Inspection on 30/12/05 for 2 Dunstans Drive

This inspection was carried out on 30th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 Dunstans Drive 05/09/06

2 Dunstans Drive 27/06/05

2 Dunstans Drive 25/10/04

2 Dunstans Drive 06/05/04

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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 2 Dunstans Drive Winnersh Wokingham Berks RG41 5EB Lead Inspector Marie Carvell Unannounced Inspection 10:30 30 December 2005 th DS0000051745.V262948.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 DS0000051745.V262948.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. DS0000051745.V262948.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 2 Dunstans Drive Address Winnersh Wokingham Berks RG41 5EB 0118 929 7900 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) New Support Options Limited Mrs Caroline Lisa Bilsby Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000051745.V262948.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: Dunstans Drive provides accommodation and personal care for four adults who have learning and associated physical disabilities. The accommodation is purpose built and is sited on a residential estate offering all ground accommodation. Toynbee Housing Association Group owns the building and the care is provided by New Support Options. The home is situated approximately ten minutes from Wokingham and Reading town centres; all community facilities are easily accessible with shops within walking distance. The home has its own vehicle and there is good access to public transport. DS0000051745.V262948.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by the lead inspector for the home on a weekday from 10.30am until 3.20pm, and was unannounced. A brief tour of the communal areas of the home and several bedrooms, at the invitation of the service users were seen. A sample of records relating to service users, staff and records required to be kept in the home, including health, safety and fire were examined, when available. Time was spent briefly with the manager by telephone, who was on sick leave, staff on duty and the four service users. At the last inspection in June 2005, one requirement and one recommendation was made, regarding the updating of the complaints procedure and written records maintained of all complaints received by the home and that the manager obtains a copy of the multi-agency procedures for the protection of vulnerable adults from abuse. The requirement has been partly met and it was not evidenced that the recommendation has been carried out. What the service does well: What has improved since the last inspection? Some staff appointments have been made. DS0000051745.V262948.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. DS0000051745.V262948.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 DS0000051745.V262948.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): None of these standards were inspected. EVIDENCE: DS0000051745.V262948.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): None of these standards were inspected. EVIDENCE: DS0000051745.V262948.R01.S.doc Version 5.0 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 the following standard(s): None of these standards were inspected. EVIDENCE: DS0000051745.V262948.R01.S.doc Version 5.0 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 the following standard(s): 20 Medication is administered in a safe and appropriate manner. EVIDENCE: Medication administration records were well maintained with no obvious gaps in recordings. All staff who administer medication receive medication training. Guidelines are in place for individual service user’s PRN (when necessary) medication. Medication is stored appropriately in a locked cabinet. DS0000051745.V262948.R01.S.doc Version 5.0 Page 12 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 and 23 The home has a clear complaints procedure. One complaint received was not recorded. This was subject to requirement at the last inspection. The home does not have a copy of the Multi-Agency Policy and Procedures for the Protection of Vulnerable Adults from Abuse. This was subject to recommendation at the last inspection. EVIDENCE: Since the last inspection the complaints procedure has been updated. Each service user has a copy of the complaints procedure in pictorial format. The last complaint recorded in the home’s complaints book was dated 19/04/04. However, the inspector was informed at the last inspection that a complaint had been received in May 2005 regarding care issues. This has not been recorded. Not all staff have received training in the protection of vulnerable adults from abuse. The home does not have a copy of the multi-agency procedures and staff on duty were unclear about the organisations procedures for the protection of vulnerable adults from abuse. DS0000051745.V262948.R01.S.doc Version 5.0 Page 13 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 and 30 The home is comfortable, homely and meets the needs of the service users. EVIDENCE: The home is in need of redecoration, as some communal areas are looking shabby. The kitchen is to be refurbished, although a date has not yet been agreed. Staff on duty said that the oven was not working properly; staff were unclear whether the oven temperature control was working correctly. The cubicle in the shower room leaks badly when used and needs urgent attention. All areas of the home were found to be clean, comfortable, homely and free from unpleasant odours. DS0000051745.V262948.R01.S.doc Version 5.0 Page 14 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 and 36 From the documentation available and discussion with staff on duty it was not evidenced that these standards are being met. EVIDENCE: In discussion with staff on duty, only one had commenced NVQ level II training recently. Training records showed that out of a staff team of eleven, only two staff had completed NVQ training. Personnel records were not available as the manager was not available. Recruitment policies and procedures were also unavailable as these are stored on the computer and the system was available. Staff on duty described the process of recruitment and confirmed that two written references and a criminal records bureau check was completed before commencing work. In discussion with the manager by telephone, she confirmed that staff recruitment procedures and documentation meet requirements and national minimum standards. Staff on duty said that they had received a five day induction training at the time of appointment. Training records are not up to date and it was not evidenced what training had been provided to staff. Some staff on duty have not received training in fire safety, protection of vulnerable adults from abuse, food basic hygiene, infection control or moving and handling. DS0000051745.V262948.R01.S.doc Version 5.0 Page 15 It was not evidenced that staff receive regular, recorded supervision at least six times per year. DS0000051745.V262948.R01.S.doc Version 5.0 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 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 and 42 Effective quality monitoring systems based on seeking the views of the service users are in place. Records relating to fire, health and safety, when available were up to date and well maintained. EVIDENCE: Effective monitoring systems based on seeking the views of the service users take place on a regular basis. Service user “house meetings” are held every two months. Reviews take place yearly and involve relatives, social and healthcare professionals. Records relating to risk assessments, hot water temperatures, fridge and freezer temperatures were up to date and well maintained. As referred to in standard 35 not all staff have received training in fire, health and safety. Accident records or accident audit records were not available for examination by the inspector. The accident book demonstrated that fourteen DS0000051745.V262948.R01.S.doc Version 5.0 Page 17 pages had been removed, whether this reflected accidents to service users or members of staff is not known or the timescale involved. DS0000051745.V262948.R01.S.doc Version 5.0 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 x x x x x Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 1 x 2 1 1 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x DS0000051745.V262948.R01.S.doc Version 5.0 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 YA22 Regulation 22 Requirement That the manager ensures that a written record is maintained of all complaints received by the home. Previous timescale of 12/07/05 not met. That the manager advised the CSCI of action taken to provide all staff with training in the protection of vulnerable adults from abuse and the multi-agency procedures. That the manager advises the CSCI of action taken to redecorate communal areas of the home and refurbishment of the kitchen and shower cubicle. That the manager advises the CSCI of action taken to meet this standard. That the manager advises the CSCI of action taken to meet this standard That the manager updates all training records are send the CSCI a copy of the home’s staff training and development plan. That the manager advises the CSCI of action taken to ensure that all staff receive regular, recorded supervision from DS0000051745.V262948.R01.S.doc Timescale for action 30/01/06 2 YA23 13 30/01/06 3 YA24 23 30/01/06 4 5 6 YA32 YA34 YA35 18 17,19 & Sch 2 18 30/01/06 30/01/06 10/02/06 7 YA36 18(2) 10/02/06 Version 5.0 Page 20 appropriately trained staff. 8 YA42 17 & sch 3(j) That the manager sends the CSCI with details of the fourteen accidents, identified during this inspection. 30/01/06 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 DS0000051745.V262948.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 DS0000051745.V262948.R01.S.doc Version 5.0 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. 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. 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