Inspection on 04/10/05 for 12 Dormy Way

This inspection was carried out on 4th October 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 found no outstanding requirements from the previous inspection report, but made 1 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 25/06/06

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 Kathryn Kirk Unannounced Inspection 4th October 2005 10:30 12 Dormy Way DS0000012362.V252226.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 12 Dormy Way DS0000012362.V252226.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. 12 Dormy Way DS0000012362.V252226.R01.S.doc Version 5.0 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 Community Integrated Care Mr Jean Steve Michael Khodabacus Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 12 Dormy Way DS0000012362.V252226.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be at least 30 years of age. Date of last inspection 11th April 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 in the area. 12 Dormy Way is located on the outskirts of Gosport. It is a detached property in keeping with others in the are. 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 DS0000012362.V252226.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to take place in the year April 2005-March 2006. It lasted for two hours. Some key standards that had been met during the last inspection in April were not assessed on this occasion. To gain a more detailed overview of the service this report should be read in conjunction with the one dated 11 April 2005. The needs of current service users are such that they are unable to contribute verbally to the inspection process, however, all were present and some time was spent in their company. Two staff members took part in the inspection, parts of the house were seen and some documentation was examined. The acting manager had completed a pre inspection questionnaire, which provided details about the premises, staff, service users and policies and procedures. One relative had also sent in written feedback. A follow up visit was carried out on 11 October 2005 to examine some documentation that was not available during the initial inspection and to talk with the acting manager. What the service does well: What has improved since the last inspection? Care planning has been updated and there was evidence from records and discussions that goals are regularly reviewed and evaluated. 12 Dormy Way DS0000012362.V252226.R01.S.doc Version 5.0 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.V252226.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 12 Dormy Way DS0000012362.V252226.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): 5 The statement of terms and conditions would benefit from some further attention to ensure greater clarity and protection for service users. EVIDENCE: At the last inspection it was discussed that some contracts between service users, the Housing Association and Community Integrated Care had not been signed. This is still the case. For service users who do not have relatives to sign on their behalf, it was recommended that an advocate should be involved in the contractual process. Although there was evidence that a written request had been made in one instance, there was no evidence that an advocate had actually been involved. The statement of terms and conditions issued by Community Integrated Care also continues to be unclear in two contracts seen as to the amount of disability living allowance that each service user receives and what it is used for. These issues will be followed up at a separate meeting with senior managers. 12 Dormy Way DS0000012362.V252226.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): 6 7 and 9 Care planning has improved. Although service users are consulted on some aspects of their daily lives, this could be enhanced if staff were trained in different communication methods. Areas of risk have been assessed and appropriate risk management strategies have been put in place. EVIDENCE: It was discussed at the last inspection that not all care plans had been reviewed at least every six months. Examination of records on this occasion showed that care plans had been reviewed since the last inspection. Significant professionals had taken part in the process. In one instance the review had been particularly detailed and included goals and specific actions needed to achieve goals identified. Through discussion and further examination of records it was evident that the actions identified had been carried out, and that they had been evaluated to assess their effectiveness. It was observed that staff respect service users rights to make decisions in their daily routines, for example choosing what clothes to wear. One service user had been involved in the choice of their holiday location by looking at 12 Dormy Way DS0000012362.V252226.R01.S.doc Version 5.0 Page 10 pictures of different holiday options, for example the seaside, and by staff gauging their reaction. Communication issues are considered as part of the assessment and reviewing process and there was evidence on file that speech and language therapists had been involved to provide advice in the past. It was a recommendation of the last inspection that staff are given the opportunity to study Maketon, as one of the service users communicates in this way. This continues to be a recommendation. Any instance of where a decision has been made by others is documented and guidelines for staff have been provided. An example of this is where a listening device has been installed in service users bedrooms to assist staff in monitoring a medical condition. Records show that this issue was discussed with relevant professionals and with family members. Records checked indicated that risk assessment and guidelines for staff have been reviewed and updated since the last inspection. 12 Dormy Way DS0000012362.V252226.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): 12 16 and 17 Although service users are offered appropriate activities, they are not always able to take full advantage of them because of transport difficulties. Choice and rights are recognised. Meals are nutritious and balanced. EVIDENCE: Although all service users have specialist external day services they are not always able to attend because of transport issues. On the day of inspection this was the case, as the two staff on duty were unable to drive. Staff said that they had been advised that service users should use their disability living allowance to contribute towards the cost of the transport. As discussed in a previous section, the contractual details need to be clarified if this is the case. Bathroom and bedroom doors are lockable, although staff said that the needs of the current service users are such that it would not be appropriate for them to have keys to their bedrooms or the front door. Staff were observed to talk and interact with service users and not exclusively with each other 12 Dormy Way DS0000012362.V252226.R01.S.doc Version 5.0 Page 12 It was observed that staff had enabled one service user to spend time alone in their room listening to music but checked regularly to ensure that this continued to be what the service user wanted. Service users were seen to have unrestricted access to all communal areas of the house. There is a four weekly menu. Service users are offered one cooked meal at day and one lighter meal as well as breakfast. Staff on duty had a good knowledge of service users likes and dislikes and said that if one service user did not like what was on the menu that day, an alternative would be offered. There was evidence on file that dieticians have been involved for specialist advice where a need has been identified. Staff said that service users like to observe and sometimes help in the preparation of food and also accompany staff to the shops. 12 Dormy Way DS0000012362.V252226.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): 19 and 20 Health care needs are identified and are acted upon appropriately. Policies and procedures are in place to ensure that medicines are dealt with in a safe way. EVIDENCE: Health care issues are identified in a document called “my health” and are reviewed as part of the care planning process. There is documentary evidence that staff support service users to access health care facilities in the locality, for example dentist, opticians and support them to attend outpatient’s appointments. Health is monitored as part of the daily evaluation record that is kept for each service user. No service users self-administer medication. The home has an agreement with a local chemist for the provision of a monitored dosage system of medication. Staff said that a pharmacist visits every year to provide information and advice. A procedure relating to medication is available to staff. Separate guidelines have been established for the administration of “as required” medication. Medication is kept in locked cabinets, which appeared clean, and in order at the time of the visit. 12 Dormy Way DS0000012362.V252226.R01.S.doc Version 5.0 Page 14 Records were seen for medications that had been returned. Records were also seen for medication administered although on one occasion this had not been completed appropriately. This was discussed with the acting manager who agreed to follow this up. Staff said that all who administer medication are provided with relevant training every three months. 12 Dormy Way DS0000012362.V252226.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): 22 Procedures are in place to ensure that any concern can be acted upon appropriately. EVIDENCE: There is a complaints procedure in pictorial form, which is on display in the house. There is also information added to the statement of terms and conditions about how to make a complaint. The information includes the stages of, and timescales for the process, and informs on how and to whom to complain. There have been no complaints received about this service either at the home or by CSCI since the last inspection. One relative who provided written feedback said that they were not aware of the complaints procedure. This was discussed with the acting manager who agreed to provide them with the appropriate information. 12 Dormy Way DS0000012362.V252226.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 The home is clean and laundry facilities are suitable for purpose. EVIDENCE: On the day of inspection the premises were clean and free from offensive odours. The home has a separate utility room, which is equipped with a washing machine with a sluicing facility. The laundry floor finish is impermeable and the walls are readily cleanable. Staff said that they are supplied with protective gloves and aprons. Liquid soap and paper towels are available in the laundry area. 12 Dormy Way DS0000012362.V252226.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 and 34 Staff are competent, but the service would benefit from the recruitment of staff that are able to drive. Recruitment procedures need to be more rigorous to ensure that all necessary information is obtained during the staff selection process. EVIDENCE: Staff on duty on the day of inspection were observed to be accessible to and comfortable with service users and spoke knowledgeably about service users needs. Staff felt that the training offered by CIC helped them to carry out their jobs effectively. Staff said that of the five regular members of the team, three have successfully completed their NVQ level 3 in care and two are studying for it. The registered manager is currently seconded and there is an acting manager who is temporarily filling this role. There are two staff vacancies, which are at present being filled by bank staff or agency workers. The acting manager said that the home is trying to recruit staff that are able to drive, because of the needs of service users, particularly with regard to day care. The rota shows that a minimum of two staff are on duty at any one time during the day. There is an additional staff member on duty between 11 am and 7pm during the week and a staff member sleeps in each night. One staff record was sampled. This included evidence that two written references had been obtained, that a satisfactory CRB check had been undertaken and that the staff member had been interviewed. There was no 12 Dormy Way DS0000012362.V252226.R01.S.doc Version 5.0 Page 18 evidence of a recent photograph, copies of passport or birth certificate on file. It is a requirement that all this information is held and is available for inspection for all staff working at the home Staff said that they have been provided with a statement of terms and conditions. 12 Dormy Way DS0000012362.V252226.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): 39 Appropriate systems are in place to monitor and evaluate the service. EVIDENCE: Service users views and reactions to the service provided to them are considered as part of the care planning process. Community Integrated Care have completed a quality audit as an organisation. Views were sought from service users, relatives and staff. The most recent results were published in December 2003 A senior manager from Community Integrated care visits the home every month. During this time they talk with service users and staff in order to form an opinion of the standard of care provided within the home. A written report of the results of the visit is sent CSCI. The previous requirement identified at the last inspection has been met within agreed timescales. 12 Dormy Way DS0000012362.V252226.R01.S.doc Version 5.0 Page 20 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 X X X 2 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 X 3 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 2 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 12 Dormy Way Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X X X DS0000012362.V252226.R01.S.doc Version 5.0 Page 21 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 YA34 Regulation 19 Requirement That all staff records as listed in Schedule 2 of the Care Home regulations are kept at the home. Timescale for action 30/11/05 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 Refer to Standard YA55 YA35 Good Practice Recommendations That an advocate be contacted to support service users in contractual matters where no family support is available. 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