CARE HOME ADULTS 18-65
15 Sorrel Drive 15 Sorrel Drive Boughton Vale Rugby CV23 0TL Lead Inspector
Sheila Briddick Unannounced 01 September 2005 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. 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 15 Sorrel Drive Address 15 Sorrel Drive 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) 01788 546310 Mrs Elaine Sandra Ward Mrs Elaine Sandra Ward PC Care home 3 Category(ies) of LD Learning disability (3) registration, with number of places 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 26 March 2005 Brief Description of the Service: 15 Sorrel Drive was originally an adult placement home and was later registered as a small care home for younger adults with a learning disability. It is currently registered for 3 people. The home is a detached property, which has recently been extended, and is situated in Brownsover on the outskirts of Rugby. The home is close to local amenities and services. Service users have their own bedrooms and share the home with Mrs.Ward and her family, as part of the family. The family shared space consists of a kitchen, dining room, the lounge, conservatory and bathroom. There is a shower room facility on the ground floor. Two service users have a bedroom on the ground floor of the property. A third service user has a bedroom on the first floor. At the rear of the property there is a small, well-maintained garden. 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two visits were made to this home for this inspection. The first was unannounced and took place on 1 September 2005 between the hours of 3 p.m. and 4:30 p.m. during this time the inspector had the opportunity to meet with two service users and their views were sought on the service provision. A second visit took place on 6 September 2005 at 1.00pm when care plans and other home documents were examined. The third service user living at the home was met at this time and their views were also sought on the service provision. What the service does well: What has improved since the last inspection?
Since the last inspection the provider has completed accredited training in Food Hygiene and continues to explore further training opportunity in the field of learning disability. Risk assessment has improved to include action to be taken for service users with epilepsy. Information held in the home is kept secure and this includes ensuring that information on computers is password protected. Links have been established with the Community Learning Disability Team and each service user now has a Health Action Plan.
15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 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. 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 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 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 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) 1 The people living in this home are confident that the home is meeting their needs and aspirations. EVIDENCE: Discussion with the people living in this home evidenced that they have a full understanding of their rights and responsibilities within the home and are able to discuss with the provider any change in their needs and aspirations. This includes being able to talk to the provider quite openly about moving away from the home and the support they may need to do this. The provider is in the process of developing a Service User Guide, which could be available for any prospective service user coming to live in the home to enable them to make an informed decision about living there. 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 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 standard(s) 9 The people living in this home are supported to take responsible risks, which is enabling them to lead an independent lifestyle and achieve goals safely. EVIDENCE: The people living in the home said that they felt safe and were well aware of risks to their personal safety when in the community, in the home and regarding their health care needs. Risks are clearly identified on their care plan including completed risk assessments for epileptic seizures and actions to be taken in the event of this happening. 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 10 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 The people living in this home are supported to maintain appropriate and fulfilling lifestyles in and outside the home. EVIDENCE: Service users were happy to talk to the inspector about the range of activities they participate in both in the home, the local community and also through their day service provision. For one service user this includes attending courses at an agriculture college for country side skills, gardening, woodwork and computers. Two service users attend a day service and by doing so have opportunity to attend college for computer skill development and art. Service users also talked about the activities they participate in with the providers family and this includes working on the family allotment and going to the family caravan - we all go to the caravan together. I like it when we do and there are lots of people. Service users are also supported to access local sports facilities independently or with support if necessary. This includes going to the sports centre for swimming and coming back by taxi or bus independently.
15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 11 Service users are supported and encouraged to maintain friendships and links outside of the family home and this includes visiting friends, bringing friends back to the family home and maintaining links with relatives, which includes overnight stays. 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 12 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) 20 The provider is eager to improve their current system for medicine management to ensure that all medication in the home can be accounted for. EVIDENCE: The provider does not currently maintain a written record of incoming medication. The provider demonstrated an understanding of the importance of all medicine being accounted for in the home and the possible risks there may be for service users if this does not happen. 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 13 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) These standards were not assessed on this occasion. The standards were met however at the last inspection visit. EVIDENCE: 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 14 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) These standards were not assessed on this occasion. The standards were met however at the last inspection visit. EVIDENCE: 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 15 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) These standards were not assessed on this occasion. EVIDENCE: The majority of these standards do not apply, as the home does not permanently employ any staff. The provider ensures that service user needs are met on a daily basis and they are cared for. 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 16 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) 39 The systems for service user consultation in this home are good with a variety of evidence that indicates that service users views are both sought and acted upon. EVIDENCE: The provider is working closely with day services, social services, psychology services and community learning disability nurses to ensure that the aims and objectives of each person living in the home are actioned and reviewed regularly. It was demonstrated throughout the inspection that people living in the home are facilitated to make day-to-day decisions regarding lifestyle activities and personal choices and that their opinions are valued. Service users were comfortable in the home and a positive relationship was evident between service users, the provider and other family members. The provider said they have, and do, receive positive feedback from family members of service users and specialist services involved in the care provision and this has sometimes has been in written feedback. It is the providers
15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 17 intention to maintain a record of all feedback as part of the quality monitoring system that is to be developed. 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 18 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 3 x x x x Standard No 22 23
ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
15 Sorrel Drive Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x x x E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 19 Yes 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 20 Regulation 13 Requirement The registered provider must ensure that there is record of incoming medication. It must be clearly stated how unused medication is disposed of. (Previous timescale of 31 May 2005 not met) A quality assurance and quality monitoring system needs to be implemented which demonstrates that the manager regularly reviews the quality of service being provided to the service users. (Previous timescale of 31 April 2005 not met) Timescale for action 1 December 2005 2. 39 24 1 January 2006 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 1 Good Practice Recommendations It is recommended that a service user guide for the home be developed in the event of perspective service user coming to live in the home. This will enable an informed decision to be made. It is recommended that the views of other professionals
E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 20 2. 39 15 Sorrel Drive involved in the care provision in the home are sought as part of the quality monitoring system being developed in the home. 15 Sorrel Drive E53 s4332 15 Sorrel Drive v247955 010905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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