Inspection on 11/04/05 for 12 Dormy Way

This inspection was carried out on 11th April 2005.

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

The inspector 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

12 Dormy Way 28/11/07

12 Dormy Way 25/06/06

12 Dormy Way 04/10/05

12 Dormy Way 18/10/04

12 Dormy Way 18/10/04

12 Dormy Way 18/10/04

12 Dormy Way 18/10/04

12 Dormy Way 29/04/04

12 Dormy Way 29/04/04

12 Dormy Way 29/04/04

12 Dormy Way 29/04/04

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

CARE HOME ADULTS 18-65 12 Dormy way Gosport Hampshire PO13 9RF Lead Inspector Kathryn Kirk 11 April 2005 10:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 12 Dormy way Version 1.10 Page 3 SERVICE INFORMATION Name of service 12 Dormy Way Address 12 Dormy Way, Gosport, Hampshire PO13 9RF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01329 231737 Community Integrated Care Mr Jean Steve Michael Khoddabacus CRH 4 4 Category(ies) of PC Care home only registration, with number of places 12 Dormy way Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: All service users must be at least 30 years of age on admission to the home. Date of last inspection 18 October 2004 Brief Description of the Service: 12 Dormy Way is registered to provide residential care for up to four adults who have a learning disability. Knightstone Housing Association manages the property. Community Integrated Care manages the service and is the registered person in respect of the home. Community Integrated Care is a national organisation with a number of homes in the area. 12 Dormy Way is located on the outskirts of Gosport. It is a detached property in keeping with others in the area. Shops, a health centre and a pub are all within walking distance. All of the bedrooms are single. Service users share the use of kitchen dining and lounge areas. There are two bathrooms, one upstairs and one on the ground floor. The property has a large enclosed rear garden. 12 Dormy way Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the homes first unannounced inspection for the year April 2005-March 2006. It took place on 11 April 2005 and lasted for four hours. A follow up visit took place on 14 April 2005 so that some issues could be clarified with the manager. The needs of the service users are such that they are unable to contribute verbally to the inspection process, all were present part of the inspection and time was spent in their company. The inspector spoke with two staff members and some policies and procedures were also viewed. The follow up visit comprised a one hour discussion with the manager and with one staff member and an examination of some records that were not available on the day of inspection. What the service does well: What has improved since the last inspection? Service users have an increased opportunity to go out individually, with appropriate staff support. There is a full complement of staff. 12 Dormy way Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 12 Dormy way Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 12 Dormy way Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 5 Any service user can be confident that staff are aware of their needs and aspirations because no one is admitted before an assessment has been undertaken. The statement of terms and conditions would benefit from some further attention to ensure greater clarity and protection. EVIDENCE: The two most recent service users to move into the home were admitted about 18 months ago. Records show that a care management assessment was completed in both instances, to ensure that identified needs could be met. Some staff who knew and were known to the service users were also employed, to assist with the move and to help with continuity of care. All service users have been issued with a licence agreement by Knightstone Housing Association. This details rights and responsibilities of both parties with respect to service users accommodation. All service users also have a statement of terms and conditions, which have been issued by Community Integrated Care. There was evidence that in some but not all cases, family members had signed agreements on behalf of service users. It was discussed that where possible service users next of kin should be consulted and if in agreement should sign as their representatives. Where this is not appropriate or possible it continues to be a recommendation that an advocate should be involved in the contractual process. 12 Dormy way Version 1.10 Page 9 The statement of terms and conditions issued by Community Integrated Care continues to be unclear in some instances as to the amount of disability living allowance that each service user is entitled to and how it is used. It is recommended that this be clarified. 12 Dormy way Version 1.10 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 9 and 10 As some reviews of care plans are overdue they may not reflect any changes in needs or in personal goals . Some paperwork relating to risk is out of date and therefore does not accurately reflect current interests and lifestyles. Staff would benefit from clear guidelines regarding the sharing of information about service users with other agencies. EVIDENCE: Staff said that care plans are reviewed during essential life planning meetings. Records show that relatives and relevant professionals are invited to attend these meetings. It was evident that some reviews had not been undertaken for over six months and it is a requirement that this is done. Areas of identified risk have been evaluated for each service user and any necessary action that staff must take in order to minimise the risk is identified. Staff sign these risk assessments to confirm that they have read and understood them. These are updated annually. Some risk assessments seen related to activities which no longer occur. This was discussed with staff who agreed to ensure that records are up to date. There was evidence in one service users file that a form issued by social services, which gave permission to share information about the service user 12 Dormy way Version 1.10 Page 11 between agencies had been signed on behalf of a service user by a staff member. This was discussed with the manager and it was agreed that this practice should be reviewed. It was discussed that any action taken needs to be consistent with the homes written policies and procedure regarding confidentiality and with the Data Protection Act. 12 Dormy way Version 1.10 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 13 and 15 Service users are offered appropriate daytime activities and there is good liaison between day service staff and staff at the home. Although service users have access to local community facilities this is limited to some degree because of current transport arrangements. Family involvement is encouraged. EVIDENCE: Staff said that all service users attend a day service for between two and five sessions a week. There is evidence on file that day service staff attend care reviews and provide reports on the effectiveness of therapeutic or other activities. Staff at the home said that they believe that one service user in particular enjoys these sessions and would benefit from more. The rota shows that each service user is also supported by staff to have a 1-1 activity outside the home at least one time a week. Two vehicles are available to enable service users with staff support, to access community facilities and events. Staff said that service users are also able to use public transport. At present, only two full time members of staff are able to drive. These are the acting manager and the senior support worker. The manager who is currently seconded is also a driver and is on the rota for one 12 Dormy way Version 1.10 Page 13 shift a week for the next six months. Under current arrangements the service users go in the home transport to their day service. This is a round trip of around 26 miles. As each session is generally for half a day, this means that staff who drive are spending a significant proportion of their day escorting service users to and from day care. The home has a policy, which states that there are no restrictions on visiting. Important relationships are documented as part of the person centred planning process. 12 Dormy way Version 1.10 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Staff provide appropriate personal and healthcare support to service users. EVIDENCE: Service users personal and health care needs are identified within their personal plans. Clothes are particularly important to one service user and it was clear through discussion with staff and by observation that staff support her to choose her own outfits and assist her to buy clothes which she likes. Service users have aids and equipment to meet their needs, for example there is a parker bath in the downstairs bathroom and one service user has an adapted chair. There was written evidence that support and advice is provided by specialists as necessary. There is also evidence that the staff at the home follow guidelines given, for example, to improve the diet of one service user and to manage the behaviour of another. 12 Dormy way Version 1.10 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Training offered to staff, along with policies and procedures that are in place, help to protect service users from abuse neglect or self-harm. EVIDENCE: Policies and procedures regarding the protection of vulnerable adults are available at the home. Records show that some staff have completed a training course regarding the protection of vulnerable adults. All staff have also been trained in Crisis Prevention and Intervention (CPI) to help them to manage any challenging incidents with service users. Community Integrated Care act as appointees for service users. One service user has an individual savings account but attempts to open these for others have proved to be unsuccessful. Finances are held centrally and each service user is issued with an individual monthly statement. Two statements were seen. These detailed interest accrued. This meets a requirement made at a previous inspection. One resident’s money held at the home was checked against records kept and was found to be accurate. 12 Dormy way Version 1.10 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The environment meets current the needs of service users EVIDENCE: The house is comfortable and homely and has a large level rear garden. There is an appropriate amount of private and communal living space for each service user. The premises were observed to be clean, bright and free from offensive odour. Staff said that the temperature of the home is monitored weekly to ensure that it does not drop below acceptable levels. This meets a recommendation made at the last inspection. Three bedrooms are on the ground floor as is one bathroom and the communal kitchen dining and lounge areas. Communal areas are accessible to all service users. Furnishings fixtures and fittings are of reasonable quality and fulfil their purpose. The home met the requirements of the local fire service during their most recent visit in 2001 24 12 Dormy way Version 1.10 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 35. Although the number of staff available may be sufficient to meet need, the use of staff time should be reviewed to ensure that the team is working as effectively as possible. To comply with minimum standards clear policies and procedures should be in place regarding the duties of staff that are under the age of 21. Staffing responsibilities at weekends, particularly when one staff may be supervising three service users should be reviewed be ensure that current arrangements meet service users needs. Training opportunities for staff are good and are relevant to their jobs. EVIDENCE: There is a total of eight full time staff that work at the home. These comprise an acting manager; a senior support worker and six care staff. The registered manager is currently seconded but works one shift a week at Dormy Way. The rota shows that a minimum of two staff is on duty at any one time during the day. There is an additional staff member employed from 11 am to 7pm during the week and there is one staff member who sleeps in each night. Staff at the home showed on the day of inspection that they are willing where possible to cover any vacant shifts to ensure continuity of care. Where a gap in the rota 12 Dormy way Version 1.10 Page 18 does occur staff said they could ask for bank staff, who know the service users to cover. It was apparent that one senior member of staff is not yet 21. Although she demonstrated a commitment and understanding of her role the standards state that staff left in charge of the home must be at least age 21. At weekends there are two members of staff on shift at all times. Staff have been informed that one member of staff could supervise up to three service users within the home so that one service user can go out with an escort. There is no written evidence that this practice has been risk assessed. Community Integrated Care employs a locally based training and development officer who co ordinates training within the region. Staff describe training opportunities as good. All staff are trained in first aid, food hygiene fire safety moving and handling medication and in the principles of care. Other training is offered as well, for example CPI (Crisis Prevention and Intervention) protection of vulnerable adults and epilepsy. Three staff members have nearly completed their NVQ level 3 and one has already done so. Records examined for one service user reflected that Maketon was being actively used at day services to improve communication. The inspector was informed that no staff employed within Dormy Way are trained in Make ton. 12 Dormy way Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 42 Arrangements are in place to ensure that the management of the home remains consistent. Health and safety of service users is promoted. EVIDENCE: As discussed in previous sections the registered manager Mr Jean Khodobacus is seconded for six months but will continue to work at Dormy Way for one shift a week. The acting manager has worked at Dormy Way for as a senior support worker and so has some experience of management tasks. She has completed her NVQ level3. She will be supported by a newly promoted senior support worker who has worked at Dormy Way for 2 years. She is studying for her NVQ level 3. In date service certificates were seen for fire alarms, gas appliances and portable electrical equipment. The fire risk assessment for the home had been updated in January 2005. Records show that a health and safety checklist is completed every week and that fire alarm and prevention systems are also checked weekly. 12 Dormy way Version 1.10 Page 20 Water is thermostatically regulated and checks showed that it was running around 43 degrees C on the day of inspection. Staff said that there is a procedure in place to ensure that bath water temperature is checked before service users bathe. One risk assessment seen confirmed this. Window restrictors were observed to be fitted to one upstairs window. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 2 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 12 Dormy way Version 1.10 Score Page 21 LIFESTYLES Standard No 11 12 13 14 15 16 17 Score x 3 3 x 3 x x 31 32 33 34 35 36 x x 2 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x 12 Dormy way Version 1.10 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. 1. Standard 6 Regulation 15 Requirement Care plans must be reviewed every six months. Timescale for action 31/05/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 5 10 13 35 Good Practice Recommendations That an advocate be contacted to support service users in contractual matters where there is no family support available. Staff should be given guidance as to what information to share and with whom A review of the current arrangements for escorting service users to day services should be undertaken Staff should have the opportunity to study maketon 12 Dormy way Version 1.10 Page 23 Commission for Social Care Inspection Overline House Blechynden Terrace Southampton SO15 1GW 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 12 Dormy way Version 1.10 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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