Inspection on 09/11/05 for 114 Douglas Road

This inspection was carried out on 9th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

114 Douglas Road 25/03/09

114 Douglas Road 18/02/08

114 Douglas Road 24/08/06

114 Douglas Road 13/07/05

114 Douglas Road 06/10/04

114 Douglas Road 29/06/04

114 Douglas Road 25/02/04

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Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 114 Douglas Road Newcastle under Lyme Staffordshire ST5 9BJ Lead Inspector Wendy Snell Unannounced Inspection 9 November 2005 13:00 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 114 Douglas Road Address Newcastle under Lyme Staffordshire ST5 9BJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01782 711041 Staffordshire County Council, Social Care and Health Directorate Mrs Caroline Brenner Care Home 13 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (3), Learning disability (13), Learning disability of places over 65 years of age (6), Mental disorder, excluding learning disability or dementia (3), Physical disability (4) 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 learning disability 16-18 yrs on admission Date of last inspection Brief Description of the Service: The home in Douglas Road is a purpose built local authority respite care unit catering for up to 13 persons, originally only younger adults with a learning disability, but now the categories have been extended to also cater for both younger and older adults with Dementia, and younger adults with both Mental Health problems, and Physical Disabilities. It offers short stay respite accommodation to both male and female service users, and can accommodate couples in either of its upstairs rooms with double beds, or two who wish to share in a room that can have a second single bed installed. Like the doublebedded rooms this is upstairs, so like them would only be available to service users who can manage climbing stairs, as currently there is no passenger lift. The four ground floor bedrooms have been adapted to take wheelchair users. The home is conveniently situated to access a wide variety of community facilities, with the town of Newcastle approximately one mile away. A supermarket is within walking distance. It is located in its own extensive grounds with a safe bounded rear garden containing a patio and a fountain. Communal space on the ground floor comprises two dining rooms with kitchenettes, two sitting rooms, and a separate games and activities room housing a pool table. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on a Wednesday afternoon over a period of four hours. During this time three guests, two care managers, one support worker, an administration officer, the registered manager and service manager were spoken with. Three guests files were inspected as were training records and other documentation related to the management of the home. Certain areas of the homes were also looked at including the laundry and two guest’s bedrooms. What the service does well: The atmosphere within Douglas Road is friendly and welcoming. The guests spoken with expressed very positive views about how they are supported by staff during their stays. Staff interaction with guests was observed to be helpful and caring. The staff that were spoken with had a good understanding of the needs of the guests and of their roles within the home. There were good records of guest’s needs and very comprehensive risk assessments in place. The home has a good system of collecting pre admission information, which ensures that any change in care need is identified before admission. Management systems within the home are good. There are good communication systems between management and staff and regular staff meetings take place. The views of guests and carers are also sought via regular guest’s meeting and the homes quality assurance system. Staff said that the manager is approachable and that she has an ‘open door’ approach to managing the home. They also said that they feel confident that she will deal appropriately with any issues raised. The manager is proactive in dealing with situations and liaises well with other agencies and individuals. Responses to CSCI requirements or recommendation have been timely and effective. Training information is recorded and training needs are identified. Progress is also being made to ensure that all care staff have appropriate NVQ qualifications. The home, although purpose built, is well maintained and provides service users with a ‘homely’ environment for short stays. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home has clear assessments of guest’s needs, which enable staff to support them appropriately. EVIDENCE: Three guests files were inspected. Comprehensive Care Management assessment documentation was in place. In addition to this it was noted that pre-admission forms are sent out to all guests and their carers to ensure that the home is aware of any changes in their care prior to admission. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 Guests are encouraged to make decisions about how they are supported whilst staying at Douglas Road. There are good risk assessment and risk management strategies in place, which balance guest independence and safety. EVIDENCE: The guests stay at Douglas Road on a short stay basis. The managers stated during their time at the home guests are encouraged to make decisions about certain aspects of the running and day to day conduct of the home. Guests have a meeting every Monday evening where issues such as menus are discussed. A service user and staff member confirmed that regular meetings take place. It was noted that individual guest’s personal choices were recorded within the assessment documentation, pre-admission forms and care plans. These choices and decisions ranged from whether guests wanted their bedroom doors open or closed at night, whether they wanted staff to check on them, information about how they wanted support to be delivered and whether they want to handle their own personal allowance. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 10 The manager stated that there are wider plans within Staffordshire Council’s Social Care and Health Directorate to involve service users in the decision making process regarding staff recruitment. Risk assessments for three guests were checked. The risk assessments were comprehensive and robust and contained clear guidance for staff regarding risk management strategies. The risks in relation to one guest who was having a first short stay at Douglas Road were discussed in depth with the manager and the service manager. The manager had sought appropriate advice from the placing social worker and psychological services to assist in the risk assessment and management process. She had also consulted and liaised with the CSCI and the guest’s family members. It was noted that staff acted in accordance with the guidance and demonstrated a good understanding of the risks involved. These risks had also been discussed with all staff at a staff meeting. A discussion took place with the manager and the service manager about how the risks in relation to this service user can be minimized whilst still encouraging personal and independent development. It is the CSCI’s understanding that these issues will be addressed when the guest has settled and familiarised himself with the staff and routines of the home. A written procedure was in place in respect of ‘missing persons’ and unexplained absences. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 & 16 Guests are able to continue with their education and occupation and retain their family links whilst having a short stay at the home. EVIDENCE: As the home is a short stay provision there is not always contact with or by the relatives of guests during their short stay. However, staff demonstrated a good understanding of the family networks of the guests and care files indicated that there is regular contact and exchanges of information. Most of the guests have already well established daily routines, which involve day services and other forms of education. These continue whilst staying at Douglas Road. Staff were observed to interact with guests in a courteous and appropriate manner and all guests appeared relaxed and at ease in the staff company. There was a positive and friendly atmosphere within the home with much talk and laughter between guests and staff. The home provides ample space for guests to choose to sit together or to spend some time alone. The registered manager, two care managers and a support worker were spoken with and all demonstrated a good understanding of the values and principles of the promotion of independence. Access and exit from the home is unrestricted, 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 12 however, due to identified risks the doors are alarmed. Robust risk assessments and protocols are in place in respect of this. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Guests at Douglas Road receive personal support in the way they prefer and require. EVIDENCE: There was good information within guests’ files relating to care needs and how they wanted to be supported. Staff confirmed that, where possible, intimate care is provided by a staff member of the same sex. A female service user confirmed that female staff assist her with personal care. She also said that staff were mindful of issues relating to privacy and dignity when assisting with personal care. A guest confirmed that there is flexibility and choice regarding going to bed and waking in the morning. There is a key working system in place and staff spoken with demonstrated a good understanding of the needs of the guests that they support. Guests bring any technical aids and equipment with them when having a short stay in the home. Guest’s with mobility problems use the ground floor bedrooms, as this home does not have a lift. One service user in a ground floor bedroom said that she was unsure of how to use the alarm call system at night. This was discussed with the manager and key worker who sought to 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 14 address this omission. It is recommended that staff clarify and assess whether guests are aware of how to summon assistance during the night. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 There are satisfactory systems in place to safeguard guest’s from potential abuse. EVIDENCE: Douglas Road is managed by Staffordshire County Council Social Care and Health Directorate. Staffordshire County Council have robust vulnerable adult and safeguarding procedures in place. There have been no adult protection referrals made since the last inspection. The manager stated that she and most of the staff have received training in respect of identifying and reporting abuse. She stated that those staff who had not received the training were scheduled for the next intake. Staff members spoken with demonstrated a good understanding of the signs of abuse but there was some confusion in respect of the reporting procedures regarding a potential vulnerable adult investigation. This was discussed with the manager who said that she would remind staff at the next staff meeting on the 17th December 2005. Two service users’ personal allowances were checked. The monies were accurate, however, there was one withdrawal for which a receipt was not available. This was discussed with the administration officer and the manager. The manager said that she would remind all staff to ensure that there is an accurate audit trail of receipts held within guest’s personal allowance records. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Good systems are in place to ensure that the home is suitably clean and hygienic. EVIDENCE: The home was well maintained and clean. The manager said that there are two domestic staff. These staff members are responsible for general cleaning and hygiene within the home. There is a separate laundry area, which is situated off the ground floor corridor. A member of staff said that the domestic staff do the bulk of the laundry but that all care staff help as and when required. Guests are encouraged to take their laundry to the laundry area, however some guests need support with this task. Appropriate gloves, hand wash and aprons were in place. The staff member spoken with demonstrated a good understanding of the issues of cross contamination and infection control. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 35 Guests at Douglas Road are supported by appropriately trained and competent staff. EVIDENCE: The home has a stable and experienced staff team with little turn over of staff, which provides guest with consistency of care. On the day of the inspection the home was well staffed. The staffing levels reflect the activities within the home. During the day a number of guests are out at day services or college and therefore the staffing numbers are reduced. There are always staff within the home and there is always a manger on duty. On this occasion the evening shift from 5pm onwards consisted of one care manager and three support workers. There are two waking night staff and one sleep-in manager. The staff on duty within the home were observed to interact with guests in an appropriate and sensitive way. Three guests were spoken with. All the views expressed about the staff and the managers were positive. Each staff member spoken with demonstrated a commitment to the guests and to the home. It was also noted that there were good communication systems between all staff regarding guest’s needs. The manager stated that there is a concerted effort within the home to ensure that the appropriate percentage of staff receive NVQ training. It is envisaged, however, that by the end of 2005 only 43 of staff will have achieved NVQ2 or above. The manager stated that staff movement has reduced the percentage. It was pleasing to note that the manager has drawn up an action plan which 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 18 indicates that by July 2006 52 of staff will be appropriately qualified. The home has also sought to ensure that three managers are trained to assess competency. The CSCI will monitor the progress of this at the next inspection. Staff spoken with confirmed that a variety of training is available for staff. Documentation indicated that records are kept of the training events that each staff member attends. The manager stated that two care managers have delegated responsibility for ensuring that training records are updated. Staff confirmed that two hours are allocated on the rota per fortnight for staff training, guidance and up-dates. The manager stated that presently she supports staff with LDAF training but it is planned for the end of November 2005 to include care managers in the support process. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 Douglas Road is a well managed home with good systems in place to ascertain and respond to guests and carers views about the service. EVIDENCE: The manager has the appropriate qualifications and experience to run the home and meet its stated purpose and objectives. The manager is interested in her own professional development and undertakes periodic training and development to maintain and update her skills. The manager liaises well with other agencies and has demonstrated a proactive approach in addressing and managing situations within the home. Staff said that her management style was open and inclusive. All the staff spoken with felt able to approach the manager and felt confident that she would deal with their issues. The manager stated that there are quality assurance systems in place. There is an annual survey of guests and carers about the quality of service delivered at Douglas Road. Feedback from these surveys is recorded in the newsletter, 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 20 which is then sent out to all guests and carers. The manager stated that all unit managers had recently attended a quality assurance workshop-training event. Further work is taking place to ensure that the views of guest’s who have difficulty communicating can be sought. Thank you letters and feedback from guest’s and carers also form part of the quality assurance process at Douglas Road. Requirements and recommendations made by CSCI as part of the inspection process are responded to in a timely and effective way. 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 3 x 4 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 114 Douglas Road Score 3 x x x Standard No 37 38 39 40 41 42 43 Score 4 x 3 x x x x DS0000028866.V265815.R01.S.doc Version 5.0 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA18 Good Practice Recommendations It is recommended that staff clarify and assess whether guests are aware of how to summon assistance during the night 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 114 Douglas Road DS0000028866.V265815.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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