Inspection on 07/06/05 for 46 Derby Road

This inspection was carried out on 7th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 6 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 06/01/06

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 46 Derby Road Burton on Trent Staffordshire DE14 1RP Lead Inspector Wendy Jones Unannounced 07 June 05 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 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 Stationary 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 E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 46 Derby Road Address 46 Derby Road Telephone number Fax number Email 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 LD 3 registration, with number of places 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 21 March 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 E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection carried out on 07 June 2005, a manager designate, who was supported by two other staff, managed the service. The three services users were not at home at the start of the inspection, but arrived for lunch before departing again for other activities. The inspection included discussion with the designated manager Mrs Jones, inspection of staff rota’s, staff records, training, fire safety and care records, menu plans, staff and service user meeting records; inspection of the physical environment and discussion with service users. What the service does well: What has improved since the last inspection? The lounge has been redecorated and refurbished. The majority of requirements of the previous inspection have been addressed. Service users quality of life was reported to have improved. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 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. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 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 standard(s) 1. The homes Statement of Purpose and Service User Guide are good providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: The statement of purpose for the home must be amended and updated to include the change in management and staff. The inspector noted that there was a copy of the service user guide in a service users care records. The service user guide used pictorial symbols to explain the information about the home. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 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 standard(s) 6,7,9. The standard of care planning and risk assessments was good. Assessment information was detailed and addressed the identified risks. EVIDENCE: There was evidence that care plans were reflective of the assessed needs of service users and that service users had been involved with their implementation. Risk assessments where in place which enabled service users to take responsible risks. It was evident that service users had been able to make decisions about their lives, and assistance had been provided when necessary. This was confirmed from discussion with one service user. Records showed detailed care planning, with a comprehensive personal history details and also good information regarding the individuals usual routines, likes and dislikes. It was noted that reviews of care/support action plans and risk assessments in the sample seen had not been carried out regularly. One example showed that the support action plans had last been reviewed in 09/04, and in another instance a risk assessment had not been reviewed since 08/04. The usual arrangement for reviews was understood to be 6 weekly. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 10 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 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 standard(s) 12,14,16,17 Service users were supported to access a range of social, recreational activities that are located in the community. Dietary needs of service users were well catered for with a balanced and varied selection of food available that met service users tastes, choices and dietary needs. EVIDENCE: At the time of the inspection all service users were out of the home. One was at a college placement; another working and the third had been escorted to the town to undertake some personal shopping. In the afternoon two service users were attending an art class. Records showed that service users were engaged in a number of activities in and outside of the home. Some were in integrated others were more specialised, dependent on the needs and ability of the individual. Activities included weekly swimming sessions, college and art sessions as previously 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 12 stated, visiting the cinema, pubs and a youth group and participating in other community based events. The records of service user meetings indicated that further efforts were being made to ensure that service users could increase their level of participation in community activities. The last record of a meeting was recorded as February 2005. It was recommended that further efforts be made to increase the frequency of service user meetings or the 1:1 discussions between service users and their key workers. All service users reported that holiday’s had been arranged for the year in consultation with them and their key workers. Individual menu plans were included in each of the care records, the evidence form the sample seen was of a well balanced diet. The approach of the service was to adopt a healthy eating regime, dependent on the needs of the individual and was sensitive to the differing dietary needs of service users. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 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 standard(s) 18,19,20 The relationships between staff and the young people were good and created a supportive and caring atmosphere in which the young people felt secure and comfortable. The health needs of service users were met with evidence of good multi disciplinary working taking place on a regular basis. The medication at this home was generally well managed promoting good health. EVIDENCE: Service users confirmed satisfaction with the service they received, they knew whom their key workers were and were observed to engage in banter and friendly discussion with staff on duty. The records showed that service user health care needs were appropriately met with regular health checks and appointments. Additional access to specialist health professional was also reported to be provided, for example clinical psychology input. Specific health issues included epilepsy, which the records showed was being appropriately monitored and reviewed. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 14 The medication was stored in an appropriate storage facility, accessed by the senior staff on duty. Records were properly maintained and signed by staff, a good practice recommendation was made regarding maintaining a list of staff signatures and initials on file. It was also suggested that a review of the as required medication of one service user should be undertaken with the G.P due to the report that it had not been administered for some considerable time. A medication reference book was available for the benefit of staff; Mrs Jones stated that all the relevant information for each prescription is retained in the home. It was reported that all staff responsible for the administration of medication have undertaken a certificated medication course through Boots Chemist. None of the service users at the home self medicated. Medication reviews were reported, to be undertaken at least annually. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 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 standard(s) 22 The service has a complaints procedure in place, which provides service users, relatives and others with relevant information. EVIDENCE: The complaints procedure was included in the service user guide, statement of purpose and displayed in the home. It provided service users, relatives and other visitors with the information they required to enable them to make a complaint or to contact other relevant agencies such as the CSCI and the Ombudsman. No complaints have been received by the CSCI since the last inspection visit. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 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 standard(s) 24, 25,26,27,28,30. Recent investment has improved the appearance of this home creating a comfortable environment for those living there and visiting. EVIDENCE: The service provides domestic facilities, typical of ordinary living. The lounge had recently been redecorated, providing a very pleasant and comfortable room with sufficient seating for service users and staff. A dining room provided seating for up to 8 people and appeared to be functional and suitable for the purpose with pine furnishings and wooden effect flooring. The carpet in the main hallway and stairs was showing signs of wear, it was badly stained in places and had worn or perished at the edge of the step leading to the dining room. Attention must be paid to this matter by deep cleaning and repairing or replacing the carpet. Toilet facilities were provided on the ground and first floor, the main bathroom was located on the first floor, and a ground floor bedroom had an en-suite shower providing adequate facilities for service users. The flooring in the ground floor toilet was not adhering to the walls properly in some places, 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 17 presenting a risk for odours and spillage. Action must be taken to ensure that the flooring is properly fitted and secured. Each of the bedrooms is for single occupancy; two were seen during this visit with the kind co-operation of service users. Each had lockable doors; service users had keys provided. Both bedrooms were adequately furnished and decorated, with evidence that service user had been supported to take ownership of their rooms, in the number of personal possessions, and evidence of hobbies and interests displayed in them. The laundry facilities were located on the first floor. The kitchen provided adequate storage and cupboard space. The rear garden provided service users with a grassed area and a seating area. Mrs Jones reported that the home has successfully applied for some additional monies to make the garden a more pleasant and usable environment for service users. She also commented that the garden area had improved since the last inspection. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,34,35,36, Staffing levels were adequate, further efforts are required to recruit a full compliment of staff and a manager. Recruitment practice was generally adequate, the service must ensure that recruitment records contain all of the information required by regulation. EVIDENCE: The service provided one to one staffing through the waking day, with one sleep-in and one waking night staff. Since the last inspection the acting manager has left the home, the vacancy has yet to be filled, in addition a fulltime team leader vacancy was reported as was a fulltime and part time care worker vacancy. The service had an established bank list to access to assist in maintaining adequate staffing numbers. Three staff were reported to have achieved NVQ level 3, one was undertaking the training and another was undertaking NVQ level 4. There was a number of staff undertaking induction and LDAF training. Mrs Jones confirmed that all staff had received relevant mandatory training or had been nominated for it, this training included first aid, medication, fire training, management of challenging behaviour, vulnerable adults and adult protection issues. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 19 The records of training were not checked on this occasion, but records of planned training indicated that the organisation offered a good range of training opportunities. A sample of recruitment files showed that the services recruitment practice was generally adequate, with the exception of one file where there was only one reference, no evidence of a work permit, police check or qualifications. Mrs Jones stated that the information had been sought but was with the human resources department of the company. The records showed that staff had received very regular( bi monthly) staff supervision up until March 2005. Mrs Jones confirmed that she had undertaken supervision training and intended to re start the supervision programme. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,42 The management arrangements at the home did not provide adequate hours to enable the manager to effectively undertake her role. EVIDENCE: Mrs Jones was the nominated manager until a suitable candidate had been recruited. It was noted that Mrs Jones was include in the staffing numbers giving little time to address any managerial tasks and responsibilities. It was recommended that some additional supernumerary hours are provided for Mrs Jones, to enable her to satisfactorily undertaken the role. The arrangements for fire safety were adequate, records showed that fire training had been undertaken, included all staff. A fire safety risk assessment had been completed and a review undertaken on 01/06/05. Fire equipment and the fire alarm system had been serviced. Records of fire alarm tests indicated that the last test had been carried out on 07/05/05, Mrs Jones stated that weekly tests had been carried out but the records had not been 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 21 maintained. Fire drills had been carried out regularly, a good practice recommendation was made for the records to include the names of all staff involved with the drill as, from the information seen, it was not possible to ascertain if all staff had received a fire drill. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 22 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 2 x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x 3 x 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 46 Derby Road Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 1 x x x x 1 x E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 23 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. 2. Standard YA42 YA1 Regulation 13,23 4 Requirement Ensure that fire alarm tests are recorded on each occasion. Ensure that the Statement of Purpose reflects the current staffing and management arrangements. Deep clean and repair or replace the carpet in the main hallway and stairs. Repair the flooring in the ground floor toilet. Recruitment records must include evidence of qualification, two written references, appropriate criminal check and current work permit. Staff must be recruited to address the vacancies within this home. It is understood that this process is underway (previous timescale 21/04/05). Timescale for action weekly 21/06/05 3. 4. 5. YA24 YA27 YA34 23 23 17 schedule 4 18 07/08/05 14/06/05 07/07/05 6. YA33 07/07/05 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 E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 24 46 Derby Road 1. 2. 3. 4. 5. YA41 YA20 YA14 YA6,7 YA20 Record the names of all staff who are involved fire drills. Maintain a records of staff signatures and initials in the medication file. Increase the frequency of service user meetings or 1:1 service users and key worker discussions. Care plans and risk assessments should be reviewed regularly. Discuss the possibility of a review of the, as required medication identified at inspection. 46 Derby Road E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Stafford - 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 E51 E09 S4931 46 Derby Road V232292 080605 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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