Inspection on 06/01/06 for 46 Derby Road

This inspection was carried out on 6th January 2006.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

46 Derby Road 28/06/06

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 Unannounced Inspection 6 January 2006 13:00 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 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.V279201.R01.S.doc Version 5.1 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.V279201.R01.S.doc Version 5.1 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 Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 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.V279201.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out on 06 January 2006. Information for the report was provided from discussion with the newly appointed manager and staff; from discussion with a service user; from inspection of care records, staff rotas, fire records and other documentation relevant to the inspection process. What the service does well: The service has a Statement of Purpose and Service User Guide, a review of both documents was being undertaken by the organisation, and copies were to be provided to the Commission for Social Care Inspection. The standard of care planning was good, with evidence of review and that service user were involved in their care planning. The service was introducing a different care planning format to reflect person centred planning principles. Service users were supported to engage in activities of their choice, including work experience, recreational and social activities. The healthcare needs of service users were met, and the systems for the safe administration and recording of medication satisfactory. The procedures for investigating and recording of complaints were adequate, with evidence that any concerns/ complaints received are taken seriously. The standard of environment was good providing the service user with a clean, pleasant, well maintained and decorated home to live in. A core team of staff had ensured service users received consistent standards of care. Policies and procedures provided a framework for staff to work from and were reflective of those required by regulation. Service users expressed satisfaction with the service received and reported positive relationships with the staff team. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 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. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 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.V279201.R01.S.doc Version 5.1 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): 1,2,5. The homes Statement of Purpose and Service User Guide are good providing service users and prospective service users with details they required to make an informed decision about admission. Both documents must be reviewed to ensure that they are reflective of requirements. EVIDENCE: The service has a Statement of Purpose and Service User Guide; reviews of both documents were reported to be underway to reflect the change of staff, management and the qualifications of the staff team. This was a requirement of the inspection. The service user guide was included in the care records of each Service User, the manager reported that the organisation had consulted a company to assist with changing the format to make it more service user friendly. The content of the Service user Guide was discussed in detail and a requirement made to ensure all items required by regulation were included: a) A summary of the Statement of Purpose. b) The terms and conditions of residency including the amount and method of payment of fees. c) A standard form of contract between the provider and the service user. d) The most recent inspection report. e) A summary of the complaints procedure. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 Page 9 f) The address and telephone number of the Commission. A copy of the Service user Guide must be provided for each service user and to the Commission. Pre admission and post admission assessments demonstrated that the service was able to meet the needs of service users. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8. The standard of care planning was good providing staff with the information they needed to provide appropriate care. EVIDENCE: A review of the care planning and life planning documentation was underway, the existing format was to be replaced and training provided for the staff team. The original training had been cancelled and was to be rearranged. A sample of care plans was reflective of the assessed needs of the service user. There was evidence of review of care plans and 6 monthly reviews of care in general, in line with principles of good practice and person centred planning. A good standard of risk assessment was also evident. The manager expressed concerns that one service user had not had a social worker review for some considerable time, despite attempts by her to contact the funding authority regarding this. It was advised that the manager arranges a formal review for the service user inviting any other interested parties, including family, friends and other professionals. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 Page 11 Following discussion with a service user it was clear that care issues were discussed on a regular basis, he was familiar with the daily diaries staff recorded the day’s events in and indicated that he could, if he chose to, record and sign to indicate that they were a true record of events. He stated that he was supported to make decisions about his daily lifestyle. Records showed service users meetings took place to discuss plans for the following month and any other relevant matters arising. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15. Links with the community are adequate, providing some social and recreational opportunities for service users. EVIDENCE: The location of the service on a busy main road poses some difficulty in building relationships with neighbours. There are local shops and facilities within walking distance of the home and good local bus links. One service user had part time job at local pub he worked for three mornings per week and received a weekly payment for it. Other service users attend college courses. One service user discussed his interest in aviation, sharing details of his hobby, staff confirmed that they had arranged visits to airports, and had made arrangements for him to go on a plane in the past. Annual holidays were also organised with the specific interests of the individual service user in mind. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 Page 13 There was evidence that service users were supported to access socially valued recreational activities such as attend local football matches, visit cafe’s and pubs, go to the swimming pool. The manager stated that service users were supported to maintain contact with family and friends where care planning and assessment indicated that it was appropriate to do so. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 The health care needs of service users were met with evidence of regular health checks and appointments taking place and the involvement of general and specialist health services. The medication at this home is well managed promoting good health. EVIDENCE: A sample of records showed that service users health care needs were appropriately met; there was evidence of health appointments and referral for regular health checks. Access to specialist health professional was also facilitated for example clinical psychology input. Specific health issues included epilepsy, which the records showed were being monitored and reviews of treatment undertaken. Behavioural management advice and the involvement of psychological input were also provided. The medication was appropriately stored in a locked cupboard, accessed only by the senior staff on duty. Medication Record Sheets were properly maintained and signed by staff, with evidence that the medication received in the home was checked and a record of it maintained. A separate record of medication returned to the pharmacy was also kept. Protocols for the 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 Page 15 administration of as-required medication were in place and records showed that there was no inappropriate use of as-required medication. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 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. The procedures for of Adult Protection provide service users with safe guards against abuse. EVIDENCE: A complaints procedure was provided in the home and was included in the Statement of Purpose and Service users guide. A service user stated that he knew who to go to if he had any concerns, but was satisfied with the service he received. The records showed that one complaint had been received in the 12 months prior to the inspection this matter had been addressed by the manager. Vulnerable adults issues were discussed with the manager and deputy, one allegation of inappropriate touching by a service user to another service user had been made. Referral to the local social services office as per VA procedures agreed in Staffordshire had been made an investigation carried out and conclusion reached. The manager stated that not all staff had received VA training; this was a requirement of this inspection. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 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 The appearance of this home creating a comfortable, clean and safe environment for those living there, and visiting. EVIDENCE: The home is a large semi- detached property located on a busy main road in Burton on Trent. It has a small front garden and a larger rear garden with parking space. This inspection did not include a detailed inspection of the environment, but all areas seen were clean, well maintained and decorated. Since the last inspection the carpet on the stairs and in the main hall have been replaced and flooring in the ground floor toilet replaced. The home provides accommodation over three floors, all bedroom are for single occupancy, the bedroom on the top floor has an en-suite facility. There is a pleasant lounge and a separate dining room, which have modern furniture and décor appropriate to the age of the service users. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 Page 18 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, 35 Staffing levels were generally adequate to meet the needs of service users, a recent recruitment drive had taken place to ensure that the staffing was of a good level at all times. The numbers of NVQ trained staff were not sufficient to meet the minimum standards recommended. EVIDENCE: Staffing levels on the day of this visit included the newly appointed manager Ms Morrall, who had been employed by the organisation on 24/10/05. An application form, to be approved as the registered care manager, has been submitted to the Commission for Social Care Inspection. An interview date has yet to be agreed. Her hours were supernumerary to the care staff team; she worked from 9am, a team leader worked from 7.30am-3pm, supported by 2 care staff 7.30am-3pm. A team leader from 3pm-10.30pm and sleep over, 2 care staff 2.30pm-10pm. 1 waking night staff. A sample of staff rota’s showed that 1:1 staffing was usually provided throughout the waking day. There were occasions when two staff were deployed, the manager stated that this was usually due to unexpected staff sickness or when a service user was visiting family. The service has 1 team leader and 1 full time and part time vacancy, a recruitment drive has been 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 Page 19 undertaken and interviews for the vacancies have taken place, the vacancies will be filled once the appropriate checks have taken place. NVQ training does not meet the standards in relation to 50 of the work force trained to level 2. The manager stated that she has achieved NVQ level 2 and 3 in care and has completed NVQ 4, which has yet to be verified. Out of the 11 staff employed, 2 staff have NVQ level 3, 1 has NVQ level 2. It was reported that 2 team leaders were being nominated for NVQ level 4, 1 care worker had undertaken NVQ level 2, but was waiting for the work to be verified. 2 more care staff were being nominated for NVQ level 2 training. Mandatory training was reported to be up to date, or staff had been nominated to attend the relevant courses. The manager was asked to provide documentary evidence that all staff had received mandatory training. The information provided evidence that some staff required mandatory training or updates. Records showed that staff meetings had been arranged every month since the manager had taken over. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 Page 20 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, 42 Service users health and safety was assured by satisfactory, fire safety checks and regular fire drills, and policies and procedures. EVIDENCE: The manager had been appointed to the service in October 2005, she had yet to submit an application to the Commission for Social Care Inspection for consideration and for approval. Fire safety records showed that weekly fire alarm and monthly emergency lighting were undertaken. Fire drills were undertaken regularly, it was recommended that the names of staff attending fire drills were recorded. Policies and procedures were in place to provide a satisfactory framework for staff to follow and to deliver care. The manager was asked to provide evidence that staff had received mandatory training. The information showed some gaps in individual staff training that must be remedied by the service. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 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 2 2 3 3 x 4 X 5 3 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 4 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 X x LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 X 2 X X X 3 X X 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No 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 2 Standard YA32 YA1 Regulation 12,13 6 Requirement Staff must receive mandatory training and regular updates. A review of the Statement of Purpose must present an accurate account of the registration categories of the home. A review of the Service User Guide must be undertaken and a copy provided to the Commission for Social Care Inspection. Staff must receive autism training. The registered person must ensure that the care manager application is forwarded to the CSCI and is concluded satisfactorily. Timescale for action 06/04/06 06/02/06 3 YA1 6 28/02/06 4 4 YA35 YA37 18 9 06/04/06 06/04/06 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 Refer to Standard YA42 Good Practice Recommendations A record of the names of staff attending fire drills should DS0000004931.V279201.R01.S.doc Version 5.1 Page 23 46 Derby Road, 2 3 YA32 YA6 be maintained. The service should ensure that 50 of the care team have achieved NVQ level 2. Staff should receive PCP training. 46 Derby Road, DS0000004931.V279201.R01.S.doc Version 5.1 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.V279201.R01.S.doc Version 5.1 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. 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!