Inspection on 22/02/07 for 16 Godwyne Road

This inspection was carried out on 22nd February 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

16 Godwyne Road 12/12/05

16 Godwyne Road 20/06/05

16 Godwyne Road 30/11/04

16 Godwyne Road 24/05/04

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Insight - Eastchurch

Southfields

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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 16 Godwyne Road 16 Godwyne Road Dover Kent CT16 1SW Lead Inspector Julie Sumner Key Unannounced Inspection 22nd February 2007 10:00 16 Godwyne Road DS0000023285.V307186.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 16 Godwyne Road DS0000023285.V307186.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. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 16 Godwyne Road Address 16 Godwyne Road Dover Kent CT16 1SW 01304 201714 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) Mr Peter John May Mr Peter John May Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 Brief Description of the Service: Godwyne Road, is a large semi-detached period residence, occupying a corner plot in a residential area of Dover. The current fees for the service at the time of the visit range from £551.00 to £581.00. Information on the home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The home is located on a hillside overlooking the town and has views of Dover castle. The home is within walking distance of local bus routes, leisure facilities, shops, pubs and restaurants. Some street parking is available. Although registered for 10, only 8 service users are in residence. The accommodation ranges over four floors, access to all levels is via two staircases to the front and rear of the building, all service users must, therefore be ambulant and able to negotiate stairs. Seven service user bedrooms are used for single occupancy; they all have washbasins installed. A shared bedroom is located on the top floor. There are a satisfactory number of shared communal washing facilities for the existing number of service users, with two bathrooms and toilets, one shower facility, and one single toilet, staff have their own toilet and wash facilities. The home has one main lounge on the first floor and an activities/dining room on the basement/ground level. The kitchen and a separate laundry area are also provided at basement level. The home benefits from a good-sized rear garden mainly laid to lawn, which can be accessed from the laundry area. There is some garden seating and furniture for residents use. Two double gates are located to the side and end of the garden, these are kept shut. The current mixed sex user group are aged between 40 and 70 years of age. The home operates a key worker system. The present owner also undertakes the day-to-day operational management of the home. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. 16 Godwyne road provides a safe, stimulating and homely environment for service users. The inspector visited the home to talk to service users and staff and view records and practices. The time spent in the home overall was around 9 hours at different times over two days. Information was gathered for this inspection by a variety of means both prior to and during the visits to the home. The CSCI request information from the home routinely and the owner, Peter May, provided all the information requested for this inspection. Feedback was received from service users and relatives. Service users talked about their lifestyle and said that they liked living here “staff are nice”, ”food is good” like my room” and “like going out”. All comments received about the home were positive for example one service users’ relatives commented “they are really happy with the home” and “can visit any time they like, staff are always welcoming and friendly”. All requirements and recommendations from the previous inspection have been acted on. There were no requirements or recommendations as a result of this inspection. What the service does well: The owner and deputy manager have a good vision and know what direction they want the care planning system to go into and how to encourage service users to participate in the plans and running of the home. Staff spend a great deal of time talking to service users to find out what they want and if there is anything that they want to do differently. A good mixture of activities are offered to keep everyone occupied and develop daily living skills. The home provides a comfortable, domestic setting and is designed and decorated in the way service users want. Staff are motivated and enthusiastic in their work and training is based on what staff want to learn and developing the skills of the team to meet the assessed needs of service users. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 16 Godwyne Road DS0000023285.V307186.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 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Previous admissions would indicate that prospective service users are appropriately assessed by the home to ensure their needs can be met, not only by the staff team but the home environment. EVIDENCE: There have been no new service users. The owner makes sure that service users moving into the home are compatible with the group already living in the home and so far no one has come forward. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff take great care to consult with service users to enable them to be involved and participate in the contents of the care plan. Service users are supported to influence decisions about their own lives. Risks are identified, recorded and minimised ensuring that service users are protected and kept as safe as possible. EVIDENCE: The care planning system is being redesigned. A sample of plans were viewed and discussed with the deputy manager who showed different examples of the old system and the revised system as the care plans are being reviewed. There was good evidence of consultation with service users. They have signed in some places. There is a pictorial summary with smiley faces with different expressions and other symbols for service users to complete to state how they 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 10 think their plan is going and whether they are reaching their goals and if they still have the same goals. A sample of completed summaries was viewed. Meetings and one-to-one consultations are arranged routinely with service users and the owner, deputy manager or key worker to give everyone the opportunity to express their views and wishes in whatever forum suits them. Each person’s communication board is used as a tool to assist service users in making choices about how they want to spend their day and staff spend time both planning the day at the beginning and talking about what went well and how the day went at the end. Risk assessments are written and relate to the different experiences and opportunities being focused on as part of the service user plan. A sample was viewed and contained clear guidelines for staff. Staff confirmed that the guidelines were easy to follow and that they were listened to if they needed altering/reviewing. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to choose from a good range of occupational activities to participate in both in the home and outside. Help with communication skills is given by staff to assist with pursuing interesting activities both in the home and in the community Service users have the opportunity to maintain important personal and family relationships. Routines in the home are flexible and service users’ privacy is respected. The food in the home is of good quality and attractively presented. EVIDENCE: The deputy explained that the staff team started by supporting basic self help skills like getting washed and dressed themselves. Gradually they have been making choices with day to day living skills and have participated in housework 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 12 tasks, cooking and going out shopping etc. In conversation with service users and staff it was explained that how each person spends their time depends on his or her interests. Service users talked about their interests and they were also observed pursuing some of them during the visit, for instance, one service user was knitting whilst talking. Relatives said that the home was always welcoming and there were no limits to visiting time. They felt involved in the support of their relative as much as they wished to be. Service users spoke about their families, going home on visits or having event that the families attended. Staff were observed interacting with service users, encouraging their participation in household activities e.g. helping with meal preparation in the kitchen and clearing up after meals. Service users behaved in a relaxed and unrushed manner as they carried out different activities throughout the inspection visits. The inspector had lunch with service users and staff. It was well presented in a social atmosphere and balanced with a consideration for service users’ health and wellbeing. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their wishes and preferences will be taken into account in how they are supported. Service users benefit from good health care support and are able to access community health care services. Medication procedures have improved and medication is stored and administered correctly and safely. EVIDENCE: Staff have spent time getting to know service users to find out what their preferences are. There are clear guidelines in the service user plans for staff and these are also referred to when there has been a change in need and approach. Service users said they could tell staff what they wanted and they could change things. Each service user has a photo communication board in their room to use as the planner for their day and to reflect at the end of the day. The speech and language therapist has been involved with those who need it and one person is going to have a planning board using objects instead of pictures. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 14 Service users attend regular appointments with dentist, optician and a chiropodist visits. There is a record of all appointments attended. Service users are supported to maintain a healthy lifestyle and their health is included in the monthly care review. One service user has had additional support with changing needs due to ageing. Medication storage was viewed and discussed with the owner. All boxed and bottles of medication had been dated when opened and all were clean and stored tidily. The home uses a monitored dosage cassette system. All records were completed accurately using appropriate codes and all medication is countersigned at the end of each day. Staff have attended training and there is relevant information in the file of all medication used including a description of each tablet, what they are for, all different names used for each medication, explanation of side effects and guidelines of what to do if something goes wrong. The auditing was discussed with the owner. Checks are in place daily, weekly and monthly. Medication is also included in the 3 monthly quality assurance monitoring check. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an effective complaints process. Service users are given the means to express their feelings. Service users are protected from harm by the policies and procedures in the home. Staff are knowledgeable about adult protection. EVIDENCE: Service users said if they had a problem they would speak to staff. “Staff are nice.” Staff described both the formal complaints procedure and the in-house policy of being open with each other if there are practices that they are unsure or unhappy about. Service users are assisted to express their wishes with communication aids including their communication boards, photos and symbols. Staff were asked about the home’s adult protection procedures and were confident and clear in their responses. Positive and supportive interactions were observed between service users and staff. All staff have attended adult protection training as part of their induction training. Behaviour support guidelines were discussed with the deputy manager and staff. A sample of intervention plans were viewed and contained clear descriptions and guidelines for staff to what to do. Staff explained that the plans are discussed with service users and agreements made about how to minimise the causes e.g. times and places to go out. Service users confirmed that they were consulted and were happy with the support they received. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 16 Staff also described the procedure for supporting service users with their personal allowance and how their money is accounted for. Records of all transactions are kept. Personal inventories were seen in service user plans. Relatives act as appointees for most service users. The finances are also part of the quality assurance audit which was viewed. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and a positive environment is provided for service users to live in. Service users are actively involved in choosing the furniture and décor in the home. It is clean and well maintained. EVIDENCE: A service user showed the inspector around the home. Service users said they were happy with the home and liked their bedrooms. One service user has recently moved bedrooms due to a change in need with regard to mobility and now has a more accessible room. Various parts of the home were identified in the development plan for improvement and redecoration and at the time of the visit the hallway and stairs were being painted. One service user said he had chosen the colour for the hallway and stairs and from discussions during the visit service users are generally encouraged to participate in the decision about colour schemes. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 18 There is a daily checklist that staff complete at the end of every shift to make sure all tasks and checks have been done. This includes checking that parts of the house are clean including the oven and general cleaning schedule. Appropriate infection control measures were observed to be in place. All staff have attended infection control training. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team have a strong commitment to enabling service users to develop their skills, including social, emotional, communication, and independent living skills. There is a robust recruitment process and good induction process. Service users benefit from an enthusiastic and supportive staff team. EVIDENCE: The staffing level is proportionately the same as there are less service users living in the home at present however on some days there are still 4 staff on a shift and at these times more one to one activities are carried out. A sample of staff files were viewed and the recruitment process discussed with the owner. All records were in good order with all required checks carried out. The newer staff also spoke about the recruitment from their perspective. They said that they had been given a good range of training and had felt supported when they first started work with a good induction. Training was discussed with the owner and the training matrix viewed. The owner intends to design more training that is relevant and useful for supporting service users with learning disabilities in a care environment. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 20 Following feedback from the staff where some of the training they have recently attended particularly the mandatory training they have only found partially useful and it has been directed at either nursing care (infection control) or a factory/product style work environment (health and safety). Staff explained their day to day role. Different staff have specific responsibilities in the home and this gave continuity and accountability in the team. Staff said they had regular consultations (supervisions) with the deputy manager and found these useful to express their thoughts and also to discuss ideas for supporting service users development and lifestyle. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 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 a well managed home. There is a good quality monitoring system in place. Feedback is sought in a variety of ways from service users depending on their understanding and communication skills. The home has a good record of meeting health and safety requirements. EVIDENCE: The owner and deputy manager have both completed NVQ level 4 – the registered managers award. The system for monitoring the quality of the service has been developed. There is a daily checklist that staff complete at the end of every shift to make sure all tasks and checks have been done. This includes checking that aspects of care have been completed, parts of the house are clean, checking food 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 22 stocks of essentials and the food needed for the menu is there, checking that the mobile phone is charged and the digital camera is there. They use this to take photos of activities, food on the menu etc as communication pictorial aid. There is a quality assurance monitoring form that is completed 3 monthly. The owner has created a staff post of care executive to monitor quality so that it is consistent. They go through all aspects of the checklist routinely so that everything has been checked and shortfalls highlighted every 3 months. They will check the daily logs, and sample all other documentation including health checks, medication, service user plans, 4 weekly summaries made by the key worker amongst others. Feedback is also sought from relatives and visiting professionals and views of service users are sought as part of the daily routine, in reviews and one-to-one meetings. The home has a development plan that covers all relevant aspects and highlights the priorities for the year with proposed timescales. The home has a fire risk assessment and keeps a log of all checks and fire training which was kept up to date. All equipment is regularly serviced. The home keeps certificates as a record. There is a rolling training programme to keep mandatory staff training up to date. The training matrix and a sample of maintenance check certificates were viewed. 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 23 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 x 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 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 24 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 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 16 Godwyne Road DS0000023285.V307186.R01.S.doc Version 5.2 Page 26 - 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!