Inspection on 25/06/06 for 12 Dormy Way

This inspection was carried out on 25th June 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

12 Dormy Way 28/11/07

12 Dormy Way 04/10/05

12 Dormy Way 11/04/05

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 Mr Roy Bega Unannounced Inspection 25th July 2006 09:30 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 12 Dormy Way Address Gosport Hampshire PO13 9RF 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) 01329 231737 www.c-i-c.co.uk. Community Integrated Care Pending Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be at least 30 years of age. Date of last inspection 4th October 2005 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 within Hampshire. 12 Dormy Way is located on the outskirts of Gosport. It is a detached property in keeping with others in the area. All of the bedrooms are single. Residents 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. Current fees are from £982 to £1,007 per week with additional charges for hairdresser, newspapers chiropody and toiletries. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is an assessment of how the National Minimum Key Standards for Care Homes for adults 18-65 were being met at the time of the inspection This visit took place on 25 July 2006 between the hours of 9-30 a.m. and 2 p.m., a total of four and a half hours. Opportunity was taken to look around the home view records, observe the working environment and speak with management, and staff. Due to residents low ability of verbal, signing or pictorial communication they were not able to converse with the inspector. There were not any relatives/friends present during the visit. Subsequent to the last inspection the registered manager has been dismissed. Two acting managers have been appointed subsequently. The most recent being 18 July 2006 who was a registered manager of another service within the organisation. Due to a change of management, the requirement raised as a result of the last inspection visit has not been met. Three additional requirements were raised resulting from this site visit. What the service does well: What has improved since the last inspection? Not applicable on this occasion. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this area is good. This judgement has been made using available evidence including a visit to the service. Prospective residents benefit from a stringent pre admissions assessment procedure. EVIDENCE: There have not been any new admissions to the service since 2004. Records showed that full assessments had been completed by competent staff prior to admission in consultation with families, residents where possible and relevant professionals. Recent full reviews detailing residents required level of personal support in meeting their daily living needs and wishes were seen. Areas covered included education/training/occupation, social skills and wishes, management of risk, physical and mental health care. Due to residents low level of verbal, signing or pictorial communication ability they were not able to converse with the inspector. (See also section Individual needs and Choices of this report). 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this area is good. This judgement has been made using available evidence including a visit to the service. Resident’s benefit from the care planning process and support to take risks. Residents would benefit fully if communication strategies in meeting their needs was put in place. EVIDENCE: Subsequent to the last inspection the registered manager has been dismissed. Two acting managers have been subsequently been appointed. The most recent being 18 July 2006, who was a registered manager of another service within the organisation. Discussions with the acting manager and staff, and observations indicated that this has not however had an adverse effect upon residents. (See also section “ Conduct and Management of the Home”.) A sample of two care plans seen, included the required information and detail. Records and discussions indicated that residents’ relatives/advocate had participated in agreeing the plans. It was seen that up to date risk assessments and reviews have been completed that coincide with activities participated in by residents. Records seen and discussions indicated that residents are supported to participate in new experiences in respect of daily life skills and recreational activities. For example, with a support worker one 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 10 resident using public transport had been to a concert and a meal afterwards. Corresponding documentation gave a detailed account of what was learnt from the experience and an action plan for future development put in place. Another resident had been supported to use public transport that included a local river ferry, aimed at enabling them to go on holiday by means of a cross channel ferry. Discussions indicated that residents limited communication skills restricts their ability to choose what they would like to do with regards to their lifestyle. Strategies in improving this area was discussed which included further development of pictorial references. For example, creating individual “libraries” of pictures of places where residents like to go and activities they like to do. Further guidance may need to be sought from external professionals who specialise in this area. The acting manager assured the inspector that this would be implemented. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this area is adequate. This judgement has been made using available evidence including a visit to the service. Residents would benefit from the development of meaningful communication strategies to enable them to make more informed choices with regards to activities and community access. Residents’ benefit from having their rights respected and being supported to maintain contact with families and friends. EVIDENCE: See also previous section “Individual Needs and Choices” standards 6-10. Due to residents low level of verbal, signing or pictorial communication ability they were not able to converse with the inspector. A sample of two residents daily activity programmes were seen. Residents are given the opportunity to take part in a variety of activities both within the home and in the community. Activities include day services and community access. As stated in the previous section, “Individual Needs and Choices”, the introduction of a more structured pictorial communication system would improve residents informed choice to participate in a wider range of personal and community activities. For example, inclusion of local clubs, daily living 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 12 skills in making a drink, keeping rooms clean, college courses in respect of residents’ identified interests of art, dancing and music. Discussions indicated that residents are involved with grocery shopping but are minimally involved in deciding what they eat. For example, their food likes and dislikes are known but the menu is planned by support staff. A pictorial menu would assist residents in making informed choices of what they would like to include in the menu and what day they would like to eat it. The acting manager assured the inspector that a pictorial “library” of residents known food preferences with added dishes would be put in place. Records seen and discussions indicated that residents are encouraged and supported to maintain contact with their families/advocate and friends. Staff observed and spoken with on the day of visit demonstrated an understanding of resident’s rights with the ability to ensure they are upheld. This was supported by the organisation’s clear policies and information for staff on the rights of residents. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this area is good. This judgement has been made using available evidence including a visit to the service. Residents’ benefit from being supported by staff in maintaining their physical and emotional health needs. Residents’ benefit from there being appropriate procedures in place and trained staff in the administration of medication. EVIDENCE: Due to residents low level of verbal, signing or pictorial communication ability they were not able to converse with the inspector. Observation and discussions indicated staff provide sensitive and flexible personal support to maximise residents privacy, dignity, independence and control over their lives. Care plans seen and discussions with staff showed that residents’ health care needs have been assessed, and appropriate procedures put in place to ensure they are carried out. In accordance with the organisation’s policy and procedures all residents have been assessed as not being able to manage their own medication. Records of medication administered were well maintained and up to date. Appropriate agreed procedures were seen for medication that is to be given as required. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 14 Evidence was seen that staff have received appropriate training in the handling, administration and recording of medication. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this area is good. This judgement has been made using available evidence including a visit to the service. Residents’ benefit from there being good complaints and adult protection procedures being in place. EVIDENCE: The home has a complaints procedure in place that includes the necessary information. A written format copy is displayed in the office and. A more accessible version for residents has been produced in the format of an audiotape. The acting manager informed the inspector that it is planned to produce the procedure in pictorial format. The commission has received one concern about with regards to care practices by a member of staff, which was passed on to Community Integrated Care (C.I.C.) who carried out a thorough investigation. The commission were satisfied with the outcome and no further action was taken. Records and discussions indicated that episodes of physical or verbal aggression by residents are documented and evaluated. Guidelines have been drawn up to manage behaviours and these are reviewed in consultation with the community learning disability team. The home has an adult protection policy and procedure in place of which staff spoken with had a good understanding. Staff have received adult protection training by an accredited trainer within the organisation. Records showed that staff have discussed this subject with residents. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this area is generally good. This judgement has been made using available evidence including a visit to the service. The building is generally well maintained. Residents live in a clean, hygienic homely environment. EVIDENCE: The premises are in keeping with the local community and have a style and ambiance that reflects its stated purpose. The inspector had the opportunity to walk around the communal areas and two resident’s bedrooms. In general the home is well maintained. The dining room ceiling however is water stained which according to the home’s records was reported to the organisation’s maintenance department 10 April 2006. The paintwork of the gas boiler in the kitchen is flaking and rust stained. A regulation 26 report received by the commission 21 July 2006 states that residents bedrooms are due for redecoration. Furniture and fittings are of good quality, domestic in design, unobtrusive and compatible with fulfilling their purpose. The home was clean, hygienic and free from offensive odours. Laundry facilities are of a domestic type and meet requirements. Systems are in place to control the spread of infection. Evidence was seen that staff have received training with regards to infection control. The 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 17 acting manager informed the inspector that it is planned to enable residents to become more involved with domestic duties as part of daily living skills. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this area is good. This judgement has been made using available evidence including a visit to the service. Staff benefit form training provided by the organisation. Residents’ benefit from good recruitment procedures. Staff records as listed in Schedule 2 of the Care Home Regulations are to be kept at the home. EVIDENCE: Records seen and staff spoken with demonstrated that the recruitment procedures followed in the home protect residents. All necessary checks were in place prior to staff commencing work. A sample of one record for the most recently recruited member of staff was seen which included a comprehensive induction-training programme. A requirement was made from that last inspection that all staff records as listed in Schedule 2 of the Care Home regulations are to be kept at the home. The acting manager informed the inspector that this has not yet been complied with but gave assurance that it would. This issue was stated in the recent Regulation 26 report received by the commission 21 July 2006. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 19 Community Integrated Care has a designated training officer who co ordinates training opportunities and refresher courses. Records seen showed that all staff (including “bank staff”) are provided with appropriate training in health and safety, medication assessments, moving and handling, first aid, and food hygiene. Staff on duty on the day of inspection were observed to be accessible to and comfortable with residents. Discussions indicated that staff feel training offered by C.I.C. helps them to carry out their jobs effectively. Out of seven full time staff, four have completed the National Vocational Qualification level 2 in caring for adults who have a learning disability and one has acquired level 3. The acting manager agreed that it would benefit residents and staff for C.I.C to provide appropriate training in communication, for example, the use of pictorial aids. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this area is good. This judgement has been made using available evidence including a visit to the service. Whilst an acting manager has been in post since the last inspection this has not had an adverse effect upon residents. The service promotes obtaining the views of family members, advocates and professionals on how the service is meeting its aims. Resident’s benefit from the promotion of health and safety in the home. EVIDENCE: Subsequent to the last inspection the registered manager has been dismissed. Two acting managers have been appointed subsequently. The most recent being 18 July 2006, who was a registered manager of another service within the organisation. The acting manager informed the inspector that she is uncertain how long she will remain in her current position. Discussions with staff and observations indicated that the disruptions have not however had an adverse effect upon residents. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 21 During the visit, the inspector had the opportunity to speak with staff. It was evidenced through these discussions and observations that good working relationships exist between the staff group and residents. The atmosphere was relaxed indicating an environment where resident’s abilities and aspirations are being promoted. A quality assurance system based on seeking the views of relatives, service purchasers and professionals is in place. Staff have received appropriate training with regards to Care of Substances Hazardous to Health. Hazardous substances are kept in a locked cupboard to promote the welfare and safety of residents. Required up to date service certificates were seen for equipment and systems. Fire drills and required fire safety precautions are carried out and recorded promoting the health and safety of residents. 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 23 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 YA13 Regulation 16 (2m &3) Requirement By use of appropriate communication techniques staff need to provide additional support to residents to become more involved in the local community. By use of appropriate communication techniques staff need to provide additional support to ensure residents have access to, and choose from a range of, appropriate leisure activities. The dining room ceiling requires repair/redecoration. Appropriate action needs to be taken with regards to the paintwork of the gas boiler. That all staff records as listed in Schedule 2 of the Care Home regulations are kept at the home. Timescale for action 06/09/06 2 YA14 16 (2n) 06/09/06 3 YA24 23 (2b) 06/09/06 4 YA34 19 06/09/06 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 12 Dormy Way DS0000012362.V299410.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor 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. 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