Inspection on 30/10/07 for 201 Drayton Avenue

This inspection was carried out on 30th October 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 201 Drayton Avenue Stratford-Upon-Avon Warwickshire CV37 9LD Lead Inspector Jo Johnson Key Unannounced Inspection 30th October 2007 14:30 201 Drayton Avenue DS0000069735.V354514.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 201 Drayton Avenue DS0000069735.V354514.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. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 201 Drayton Avenue Address Stratford-Upon-Avon Warwickshire CV37 9LD 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) 01789 298709 Stratford & District Mencap Mrs Julia Coppinger Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation for service users of both sexes whose primary care needs on admission the home are within the following categories: Learning Disablilty (LD) 4 The maximum number of service users to be accommodated is 4. 2. Date of last inspection First inspection Brief Description of the Service: 201 Drayton Avenue is registered for four people with learning disabilities. The home is a short stay service and one of the places is identified for emergency use. There is one ground floor bedroom that is suitable of people with physical disabilities and three bedrooms on the first floor. There is a staff office /sleeping in room. There is an open plan lounge, dining room and kitchen. It has an open front and enclosed rear garden and is situated on the outskirts of Stratford on Avon within a large estate of social housing. The town centre is accessible by bus. The current scale of charges was not available in the service users guide. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The inspection visit was unannounced (we did not let the home know that we were coming) and took place on 20th October 2007 at 2.30pm. The registered manager had left the organisation shortly before the inspection and the Assistant Service Manager for the organisation is covering as acting manager until a new manager can be appointed. The inspection involved: • • • Observations of and talking with the two people staying at the home and the support worker and acting manager on duty at the time. Observation of working practices and of the interaction between individuals and staff. Both people were identified for close examination by reading their, care plan, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’, where evidence is matched to outcomes for people. A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. • The inspector would like to thank the people who were staying at the home, the acting manager and staff for their hospitality and cooperation during the inspection visit. What the service does well: The people who stay at the home have good relationships with staff and they are relaxed with them. People are encouraged to be involved in the day-to-day running of the house during their stay. There are suitable assessments and care plans in place. Any risks to people have been assessed and the assessments are clear and easy to follow. People can take part in community leisure opportunities during their stays if they choose. 201 Drayton Avenue DS0000069735.V354514.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. The summary of this inspection report can be made available in other formats on request. 201 Drayton Avenue DS0000069735.V354514.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 201 Drayton Avenue DS0000069735.V354514.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good People’s needs are assessed and but not having information in the home means that they are not clear about their rights and entitlements during their stay. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager said that there was a statement of purpose and service user guide and that the service user guide is given to people and their parents and carers before them visiting the home. There was not a service user guide available at the home. There must be a service users guide to staying at the house for all people to look at when they stay. One person said they had not been given any information about the service before they came for their first stay. They said that he had visited and had tea before deciding to come and stay. They said “first time I’ve been anywhere, I’m staying here because Mum is poorly…I chose the bedroom with the big bed” 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 9 The acting manager explained that the existing assessments and care plans for people who have previously used the organisation’s short stay service were in the process of being reviewed. The acting manager said that any new referrals to the service are assessed in his or her own home and come for tea visits then overnight trial stays to see whether the service can meet their needs. There was an up to date local authority assessment in place for the person who was having their first stay at the home. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good Staff are provided with the information they need to meet peoples’ needs safely and consistently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records for both people staying at the home were seen. The care plans and risk assessments detailed the care and support people need during their stay at the home. The care plans cross referenced with risk assessments in place. One person’s care plan had been updated to include new information that had been provided by their parent at the start of this stay. One person showed the inspector their daily records that they had been helping to write with their daytime support worker. This is good practice to involve people in their record keeping. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 11 The staff member on duty had not met one of the people staying at the home before. They read the assessments and care plan on arrival at the home. They said that the plan had provided them with enough information to make sure that they could meet their needs. They showed a good understanding of the other person’s needs that was in their second week of their stay. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good People are supported in the local community and take part in activities. Their rights are respected and they have a varied and balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On arrival at the home, one person was in and another person returned later from their day at community day services. One person chose to spend their time sitting in the lounge drawing whilst staff prepared their evening meal. The other person chose not to assist with the evening meal but spent their time chatting with staff and the inspector whilst the meal was prepared. One person said “I’m happy here staff are nice”, the other person said they liked the staff when asked and was relaxed in the staff and acting manager’s company. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 13 When asked both people were content to stay at home in the evening and relax. From discussion with the acting manager and staff member on duty it depends who is staying at the home in terms of what evening or weekend activities they do. When there are four people staying at the home the staffing levels are increased to make sure that people can go out in the evenings with staff support if they choose to. Recent menus were seen and were found to reflect the preferences and needs of people that stay at the home. People’s food preferences and dietary needs are recorded in their care profiles. One person said “ I had pork pie for my dinner” and then chose to have cooked breakfast the next morning. The evening meal was freshly cooked and there was a relaxed and homely atmosphere. There was enough of a varied stock of food in the cupboards, fridge and freezer to make sure that people’s preferences could be catered for. There was fresh fruit and snacks available for people to help themselves. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good The health and personal care that people in this home receive is based on their individual needs. Staff respect the people and promote their dignity and privacy. Medication systems in place are safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were positive relationships and interactions observed between staff and the people who were staying at the home. People’s health needs are recorded in their care plans. The contact details of people’s GP’s are held on file so that they may be accessed in the event of an emergency during the person’s stay at the home. As the service provides a short breaks service, the prime responsibility for people’s health care remains with the person themselves or their relatives. The acting manager said that there are a number of younger people who are in transition from children’s’ services starting to be referred to the service. There 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 15 is now additional planning in the stays to make sure that the younger and older peoples needs are catered for. The acting manger identified that issues around sexuality and personal relationships have been raised during some young people’s stays. The staff need to be provided with personal relationship and sexuality training to make sure that they can safely inform and support people who use the short stay service. There is a gender mix of staff so that peoples’ gender preferences can be met. People’s parents or carers are required by the home to complete a form at the time of each new visit, detailing people’s current prescribed medication so that any changes that have taken place are made clear. People also have to bring a copy of their current prescription with them so that staff can check exactly what medication has been prescribed by the GP. This makes sure that the home holds current information and is up to date with changes in medication that may take place between the times of people’s visits to the home. There were no controlled drugs held on site at the time of this inspection visit. A bound book with numbered pages is in place for the proper recording of controlled drugs. An extra member of staff works at the home whenever controlled drugs need to be administered. Two members of staff are correctly signing the record when medication is given out to properly account for all controlled drugs that enter the home. Staff are trained in the medication policies and procedures during induction and there is a medication training programme. A risk assessment is in place for people who manage their own medication whilst staying at the home. People also sign a consent form agreeing to allow staff to monitor and check with them that they have taken their medication correctly, as an additional safeguard against administration errors. The medication records were seen and showed that the amount of medicines brought into the home tallied with the amount administered. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good Complaints procedures are in place so that people and their relatives/carers know that their concerns and complaints will be acted upon. A staff team who have a good knowledge of how to respond to any suspicion of abuse and to keep people safe from harm support the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This new service was only registered in May 2007. There have been no complaints made to the home or the commission. There is a complaints procedure in the service users guide that is supported by pictures; this is given to people when they first star using the service. There is a large poster with photos of all the staff in the kitchen so people know who they can talk to. As there is not a service users guide in the home people staying at the service, do not have easy access to the complaints procedure. One person spoken with was not sure how they could make a complaint but said they were happy with their stay so far. They said “ I’ll talk to staff if I’m unhappy”. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 17 An adult protection procedure is in place at the home to inform staff of the measures to take to report any suspicions of abuse. The staff member on duty had covered protection and whistle blowing procedures as part of her induction training (Learning Disability Award Framework induction training) and NVQ (National Vocational Qualification) knew how to report any concerns should this become necessary. At the time of the inspection, there had been no allegations of abuse made to the commission. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good The home is well maintained and furnished so that people stay in a homely, clean, comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The house was recently registered as a care home. The décor is homely, comfortable, and suitable for a short stay service. People staying there were able to move around easily and freely and to go to their bedrooms if they chose. The bedrooms have good quality and adequate storage facilities that are appropriate for short stay visits. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 19 The home was clean and free from any offensive odours. People staying at the home are encouraged to participate in the day-to-day cleaning of the house if they choose to. One person said, “ I like the new house”. At the point of registration, it was noted that there were not any window restrictors on the upstairs windows. To make sure that people are not at risk of falling out of the windows, either window restrictors need to be fitted or each person staying at the home be assessed for any risks. If any risks are identified then they must use the ground floor bedroom for their stays. There are suitable arrangements in place for infection control and laundry facilities. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good The procedures for selection and recruitment of staff are safe. The training of staff is of a suitable quality, ensuring that knowledgeable, suitable, well trained and managed staff support the people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Bookings are planned throughout the year and the staff rota is planned according to the number and needs of individuals. The training schedule shows that staff have been well trained in mandatory health and safety related training, (e.g. first aid, food hygiene and fire safety). All staff have also had epilepsy training. The acting manager said that equality and diversity training is now planned. As previously, identified staff need to be trained in personal relationship and relationship training so that they can appropriately support people who use the service in this area of their lives. The three most recently recruited staff records were seen. They included all of the necessary documentation to demonstrate that the staff are suitable to 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 21 work with people staying at the home apart from one file did not have the CRB (Criminal Records Bureau) reference number recorded. There were POVA (Protection of Vulnerable Adults) checks and references for all of the staff. It must be clarified whether the CRB check has been returned and the number be recorded on the staff file to show that all of the checks have been made to demonstrate that staff are suitable to work with people staying at the home. The acting manager is booking supervision sessions with all the staff. A staff member spoken with felt well supported by the previous manager. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good People benefit from staying in a safe and managed home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was registered in April 2007, as was the manager. The manager had left the organisation shortly before the inspection and the Assistant Service Manager was acting as manager. The post is being advertised and it is hoped to fill the vacancy as soon as possible. The acting manager will work alongside the new manager that is appointed. This is to make sure that there is consistency for the staff and the people who stay at the home. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 23 The organisation’s quality assurance system has been recently been reviewed and will now include formal consultation with families and professionals involved with people. A representative of the organisation carries out monthly monitoring visits and copies of the reports are kept at the home. The reports show that suitable arrangements are in place for monitoring the work of the home and provide an opportunity for the visitor to seek the views of people using the service and to check significant records, such as accidents, incidents and complaints. The acting manager plans to introduce a feedback form that will be sent to people at their homes following any stay at the house. This is so that any concerns can be addressed before their next stay. As the home has been recently registered, all of the relevant health and safety and maintenance checks were assessed at that time. A number of Health and Safety records were checked. These records showed that health and safety matters are well managed. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 24 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 2 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 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 25 First inspection 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 YA1 Regulation 5 Requirement There must be a service users guide or house guide available in the house. This is so that people know their rights and how to make a complaint when they are staying at the home Staff must be provided with personal relationship and sexuality training. This is to make sure that they can safely inform and support people who use the short stay service. It must be clarified whether one CRB check has been returned and the number be recorded on the staff file. This is to show that all of the checks have been made to demonstrate that staff are suitable to work with people staying at the home. Timescale for action 01/01/08 2 YA19 18 01/06/08 3 YA34 19 01/01/08 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 26 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 YA24 Good Practice Recommendations Window restrictors need to be fitted to first floor windows or each person staying at the home be assessed for any risks. If any risks are identified then they should use the ground floor bedroom for their stays. This is to make sure that people are not at risk of falling out of the windows. 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 201 Drayton Avenue DS0000069735.V354514.R01.S.doc Version 5.2 Page 28 - 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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