Inspection on 28/06/06 for 46 Derby Road

This inspection was carried out on 28th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

46 Derby Road 06/01/06

46 Derby Road 07/06/05

46 Derby Road 15/05/05

46 Derby Road 24/06/04

46 Derby Road 08/12/03

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

CARE HOME ADULTS 18-65 46 Derby Road, Burton On Trent Staffordshire DE14 1RP Lead Inspector Ms Wendy Jones Key Unannounced Inspection 28 June 2006 9:00 46 Derby Road, DS0000004931.V299581.R02.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 46 Derby Road, DS0000004931.V299581.R02.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. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 46 Derby Road, Address Burton On Trent Staffordshire DE14 1RP 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) 01283 536290 Robinia Care Homes (2) Limited Ms Tracy Jane Morrall Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To complete the Registered Care Manager’s Award by 2008. Date of last inspection 6th January 2006 Brief Description of the Service: 46 Derby Road is registered for three younger adults with a moderate learning disability. This setting provides a home for life with support, which promotes independence and development of social skills, for each service user. The building is a large period semi-detached house located in a residential area on the outskirts of Burton upon Trent town centre and as such does not present as a care setting. The home is conveniently situated close to a town, on a bus route and close to shops and all amenities. The house is set back from the main road and has parking spaces at the rear, which is accessed by drive to the side of the house. The building is on two floors and comprises; three bedrooms (1 en-suite shower), an office, sleeping in room, lounge, dining/activity room, kitchen, on bathroom with shower, and one separate toilet, laundry room and storage. The home is not suitable for any person with a severe physical disability. There is a garden at the front and rear, and a useful patio area at the rear. 46 Derby Road, DS0000004931.V299581.R02.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 of 46 Derby Road Residential Care Home, carried out on 28 June 2006. The inspection methodology included pre inspection details; service user, and relative questionnaires, discussion with social workers; inspection of the environment; discussion with service users, staff and the manager; inspection of care records and other documents pertinent to the inspection process. The service provides care and accommodation for 3 service users, who have Learning Disabilities, dependency levels were described as high. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that all fire safety issues identified have been addressed, including remedial action to the fire doors, review of the fire evacuation procedures, replacement of the fire alarm system. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 6 Improve the of staff trained to NVQ level 2 and above. Consider the service users request for new garden furniture. 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. 46 Derby Road, DS0000004931.V299581.R02.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 46 Derby Road, DS0000004931.V299581.R02.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): 1, 2. The quality outcome for these standards is good. This judgement was based upon information provided and a visit to the home. The homes Statement of Purpose and Service User Guide provided service users and prospective service users with the details they require to make an informed decision about admission. EVIDENCE: The Service User Guide was included in the care records of each service user; the Statement of Purpose had been updated since the last inspection. Pre admission and post admission assessments demonstrated that the service was able to meet the needs of service users. Social workers comments indicated that the service was meeting the service users care needs. Service users made favourable comments about the service they received. Contracts and terms and conditions of residency were in place. 46 Derby Road, DS0000004931.V299581.R02.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 and 9 The quality outcome for these standards was good. This judgement was based upon information provided and a visit to the home. Care plans showed that they were reflective of the identified needs of service users. EVIDENCE: There was evidence of reviews and audits of the plans and service users knew who their key worker was. Each service user had a personal file that is to be stored in their rooms, containing aims and objectives, service user guide, activity plans and risk assessments. Service user confirmed that they were able to make decisions relating to their lifestyles and gave examples of weekly meetings when they discussed their individual plans for the following week. At these discussions they were supported to record their choices on a planner, a copy was kept in the office at the home the other in the individual’s bedroom. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 10 Regular monthly reviews of care were also undertaken and more formal reviews arranged with social workers and family. Individual risk assessments were of a good standard, with evidence that service users had been consulted and knew what their assessments said. Personal files contained invoices from the organisation about the charges and fees, it was suggested that these statements were issues more regularly. Service users are supported to manage their own finances and have individual savings accounts. 46 Derby Road, DS0000004931.V299581.R02.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 The quality outcome for these standards was good. This judgement was based upon information provided and a visit to the home. Social and recreational opportunities were established in community facilities. EVIDENCE: A sample of service users activity record showed that they were involved with a range of opportunities outside of the home, including, therapeutic sessions such as music and art therapy, horse riding and college sessions. This service users enjoyed meals out and had hobbies and interests out of the home that they were supported to follow. One service user was interested in finding part time employment; he was being supported to pursue this. A participation records on each service user file indicated if they had been engaged in activities throughout the week. Holidays were planned for each service user for the summer. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 12 Pre inspection information confirmed that service users were supported to maintain contact with family and friends. During the visit service users confirmed this. All service users were involved in household, domestic routines and involved in meal preparation and cooking. One service user discussed his care plans relating to healthy eating and was aware of the reasons for following this type of plan. A sample of menu’s showed a balance diet, with alternatives available on request. Service users confirmed this and that meal times were fairly flexible, dependent on the routines of the day. 46 Derby Road, DS0000004931.V299581.R02.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 The quality outcome for these standards was good. This judgement was based upon information provided and a visit to the home. Arrangements for meeting the personal and health care needs of service users were in place. EVIDENCE: The care files showed that service users were supported to attend regular and routine health appointments, such as dental, chiropody, opticians. The community nursing team gave a positive account of the co-operation they received from staff in the implementation of health plans. Specialist health needs were known, plans and risk assessments were in explicit detail and supported by specialist health services. Reviews of these conditions were carried out regularly. Policies and procedures for the safe administration of medication were in place. Staff who had responsibility for the medication had received training and been assessed as competent to administer medication. The medication file included photographs of individuals, and descriptions of how to administer medication for each individual. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 14 There were protocols in place for the administration of as required medication to ensure that staff, were consistent with administering this. The records showed that staff signed for the medication they administered. There was evidence of good practice in relation to the receipt and return of medication and the storage facility was suitable for the purpose. The manager had introduced a medication audit which she intended to undertake on a monthly basis, the last audit had been carried out on 18/05/06. One service user had a risk assessment for the self administration of medication. 46 Derby Road, DS0000004931.V299581.R02.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 The quality outcome for these standards was good. This judgement was based upon information provided and a visit to the home. The arrangements in place provided service users with the information they required to make a complaint and offers protection against abuse. EVIDENCE: The service has a complaints procedure in place, which provides service users, relatives and others with the information they need to enable them to complain if necessary. This information is included in the service user guide. In the pre inspection feedback a relative stated that they had made complaints in the past, but was now satisfied with the service. The manager indicated in the pre inspection information that the service had received two complaints since the last inspection that had been resolved. Service users comments included “I know how to complain if I want to,” “ staff listen to me.” The Commission for Social Care Inspection have not received complaints about this service since the last inspection. The service had procedures in place for Adult Protection that provided staff with clear guidance about how to safe guard service users from abuse. Training had been provided in the past and further training was planned. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 16 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 The quality outcome for these standards was good. This judgement was based upon information provided and a visit to the home. The home provides a safe and pleasant environment for service users. EVIDENCE: This inspection did not include a detailed inspection of the environment, although service users did give a tour of the building. The environment was well maintained, clean and provided suitable communal space in a pleasant lounge and in a separate dining room. All bedrooms were for single occupancy; one had en-suite facilities. All service users had a lock to their bedroom doors. The laundry was located on the first floor and action must be taken to ensure that the door to this area closes too properly. This also applies to the lounge door. Since the last inspection the garden area to the rear of the property has been developed, service users have been involved in this. They stated that they would like some new garden furniture. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 17 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. The quality outcome for these standards was good. This judgement was based upon information provided and a visit to the home. The service provided adequate staffing numbers, and an effective staff team . EVIDENCE: Staff numbers were maintained as three throughout the waking day, one sleep in and one waking night staff. The staff rosters confirmed this. It was recommended that the manager should record her shifts on the roster. The service has three team leaders who have achieved NVQ level 3 in care. The percentage of staff who had achieved NVQ level 2 or above was 33 less than the 50 expected, it was understood that 2 more staff were working towards achieving the qualification. The service currently employs 12 staff excluding the manager, total care hours equate to 452.50 per week. Staff meetings were reported to take place every two months, the records did not reflect this the deputy manager and manager stated that additional meetings had taken place, but the notes had not been written up. A sample of staff records showed that the staff recruitment practice was good, in that there were two references, application form and evidence of qualifications, Criminal records checks, and confirmation of identity. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 18 In one example a copy of a birth certificate wasn’t included in the file, the manager was reminded of the requirements of schedule 4 of the Care Homes Regulation 2001. Staff receive individual supervision sessions regularly, the manager delegates some of this responsibilities to team leaders who have undertaken training in staff supervision. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 19 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, 38,41,42 The quality outcome for these standards was adequate. This judgement was based upon information provided and a visit to the home. The management arrangements for this service operate in the best interests of service users. EVIDENCE: The manager has been approved by the Commission for Social Care Inspection since the last inspection. She has demonstrated her ability to manage and to lead her team. The service has policies and procedures in place as required, some had been updated others had not and may not reflect current good practice. The fire safety manual included a pictorial explanation of the evacuation procedure for the home and location of fire exits. A fire safety risk assessment had been reviewed on 23/03/06 and updated on the 4th May 2006. Fire training had taken place, 19/04/06 and fire safety checks had been carried out. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 20 Information in the pre inspection information showed that the regular servicing and maintenance of equipment in the home was carried out. At the time of the visit the fire alarm system was not fully operational, the manager stated that a replacement had been ordered. Action had been taken to provide smoke detectors, provided instructions to service users and staff regarding the different sound of the alarms, the checks to be carried out and the additional precautions to take. It was confirmed with the fire safety officer following the inspection that these temporary arrangements were satisfactory. Health and Safety checks were undertaken and recorded weekly. It was recommended that staff who use the computer regularly should have a VDU risk assessment carried out. 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 21 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 3 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 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 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 4 4 x 3 3 X X 3 2 X 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 22 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. 1. Standard YA42 Regulation 23(4) Requirement The registered person must ensure that fire doors close properly to ensure the safety and well being of service users. The fire evacuation procedure must be amended to reflect the temporary fire alarm arrangements. The registered person must ensure that all records required for the recruitment of staff are in place. Timescale for action 30/06/06 2 YA42 23(4) 30/06/06 4 YA34 17 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA33 YA32 YA42 Good Practice Recommendations The care manager should record her shifts on the staff roster. The service should ensure that 50 of the care team have achieved NVQ level 2. Staff using the computer regularly, should have a risk assessment for the use of the visual display unit. DS0000004931.V299581.R02.S.doc Version 5.2 Page 23 46 Derby Road, 4 5 6 7 YA7 YA24 YA42 YA40 The registered person should provide give further thought to providing service users with more frequent statements of their fees and charges. The registered person should consider the service users request for new garden furniture. Emergency contingency plans should be put in place, in the event of an accident, and the service becomes uninhabitable. Policies and procedures should be regularly reviewed to ensure they reflect current practice, 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Stafford Office 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 46 Derby Road, DS0000004931.V299581.R02.S.doc Version 5.2 Page 25 - 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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