Inspection on 04/07/05 for 150 Community Drive

This inspection was carried out on 4th July 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

150 Community Drive 17/07/07

150 Community Drive 05/12/06

150 Community Drive 02/12/05

150 Community Drive 21/02/05

150 Community Drive 19/07/04

150 Community Drive 06/01/04

Similar services:

Breme

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Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

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

CARE HOME ADULTS 18-65 150 Community Drive Smallthorne Stoke on Trent Staffordshire ST6 1QF Lead Inspector Berwyn Babb Unannounced 04 July 2005 13-55pm 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. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 150 Community Drive Address 150 Community Drive Smallthorne Stoke on Trent Staffordshire ST6 1QF 01782 839349 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) Choices Housing Association Limited Mrs Gillian Hussey Care Home 8 Category(ies) of 8 LD registration, with number 8 MD of places 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21 February 2005 Brief Description of the Service: 150 Community Drive is a large detached house registered to provide accommodation for eight younger and older adults who have Learning Disabilities, or Mental disorders other than Learning Disability or Dementia. It is situated close to local shops on the edge of a residential estate, and is not identified by any stigmatising signs, names, or notices, and easily blends into the locality.The home is owned by Choices, a company that operates a group of homes for people with Learning Disabilities.The current group of Service Users are all male, ranging in age from the early fifties to the late seventies. They live on two self-contained floors, each housing four residents. There are generous communal areas inside the property, and a secluded garden outside, where some of the resident service users have established an allotment, as well as the usual lawns and shrubs. Young plants are brought on in the greenhouse. This had recently been renewed.Public transport buses pass the end of the Drive. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this inspection the residents were having their individual needs and aspirations met in a domestic, friendly setting, with the help of staff who displayed a real concern for their welfare and affection for their personhood. What the service does well: What has improved since the last inspection? What they could do better: The only requirement of this report follows on from the lax attention to the keeping of the Medication Administration Record, and further training and supervision needs to be done to ensure that all staff undertaking the task of administering medication keep precise records. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 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. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 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 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 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) 2, and 5 The records detailed both the assessment of prospective new residents needs before they entered the home, and included a tenancy agreement setting out terms and conditions [a contract]. EVIDENCE: The care plan of the most recently admitted resident was examined in depth, and this showed that the pre-admission process had been robust, substantial, and protracted enough, to allow time to ensure that the assessed needs, personality and choices of that resident, were a match that would correspond with those of the existing residents, and that it was possible to observe the beginnings of a rapport developing. Initial contact had been through a local authority social worker, who had been the manager of a full care management process assessment. This had been made available to the management of the home, and had been supplemented by their own assessment on meeting the gentleman himself. Each resident had a tenancy agreement on the personal care file, and the content of these agreements coincided with the requirements in Standard 5 of the Younger Adults National Minimum Standards. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 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) 7, 8, and 9 Residents were being assisted to make decisions affecting their lives, including participating in the daily running of the home, with support when needed, to take identified risks. EVIDENCE: The inspector was able to observe during the visit how residents were encouraged and supported to take part in the day to day activities of the home, such as meal planning and preparation, minor domestic chores such as responsibility for the tidiness of their room and making their bed, as well as taking a turn at the washing up or laying the table or doing a bit of dusting. He also discussed with them their input into day out and holiday planning, and the season’s program for the greenhouse and the vegetable patch. When reading a randomly selected sample of their care plans, he was able to observe programs of education and training that had been put in place to reduce identified risks to an acceptable level for them to undertake tasks of their personal choice [such as going to the shops]. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 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, 14, and 17 The activities being undertaken by residents were observed to be appropriate, as were their choices of recreation. They were accessing the community, and their meals and mealtimes were guided by their choice. EVIDENCE: Both care plans and individual discussion with residents and staff, identified some very robust choices about engaging in activities, education, and training, or devoting their time to leisure activities of their own choosing. There was similarly supported evidence of them accessing the community, using the facilities of local shops, pubs, clubs, and other leisure related premises such as the library, theatre, or cinema. During the afternoon various people discussed what they fancied for tea, with some reaching an agreement about a joint choice, and others opting for individual alternatives. Care plans identified particular dietary needs to be taken account of, and there was physical evidence of fruit being available at all times, and of a commitment to education towards healthy eating. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, and 20. Residents were receiving personal support appropriate to their needs and wishes, and there were full records of their health needs and how they were being met, but the medication record contained a worrying number of anomalies. EVIDENCE: Examination of the Medication Administration Records revealed a substantial number of missed signatures covering all residents and spread over the whole of the month. There were also instances of the use of the F [other, define] symbol having been used, without any definition being given for the nonadministration of that particular dose of medication. Additionally, there was no regular usage of a method for recording the giving of “as required” medication. In some instances an X had been marked on the sheet when the medication had not been required, and in other instances the sheet had been left blank. There will be a requirement as a result of these discrepancies. The inspector was able to observe the sensitive manner in which personal support or prompting was offered, and a formal interview with a member of staff identified a dignified ethos and culture of care giving. Examination of care plans demonstrated that services had been appropriately accessed to support a resident at a time of emotional crisis. It also demonstrated that known health needs were planned for, and that residents were assisted to keep appointments, and to receive tertiary health care from 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 12 Dentists, Opticians, and Chiropodists. All current residents were active enough to attend their Doctors and other medical centres in normal circumstances, though community nurses did visit the home, both to give advice, and to perform specific tasks. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 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) 23 The residents were living in an environment that was geared to protect them from potential abuse. EVIDENCE: The inspector interviewed a member of staff in depth, and during discussions about the vulnerability of the residents, felt that she showed a thorough understanding of who could abuse a resident, and what acts of omission or commission could constitute an abuse, and what action she should take should she suspect that someone was being abused. Her responses confirmed the policies that the registered proprietors had available on the subject, and it was noted with satisfaction that these included making the complaints procedure available to residents in a form that had been pictorially enhanced, to aid their understanding of, and ability to access the procedure. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 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) 24, 25, 26, 27, 28, 29 and 30 The evidence gathered from observation, discussion, and entries seen in care plans suggested that residents lived in a home that had been designed with their identified needs in mind, and was maintained in good order, with the provision of specialist equipment when the need was identified, adequate personal and communal space appropriate to their choice and requirements, and clean and hygienic throughout. EVIDENCE: Not all private rooms were examined on this unannounced inspection, but those seen met the minimum space requirements, and displayed the needs and interests of those individuals for whom they were provided, including substantial evidence of their choices and memorabilia. One resident impressed upon the inspector his pleasure at the décor of his room and the style in which it was furnished, and in his ability to retain a key to the door to ensure added safety to his possessions, including his trophies and certificates of achievements attained. There was evidence from documentation and discussion, that the effects of the advancing years of one gentleman were being eased by the provision of a 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 15 replacement bath fitted with a hoist/seat on the advice of, and to the specification of an occupational therapist. Communal areas were generous, but staff are still trying to promote greater use of the lounge areas, which are more comfortably furnished than the kitchen/diners, where residents appear to enjoy spending most of their time when in the home and not in their own rooms. [Is this contemporary evidence of the old Potteries culture of the front parlour only being used on high days and holidays, or does it more reflect years of ward based care in hospital institutions, where all areas were designed to be visible from the nursing station?] The home was clean, tidy, and free from odour, and the nature of its construction blended into the surrounding buildings so not as to stigmatise it as a care home, and its location provided easy access to many local amenities such as clubs, pubs, and shops. Residents were seen to be making use of these facilities, either with assistance [escort] or on their own, and examination of a randomly chosen sample of care plans demonstrated that some people had been enabled to do this after education/training/advice, following initial risk assessments that had indicated hazards. These risk assessments had been regularly reviewed to include progress being made, and the resultant expansion in the independence of the resident. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 16 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) 35 Observation, discussion, and examination of records supported the view that staff are generally well trained to meet the needs of service users, with the proviso that greater attention needs to be paid to medication administration training so that no future report has to make requirements about the state of the M. A. R. sheets. EVIDENCE: At all times during this inspection there were two staff available for a possible total of eight residents, though for most of the time there were fewer men in the home as others were fulfilling their choice of leisure occupation, and one man was being escorted to a medical appointment by a third member of staff. Staff rota’s examined confirmed an appropriate level of input at all times, with there always being someone sleeping in at night time. In the formal interview the inspector was told that the registered providers arranged for very comprehensive programs of training compared with other employers this carer had worked for, and took responsibility for ensuring that mandatory training refresher courses were flagged up before certificates expired, and facilitating that training either through their own training department, or with outside agents. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 17 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) 38, and 42 Observation and discussion, and the examination of a sample of records confirmed the culture among management and staff of positive regard for the residents, and the primacy of their needs in determining the program for the home, and all but one of the records and observations examined and taken indicated that the health, welfare, and safety of residents was being promoted. EVIDENCE: The exception to the fullness of the records examined was the Medication Administration Record as stated in previous standards, one of which will be used to make the necessary requirement. Other records see, which were completed to the standard required, were all fire procedure checks, the complaints book, the quality assurance record of responses to the family satisfaction survey, various risk assessments both for environmental and physical needs, including client choice, retrospective menus, and the program of daily safety checks carried out each night when residents retire. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 18 Discussion with staff on duty and comments about them from residents identified the needs, choices, and aspirations of the residents as being at the centre of the running of the home. In this smaller type of home where the needs of residents were less to do with body systems failing than they were with lifelong and relatively stable conditions, the balance between ensuring homoeostasis and enabling lifestyle fulfilment allowed for the whole ethos of management and planning to be at a more personal level. The need for the group of residents being accommodated to have so much more explained to them in greater detail comes with a very positive spin off, for such a domestic style of care to succeed for them, they have to be consulted at every level of any activity undertaken in the home. The evidence seen on the day of this inspection suggests that the style of care is indeed successful for this group of residents, and that they are enjoying living in an open, positive, and inclusive atmosphere. 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 19 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 3 x x 3 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 4 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 4 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 150 Community Drive Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 x E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 20 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 YA20 Regulation Reg 1 [a] Shedule 3 [K]. Requirement The Medication Administration Record must allways be a true, accurate, and obvious record of medications administered, refused, or for any other reason, not given. Timescale for action Within 48 hours of the person in charge being notified,ie, 06/07/05 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. Refer to Standard Good Practice Recommendations 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 150 Community Drive E51-E09 S8212 150 Community Drive V239055 040705 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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