Inspection on 28/11/07 for 12 Dormy Way

This inspection was carried out on 28th November 2007.

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 25/06/06

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

Similar services:

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Hillview Farm

Dalewood Respite Care

Orchard,The

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 Nick Morrison Unannounced Inspection 28th November 2007 10:00 12 Dormy Way DS0000012362.V349681.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.V349681.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.V349681.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 Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 12 Dormy Way DS0000012362.V349681.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 25th June 2006 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 £960.33 per week with additional charges for hairdresser, newspapers chiropody and toiletries. 12 Dormy Way DS0000012362.V349681.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report represents a review of all the evidence and information gathered about the service since the previous inspection. This included a site visit that occurred on 27th November 2007 and lasted five hours. During this time we looked in all the rooms in the house including the kitchen, dining room, lounge, all bedrooms and bathrooms, looked at the files of all four service users and observed the service people were receiving. We also met with the Manager, spoke with two members of staff and observed interaction between staff and service users. All records and relevant documentation referred to in the report was seen on the day of the inspection visit. We also referred to service’s own self-assessment of the home and spoke with two relatives of service users. We also referred to comment cards received from staff and service users and to the home’s Annual Quality Assurance Assessment. What the service does well: What has improved since the last inspection? What they could do better: There were no requirements identified as a result of this inspection. The home continues to identify areas for improvement and to build these into their plans for the service. The views of people living in the home are represented within this process. 12 Dormy Way DS0000012362.V349681.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. 12 Dormy Way DS0000012362.V349681.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.V349681.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having their needs and aspirations assessed prior to moving into the home. EVIDENCE: The home requires a full care management assessment for each person before they move into the home. In addition to this, the home does it’s own comprehensive assessment. Records showed that all assessments were in place prior to the person moving in and that the Manager of the home had met with people at their previous residence to carry out the home’s assessment. 12 Dormy Way DS0000012362.V349681.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having clear care plans and risk assessments in place and from being supported to make their own decisions EVIDENCE: Person Centered Plan were in place for each person living in the home and were clearly related to the initial assessment and the ongoing information the home had gathered on each person over time. The plans were well written and explained not only what staff needed to do in order to support people well, but also the reasons why. Staff spoken with were clear about individual Person Centered Plans. Each person had a review once or twice a year and parents and Care Managers were involved in these and were able to contribute to the care planning process. 12 Dormy Way DS0000012362.V349681.R01.S.doc Version 5.2 Page 10 The Person Centered Plans were recorded against and evaluated on a daily basis and were reviewed each month. The monthly reviews contributed to the six monthly monitoring of the plans. Each person living in the home had a communication file that provided guidance for staff in how to support them and listed their individual preferences, how they liked to be supported and what things were important to them. Most people living in the home have limited communication skills. This is recognised within Person Centered Plans and there was information about the way each person communicated, what things were important to them and how they needed to be supported to make decisions for themselves. There had been input from speech and language therapists. Staff spoken with were clear about each person’s communication methods and the importance of enabling people to make decisions for themselves. Staff training supported this and emphasised the need for people to be in control of their own lives as far as possible. Risk assessments were clearly written and reviewed on a regular basis. Staff were clear about risk assessments for each person and the importance of supporting people in line with the risk assessments. Risk assessments were used to promote independence and support people living in the home to be involved safely in the activities they wanted to do. 12 Dormy Way DS0000012362.V349681.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having their rights respected and from balanced and nutritious meals. They also benefit from having the opportunity to engage in a wide range of activities both inside and outside of the home. EVIDENCE: There had been two requirements from the previous inspection that by use of appropriate communication techniques staff need to provide additional support to residents to become more involved in the local community and that 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. 12 Dormy Way DS0000012362.V349681.R01.S.doc Version 5.2 Page 12 Both of these requirements have been met. Personal Care Plans contained improved information on the interests of people living in the home and reviews of those plans showed that each person was involved in increasing use of the community and was participating in more activities. The communication files showed that staff now had more information on the interests of individuals and were more able to respond to their requests through the improved communication. Feedback from comment cards showed that people living in the home were satisfied with the amount of support they had to use community facilities and to participate in act ivies. People living in the home each have a timetable of activities, which, from observation throughout the inspection visit, were followed. Staff support was managed so that each person had the necessary support to do the activities they wanted to do. Additional staffing was in place where it was needed in order to facilitate activities for people. From observation it was also clear that people were able to choose whether or not to take part in the activities offered to them. There was support for people living in the home to maintain contact with their families. The visiting policy promoted and encouraged visitors. Records showed that people had regular contact with their families. Service users were also supported to use electronic mail to maintain contact with relatives. The menu’s showed that the diet was varied and nutritious. People living in the home were able to choose alternatives to the set menu on a daily basis. Records were kept of individual food intake. Food was well stored and food stocks showed that fresh fruit and vegetables were well used in the home. Individual preferences were recorded so that people did not have food they didn’t like. There was sufficient staff support at mealtimes and staff ensured that mealtimes were an enjoyable time for people living in the home. The home has a six-week menu and service users’ choices and preferences are taken into account when these are devised. People are also encouraged to try new and different alternatives. Staff use the opportunity of going out to restaurants with service users to find out further types of food they might like. 12 Dormy Way DS0000012362.V349681.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having their healthcare needs met and are protected by the home’s medication policies and practices. EVIDENCE: The system for administering medication in the home was clear and was stated in the home’s policies. Staff who were involved in administering medication had received good training and demonstrated that they had a good understanding of medication issues. Medication records were clear and up-to-date and all medication was stored appropriately and safely. There were clear guidelines in place for medication that was prescribed on an ‘as required’ basis. These guidelines described a number of alternative interventions to be attempted prior to resorting to the use of medication. Person Centered Plans contained information on how people preferred to be supported with their personal care. 12 Dormy Way DS0000012362.V349681.R01.S.doc Version 5.2 Page 14 The files of people living in the home demonstrated that healthcare needs were monitored and that people were supported to use healthcare services as necessary. There were comprehensive records relating to each person’s health. All identified areas of health needs were monitored and recorded on a regular basis. Where people had used healthcare services there were records detailing any outcomes as a result of the consultation. Staff in the home liaised closely with healthcare professionals in the interests of people living in the home. 12 Dormy Way DS0000012362.V349681.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The policies and practices of the home protect service users and promote their involvement in the running of the home. EVIDENCE: The home had relevant policies and procedures in place regarding the protection of vulnerable adults. Good procedures were in place to ensure that service users’ finances were dealt with appropriately and clear records were kept of all transactions where staff supported service users to manage their money, or managed it on their behalf. The Manager was very clear that service users’ money was not used to subsidise staff who were supporting them with activities. There was a clear complaints procedure in place that was given to each service user prior to them using the service and was available throughout the home in an accessible format. There had been no complaints in the previous twelve months. 12 Dormy Way DS0000012362.V349681.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a clean, comfortable and safe environment. EVIDENCE: There had been a requirement from the previous inspection that the dining room ceiling requires repair/redecoration. Appropriate action needs to be taken with regards to the paintwork of the gas boiler. The gas boiler had been re-painted. The ceiling in the dining room required redecoration because there had been a leak from upstairs, which had left an unsightly stain. Maintenance records showed that the Manager had followed this up with the maintenance department on a number of occasions throughout the year without success. It was still outstanding at the time of the inspection visit. The Manager contacted us a few days after the inspection visit to confirm that the work on the ceiling had now been completed. 12 Dormy Way DS0000012362.V349681.R01.S.doc Version 5.2 Page 17 The home provides a stimulating, safe and comfortable environment for people. The garden area is well designed and is safe and accessible. The service has a plan in place to deal with ongoing maintenance and the appearance of the building shows that this is generally effective. The company has a maintenance department that responds to maintenance issues. The Manager reported that, with the exception of the issue of the dining room ceiling, issues were usually dealt with promptly. The service aims to maintain a homely feeling in the house and the furniture and fittings are modern, domestic and comfortable. The home was kept clean throughout. Clear infection control policies were in place and staff were aware of these and of the need to maintain a comfortable and appealing environment for people living in the home. The laundry area was well managed and clean. 12 Dormy Way DS0000012362.V349681.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by adequate numbers of well trained staff and are protected by the home’s recruitment policies and practices. EVIDENCE: Staff training records showed that people working in the home received a wide range of training opportunities relevant to their work. Currently sixty-six per cent of staff in the home have an NVQ2 or equivalent in care. The remainder of the staff are working towards this qualification. Training courses covered a range of areas such as risk assessment, abuse, equality and diversity, food hygiene, health and safety, and health and manual handling as well as specific training for the particular needs of people living in the home. The induction programme for new staff was very comprehensive and good records were kept. 12 Dormy Way DS0000012362.V349681.R01.S.doc Version 5.2 Page 19 Staff spoken with were knowledgeable and demonstrated skills and understanding in working with people who have a learning disability. Training needs were formally identified with the line manager and staff were also supported to attend other courses that came up which they had a particular interest in. The home has a training plan in place and all training is well monitored. Rota’s showed that there were sufficient staff on duty at all times. There were three staff on duty each morning and two on duty each afternoon. Additional staff were on duty depending on the activities planned for people living in the home. At night there was one person sleeping-in. The home had been using some agency staffing over the previous months due to staff vacancies. Those vacancies were now being filled and the use of agency staff was decreasing. During the month of December the home had planned to use agency staff for thirty-one of one hundred and forty shifts. Staff spoken with and observed during the inspection visit were conscientious, enthusiastic, skilled and focussed on the needs of people living in the home. There had been a requirement from the previous inspection that all staff records as listed in Schedule 2 of the Care Home regulations are kept at the home. This requirement had been met. Examination of staff files showed that all necessary information was in place for all staff and that people were not able to begin working in the home before all necessary checks had been undertaken. The home had also begun to involve service users in the recruitment of staff. 12 Dormy Way DS0000012362.V349681.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a well managed home that is safe and responsive to their needs. EVIDENCE: The Manager of the home is registered and has demonstrated that she has the skills, knowledge and training to manage the service. In discussion the Manager was able to demonstrate that she has a clear understanding of the issues within the home and is able to manage them effectively. She also has developmental plans in place for the home. 12 Dormy Way DS0000012362.V349681.R01.S.doc Version 5.2 Page 21 The home has effective quality assurance processes in place that are focussed on the needs and views of people living in the home. These include internal audits, questionnaires for people who live in the home and their representatives, staff involvement and monthly Provider reports. The views of people living in the home were represented in local management meetings and staff meetings also focussed on the needs and views of people living in the home. Health and safety is well managed in the home. All equipment is serviced and checked regularly, maintenance issues are dealt with, incidents and accidents are recorded and regularly audited and good workplace risk assessments were in place. There were no outstanding health and safety issues in the home at the time of the inspection. The home had good workplace risk assessments in place, which were followed by staff. Health and safety checks in the home were very thorough and were recorded well. Incident and accident records were kept and were regularly monitored and reviewed. All servicing records were up-to-date. 12 Dormy Way DS0000012362.V349681.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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 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 3 13 3 14 3 15 3 16 3 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.V349681.R01.S.doc Version 5.2 Page 23 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. Refer to Standard Good Practice Recommendations 12 Dormy Way DS0000012362.V349681.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000012362.V349681.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!