken on the first floor bathrooms, which were showing signs of wear and tear.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 4 Key findings/Evidence Standard met? Communal space on the ground floor comprised two dining rooms with kitchenettes. One dining room as previously mentioned was being used as an office base and workshop for the contractors. One of the two sitting rooms had been converted temporarily into a lounge diner, a separate games and activities room housing a pool table was also available. On the first floor there were three open areas that can be used communally.114 Douglas RoadPage 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? Environmental adaptations appeared to be adequate for the needs of the guests at the time of the inspection.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 4 Key findings/Evidence Standard met? The home presented as clean and hygienic. There was no evidence of odours at all. The laundry was spacious, well laid out and managed, with all the required sluice and washing and drying equipment. A recommendation of the last inspection asked that COSHH information should be maintained where the substances are stored this had been addressed.114 Douglas RoadPage 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met?Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met?114 Douglas RoadPage 28 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 2 2 5 293 X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X 315 Nursing X X XXX3 Key findings/Evidence Standard met? Staffing levels on the day of this unannounced inspection were: 1 senior support worker, 7am-3pm, 1 care worker, 9am-3pm, 1xsenior support 2.30pm-11pm sleep over, 1x care worker, 3pm-9pm, 3pm-10pm and 4pm-10pm. One administrator, 9am1.30pm, 1x domestic 9am-2pm, cook 2pm-6pm and maintenance person 9am-4.30pm. Two waking night staff were deployed from, 9.30pm-7.30am. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The inspector discussed recruitment the person in charge who had been at the home for three weeks and confirmed that all procedures had been adhered to in relation to his recruitment.114 Douglas RoadPage 29 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met?Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 2 Key findings/Evidence Standard met? Systems for the supervision of staff had been started, the record showed that in June 4 staff had received an individual supervision. It is hoped that by the next inspection a regular pattern of supervision will be evident.114 Douglas RoadPage 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO0 Key findings/Evidence Standard met? The care manager was on annual leave. The inspector agreed to discuss this matter at a later date with the manager,Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Staff meetings were recorded for 18 June, 20 May, 4 May, 22 April and 25 April. Guest meetings held every Monday for the service users, and once a month carers and supporters of the service users were invited to meet, have a coffee and to be informed of the latest events or plans for the home.114 Douglas RoadPage 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met?Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The policies and procedures of the home are those of the local authority, and have been developed over many years to meet the national minimum standards required under regulation. A sample of these policies and procedures were inspected.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met ? The certificate of insurance displayed in the home was out of date, the service must provide evidence of adequate and up to date insurance for the home.114 Douglas RoadPage 32 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Fire drills were recorded very frequently, and included night staff. The senior in charge as previously explained had worked at the home since the 7th June, and although his induction had included fire procedures, and orientation he had not been involved with a drill. Given the level of responsibility he had it is recommended that he is involved in a fire drill. Fire training records did not appear to have been recorded for 2004, records of weekly fire checks were recorded up to 27 May 2004, since that time because of the building works on going in the home, the inspector was told that the supply to the alarms had been interrupted at times, making adequate checks difficult. It was suggested that records should reflect these circumstances. Other checks and servicing records were up to date. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Not inspected.114 Douglas RoadPage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsCompliancePART D114 Douglas RoadPROVIDERS RESPONSE TO IDENTIFIEDPage 34 STATUTORY REQUIREMENTSD.1 Registered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 29 June 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible A copy of the Providers comments and action plan are available at the Area Office, where these have been submitted.Action taken by the CSCI in response to provider comments: Amendments to the report were necessary 114 Douglas Road NO Page 35 Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 5 August 2004 , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here 114 Douglas RoadPage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.114 Douglas RoadPage 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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