Inspection on 06/10/04 for 114 Douglas Road

Care Homes For Adults (18 ­ 65)114 Douglas RoadNewcastle under Lyme Staffordshire ST5 9BJAnnounced Inspection6 October 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 16th May 2003 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspection 7th May 2004 no NO 29/06/04 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 36 October 2004 09:30 am Ms Wendy JonesID Code078252Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs Caroline Boughey114 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 26 January 2005 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 comprises 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 an Angel Springs water dispenser, another has a small snooker table. 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.) Eight guests were in residence at the inspection, all were described as having a learning disability, and were described as being of high to medium dependency. two guests required assistance and support with dressing/undressing, mealtimes and toileting. one guest was visually impaired. One social worker questionnaire was returned comments included service user I have placed at the home have enjoyed their stay and have returned for further stays, staff are always friendly, approachable and helpful. Of the our relatives comments cards returned all made favorable comments regarding the service their relative received, one commented they were no aware of the complaints procedure, and that at times staffing shortages had an effect on social activity out of the home. one indicated that they were not informed of inspections. two made complimentary comments about the staffs approach. Of the four guest questionnaires all indicated satisfaction with the service they received Choice of Home (Standards 1­5) 4 of the standards assessed were met, 1 standard was not inspected. Since the last inspection a review of the Statement of Purpose has been completed, Service Users Guides were available in each bedroom, and were discussed with guests. Assessments were completed on all prospective guests prior to admission. The service does accommodate emergency admissions. Individual Needs and Choices (Standards 6­10) All of the 5 standards assessed were met This service provides respite care to at least 130 guests over a 12 month period. It continues to develop appropriate strategies to meet the needs of all its guests. Person centered planning principles have been adopted, care plans and risk assessments were in place and subject to regular reviews. Guests and their representatives were routinely involved in care planning, and consulted about the operation and development of the service. Lifestyle (Standards 11­17) All of the 6 standards assessed were met, 1 standard was not inspected. Guests receive a service that aims to enable them continue a similar lifestyle to the one they were used to. All educational and occupational routines are continued with the service facilitating access. Contacts with families and friends are maintained. It was interesting to note that some guests planned their periods of respite at the same time as friends.Personal and Healthcare Support (Standards 18­21) 114 Douglas Road Page 6 3 of the 3 standards assessed were met, 1 standard was not inspected. The service supports guests to attend health appointments arranged during their period of respite. Records showed that the health needs of guests were being met. Concerns, Complaints and Protection (Standards 22­23) Both of the standards assessed were met Complaints and Vulnerable adults procedures were seen at this visit. Staff were recorded as having VA training. Guests spoken to confirmed they knew what to do and who to go to if they had any concerns. Environment (Standards 24­30) 6 of the 7 standards assessed were met The home provided more than adequate communal space, for the benefit of service users to lounges, to dining rooms with kitchenettes, a games room and a number of smaller areas on the first floor. The standards of décor maintenance and cleanliness were high throughout. Bedrooms were pleasant and appropriately furnished. Bedrooms on the ground floor were used to accommodate those service user with a physical disability, mobility difficulties or who had risk assessments which determined that a ground floor bedroom would be more appropriate. Laundering facilities were extremely spacious, given the size of the home. Staffing (Standards 31­36) 4 of the 5 standards assessed were met, 1 standard was partially met. Staffing levels were satisfactory, with just two staff vacancies reported. Additional staff have been recruited or transferred from other homes since the last inspection resulting in a full management team. Staff training was up to date or planned. Matters arising included the need to ensure staff records contained all items identified in schedule 2 of the Care Homes Regulations 2001. The number of NVQ 2 trained staff was less than a third of the care staff numbers. Conduct and management of the home (Standards 37­43) 5 of the 5 standards assessed were met, 2 standards were not inspected. The management arrangements at the home were satisfactory with a full management team recruited since the last inspection. Policies and procedures were in place as Required in regulation and legislation. Servicing documentation was up to date.114 Douglas RoadPage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY 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 StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)114 Douglas RoadPage 8 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 19, schedule 2, para 7 The registered person must ensure that records listed in schedule 2 are kept in the home for all staff employed at the home. Which demostrate that suitable recruitment practises are achieved to Immediate and ongoing1YA34114 Douglas RoadPage 9 RECOMMENDATIONS 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 4 YA1 YA27 YA36 YA15 Give consideration to the provision of the Service User Guide in a binder that allows guesst more user friendly access. Give consideration to the provision of adapted shower facilities suitable for the needs of service user who have physical disabilities. Ensure that all staff receive 6 supervision sessions per year. Give consideration to the provision of internet access for the benefit of guests who use personal computers.* 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 10.114 Douglas RoadPage 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 Duration of inspection (hrs) YES YES YES YES YES YES YES NA YES NO YES NO YES YES YES YES YES YES YES YES 4 3 X NO NO YES YES 17 X 06/10/04 9.30 8114 Douglas RoadPage 11 The 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. Range of fees charged (per night) From £ 18 To £ 19NO Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? Since the last inspection a review of the Statement of Purpose and the Service User Guide has taken place, and copies provided to the CSCI. Service User guides were in guest bedrooms, one guest requested a copy of the service user guide in a ring binder, she demonstrated that paper became loose from the current type of binder, this matter was discussed with the deputy manager. 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. 3 Key findings/Evidence Standard met? Guests are only admitted to this establishment through the Care Management procedure of the local authority, with input as appropriate from The Care Programme Approach for service users with mental health needs. Full assessments are undertaken prior to any admission, the service does accommodate guests who have been referred in an emergency. In these instances the assessment may not be as comprehensive, but arrangements are in place for the assessment to continue while at the home.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? This standard was not inspected on this occasion.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. 3 Key findings/Evidence Standard met? Introductory visits are facilitated following each referral, these are not time limited and would vary dependent on the needs of the individual. The Statement Of Purpose indicates that emergency admissions can be catered for.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. 3 Key findings/Evidence Standard met? Contracts are agreed between Staffordshire County Council and the service user and their families. Details of the terms and conditions are included in the Service User Guide.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. 3 Key findings/Evidence Standard met? Three guest files were seen to inform this inspection. All had assessments of need, risk assessments, admission details and where possible the guest had been involved with the care planning. There was evidence of guest signatures in some files. The service has adopted the principles of Person Centred Planning that fitted the unique nature of the service. It was reported that 24 hour plans would be developed with all guests. Reviews of care plans were carried out at each admission. Risk assessments were also reviewed at least four times per year. The risk assessments seen were explicit. Key workers were allocated to all guests; a member of the senior management team is usually allocated to new guest or those who have complex needs. All support workers were allocated as link workers. The role of the key worker was defined as co-ordinating reviews, liaison and setting up care packages and arrangements for admission. Three guests were interviewed during this visit, they all knew who their key worker was, two confirmed they knew about their care plans and had been involved in their development.114 Douglas RoadPage 15 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? Guests confirmed that they were involved in daily decision making at each period of respite. A meeting would be convened each week, to discuss the plans for the week, including activities, outings, menu planning, preferred routines.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. 3 Key findings/Evidence Standard met? Four guests were spoken to during this visit, they expressed satisfaction with service. They confirmed that they were included in the day to day running of the home, as much as they wanted to. Due to the unique nature of the service, some guests saw the period of respite as a holiday and expected a hotel type service. Questionnaires were routinely sent out to guests and their families, to establish their views of the service had to encourage suggestions about its future development. 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. 3 Key findings/Evidence Standard met? As discussed earlier in this report all guests files included risk assessments that were explicit and reviewed at least four times per year on average. Additional reviews would be carried out if the risk assessed required it. Risk assessment training had been provided for senior staff. There was evidence of multi disciplinary involvement in some of the risk assessments seen and evidence of close communication with day services for those guests who continued to use that service while receiving respite.114 Douglas RoadPage 16 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. 3 Key findings/Evidence Standard met? A policy relating to confidentiality was provided for inspection purposes, it was understood that all staff sign a statement regarding confidentiality of information. Documents such as care records were appropriately stored. Accident records met the requirements of Data Protection.114 Douglas RoadPage 17 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. 3 Key findings/Evidence Standard met? Guests were encouraged to maintain their independence within the parameters of risk assessment, care planning and accepted good practice.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? As a respite service the guests are supported to continue with their educational, occupational routines. Transport arrangements are organised for each person, and communication between the home and the various centres and placements plays an important part in ensuring a seamless continuity.114 Douglas RoadPage 18 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. 3 Key findings/Evidence Standard met? Most service users were at placements during the main part of the day. On their return to the home, they gave examples of the opportunities they were offered to access the local community, and to maintain contact with community based links. Of the three guests interviewed all had plans for activities outside of the home for that evening, organised or facilitated by the staff.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? The service facilitates guests participation in a range of leisure activities both in and out of the home. A recreation lounge is available, which if fitted with a pool table and has two computer games consoles as well as a music centre. This room was reported to be enjoyed by a number of the younger guests. Board games, videos, DVDs were also available as well as a Karaoke machine, which again was reported to be popular. Outings to cinemas garden centres shops, the theatre, cafes and the pub were arranged by staff following discussion with guest at the weekly meeting. A meal out had been arranged for some guests, staff were supporting a guest to visit his relative and another guest was planning an outing with some friends. 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). 3 Key findings/Evidence Standard met? Records showed that contact with families and friends was maintained as agreed at the time of admission and assessment. Monthly carers meetings were arranged to discuss the service, and plans for future development, ant concerns and how the funds, raised through donations or fund raising events, were to be used for the benefit of all guests. One such meeting took place during the visit. It was useful for the inspector to meet with relatives at such a forum., although attendance was not high. At a previous inspection a recommendation was made to provide computers and internet access for guests to maintain links with their friends outside of the home.114 Douglas RoadPage 19 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? This standard was not inspected on this occasion.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. 4 Key findings/Evidence Standard met? Mealtimes were reported to be flexible, no set times were given for breakfast, staff indicated that it was dependent on what the activities of the service user were.. Lunch time meals were usually served between 12 and 2pm, and the evening meal between 5pm and 6pm. Supper as available to all whenever they required it. two choices of main meal were provided on every occasion. One guest required a special diet at the time of the inspection. A record of meals provided indicated a varied and balanced diet. One guest confirmed that he could choose to eat what he liked.114 Douglas RoadPage 20 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. 3 Key findings/Evidence Standard met? Staff were observed to meet the needs of guests sensitively throughout the inspection. Guest spoken to confirmed that they were treated with respect at all times. Since the last inspection essential works have been carried out to provide bedroom door locks and nurse call systems to the ground floor bedrooms. 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) 3X3 Key findings/Evidence Standard met? 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. Health assessment records were maintained for all service users. Any input individuals have from specialist health services is continued while at the home or at the day services. There was some discussion regarding the future health care needs of a proposed new guest. It was determined that advice had been sought re health and safety matters and that staff training was to be arranged to ensure that the guests needs could be met safely114 Douglas RoadPage 21 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. 3 Key findings/Evidence Standard met? Medication procedures, records, storage were satisfactory, records of medication received and returned to the pharmacy were also fine. None of the guests at the time of the inspection self medicated. A medication reference book was available for staff. 4 of the management team had received certificated medication training in-house. One senior staff had received training in the administration of rectal diazepam, other training was planned, emergency procedures included contacting emergency services, when un trained staff were on duty. 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? This standard was not inspected on this occasion.114 Douglas RoadPage 22 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 X X X X X X X 3 Key findings/Evidence Standard met? A complaints procedure was displayed in the home and was included in the service users guide. Service users spoken indicated that they would feel able to express any concerns to the staff team and management if they needed to. No complaints have been received by the CSCI.114 Douglas RoadPage 23 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? Vulnerable Adults Procedures were in place. It was reported that staff training had been provided by Staffordshire County Councils Vulnerable Adults co-ordinating officer114 Douglas RoadPage 24 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 an extensive programme of works has been on going, with new bedroom door locks, new lounge carpet, a new emergency lighting system, new nurse call system for ground floor bedrooms, new ground floor ceiling, new sockets in toilets, bathrooms, bedrooms. Exposed piping has been boxed in, the laundry door replaced and vanity units fitted in some toilets.114 Douglas RoadPage 25 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 YES NO NO 13 X X X 8 62 1 X X2 Key findings/Evidence Standard met? All bedrooms were for single occupancy. Some rooms were very spacious having previously been doubles, two bedrooms had en-suite bathrooms. A number of bedrooms were smaller that the minimum standards, and in particular bedroom on the ground floor used for person with mobility difficulties.114 Douglas RoadPage 26 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. 3 Key findings/Evidence Standard met? Since the last inspection, as referred to earlier in this report, bedroom door locks and nurse call systems have been fitted to the ground floor bedrooms, for the benefit of guests. Furnishings and fittings appeared to be suitable for the individual needs of guests. The larger ground floor bedrooms had some adaptations for persons with physical disabilities.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? Bathing and toilet facilities were provided in sufficient numbers to meet the needs of service users, since the last inspection a refurbishment pf the first floor bathing and toilet facilities has been completed. During the carers meeting it was suggested that the home would benefit from an adapted ground floor shower room. The possibility of providing this was discussed with the deputy manager.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 comprises two dining rooms with kitchenettes, two sitting rooms, and a separate games and activities room housing a pool table. On the first floor there are three open areas that could be used as communal area, one has two easy chairs and a water dispenser, another has a small snooker table, and the third currently houses a large plant. The communal room designated as the smoking area is on the ground floor.114 Douglas RoadPage 27 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? The home had ramped access from the grounds to the ground floor and the main hallway and corridors were very spacious. Adaptations had been made to bathrooms and toilets on this floor. Access to the first floor was via a main and second stairway.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. 3 Key findings/Evidence Standard met? The home presented as clean and hygienic throughout.. There was no evidence of odours at all. The laundry was spacious and well laid out, allowing for a dirty and clean area, with all the required sluice, washing and drying equipment.114 Douglas RoadPage 28 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? This standard was not inspected on this occasion.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. 3 Key findings/Evidence Standard met? It was reported that a new induction programme was to be piloted, which met TOPSS standards it was understood that it was to be developed further to ensure it met the requirements of the Learning Disability Framework.114 Douglas RoadPage 29 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 Key findings/Evidence 3 5 0 300 5 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 150 150 X 411 Nursing X X XXXStandard met?3114 Douglas RoadPage 30 Staffing levels were arranged on weekly basis, to reflect the occupancy of the home, in total 300 day and care support hours were provided with an additional 111 hours management hours. The levels of NVQ 2 trained staff was low, but six staff were reported to be undertaking the training, one manager was undertaking NVQ level 3, three managers were NVQ assessors, one other manager was to start the training. The deputy manager reported she was undertaking NNEBS management course. It was also reported that on her return the manager of the home would be enrolled for the Registered Care Managers Award. Staffing levels on the day of the inspection were as follows: Deputy manager 8am-6pm. Senior x 1, 7am-3pm x 1, 2.30pm-11pm sleep over. Support worker x 1, 7am-2pm x 1, 3pm-10pm x 1, 7am-10am x 1, 2pm-10pm x 1, 7am-9am x 1, 4pm-10pm A support service administrator was on duty 9am-5pm, and 2 waking night staff were provided from 10pm-7am. Two domestic staff, 1 x 8am-4pm (37hrs per week) and 1 x 9am-12.30pm (15 hrs per week). A handy man was employed to work 20 hours per week, and a cook worked from 1.30pm6pm. 39 hours per week in total, the job was shared between two cooks. Staff vacancies were reported to include 80 hours nights over a four week period, and one full time post on days. 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. 2 Key findings/Evidence Standard met? The service has a robust recruitment procedures in place and operates a n equal opportunities policy. Staff interviews are conducted by two or more staff and a standard format is used with a scoring system. A sample of five staff files were inspected, of the five, four had two written references, one had one. All had copies of contracts of employment, four had CRB checks or had contained evidence that a check had been sent off for, one did not, one did not contain a photograph and three did not contain evidence that a birth certificate, passport or driving licence had been provided to establish evidence of identity. It was reported that there were plans to involve guests with staff recruitment, and new induction programme was to be piloted, the induction will be to TOPSS and LDAF standards, but has yet to be formally accredited.114 Douglas RoadPage 31 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. 3 Key findings/Evidence Standard met? A sample of staff training records were seen and discussed with the deputy manager, food hygiene training was reported to be booked for the following day, Health and safety and COSSH training had been arranged for 09/04. From the records seen 1 staff had yet to receive Health and Safety training and two staff had not received training in relation to Vulnerable adults training. Records of other mandatory and supplementary training were seen showing that training had taken place or was scheduled. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Staff meetings were reported to take place monthly, the last recorded meeting as for 09/04. A record of staff supervision provided for inspection purposes indicated that supervision had taken place, the need to ensure that at least six sessions per year were provided was discussed. The manager, deputy and the support service administrator were all reported to have attended supervision training. It was advised that any of the staff who had delegated responsibility for the supervision of staff should be provided with the training.114 Douglas RoadPage 32 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]. NO3 Key findings/Evidence Standard met? The care manager was on a period of extended leave at the time of the inspection. It was reported that, on her return she would be undertaking the Registered Care Managers Award.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not inspected on this occasion.114 Douglas RoadPage 33 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. 3 Key findings/Evidence Standard met? A monthly report on the conduct of the home is produced by an operational manager. Copies of this report are forwarded to the CSCI. Methods of monitoring the quality of the service were discussed, the service does send out questionnaires to guests, their representatives and sponsors periodically.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? Policies and procedures were listed in the pre inspection questionnaire and were reflective of those required by regulation, it was reported that they were subject to regular reviews.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. 3 Key findings/Evidence Standard met ? The service does not manage money on behalf of guests unless requested by individual guests, relatives or social workers. All service users have some personal allowance at the time of admission, contact would be made with guest before the date of admission if a specific outing or event was planned to ensure they had enough money when they arrived for their period of respite.114 Douglas RoadPage 34 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? Information in the pre inspection questionnaire provided by the service indicated that all maintenance and servicing of equipment in the home was up to date. Samples of documentation were seen and included, service documentation for the thermostatic controls to hot water outlets, 23/09/04, Portable appliance tests, Arjo bath and Gas. Fire drills were recorded regularly for 2004 at various times of day, a fire safety risk assessment had been completed and reviewed annually, weekly fire alarm tests, monthly emergency lighting and fire equipment checks were recorded. The fire safety officer had produced confirmation of fire safety, in a report following the completion of the maintenance work. A certificates for servicing the fire alarm system were dated 12/05/04 and 10/09/04. Other statutory training appeared to be in place. 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 ? This standard was not inspected on this occasion.114 Douglas RoadPage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsCompliance114 Douglas RoadPage 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered 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 6 October 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to inlude provider responses in the published report. In the meantime responses received are available on request.Action taken by the CSCI in response to provider comments: 114 Douglas Road Page 37 Amendments to the report were necessaryNOComments 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. 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 38 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 39 114 Douglas Road / 6 October 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000028866.V162135.R01© This report may only be used in its entirety. 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