Inspection on 15/06/07 for Cheshire Drive

This inspection was carried out on 15th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cheshire Drive 29/01/07

Cheshire Drive 03/05/06

Cheshire Drive 17/11/05

Cheshire Drive 29/04/05

Cheshire Drive 02/12/04

Cheshire Drive 17/05/04

Cheshire Drive 18/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Cheshire Drive 53-55 Cheshire Drive Leavesden Watford Hertfordshire WD25 0GP Lead Inspector Marian Byrne Unannounced Inspection 15th June 2007 11:00 Cheshire Drive DS0000039939.V343531.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 Cheshire Drive DS0000039939.V343531.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. Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cheshire Drive Address 53-55 Cheshire Drive Leavesden Watford Hertfordshire WD25 0GP 01923 682671 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) www.Adepta.org.uk Adepta Afsaneh Alizadeh Alamdari Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 2007 Brief Description of the Service: Cheshire Drive is a detached, purpose-built, two storey home that can accommodate up to six young adults who have a learning disability. It is located on a newly constructed estate and blends in well with surrounding properties. One of the bedrooms is on the ground floor and has been designed to accommodate a wheelchair user. It has a full assisted bathroom adjacent. The other five bedrooms are upstairs and can only accommodate ambulant people, as there is no lift installed. There is a lounge on the ground floor that opens onto a secure garden. There is a dining room, a utility room and a kitchen. Off road parking is available at the front of the building and the home is located a short drive away from the M25 and from Watford town centre. Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over the afternoon and evening of the 15th June 2007 by one inspector. All the service users were present at some point during the inspection. The inspector spoke with all the staff on duty and with three of the service users. The inspector was present during the evening meal. What the service does well: What has improved since the last inspection? What they could do better: The paperwork relating to the needs of the service users must be up to date. The upstairs of the house is in need of fresh paint and the rooms of the service user must be made more comfortable and reflect their personality and culture. The storage of medication in service user’s rooms must be accompanied by a risk assessment. Where a Criminal Records Bureau check shows an offence the registered manager of the home must have a record of what interview were held with the staff member. Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 6 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. Cheshire Drive DS0000039939.V343531.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 Cheshire Drive DS0000039939.V343531.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new admissions since the last inspection. Cheshire Drive DS0000039939.V343531.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is striving to meet the individual needs and choices of the service users. EVIDENCE: Review meetings have been held on two service users and decisions were taken on how to move their care forward. There were no notes of these reviews in care plans but staff were aware of the intention to prepare two service users to move to more independent living. The Registered Manager had started the process by consulting the care staff within the home. A requirement was left on this at the previous inspection with a timescale for action of the end of March 2007. While some progress has been made there was no written evidence to support this. Attention must be paid to ensure that care plans are up to date and that all staff are working together to ensure the optimum life style of the service users. Holidays and breaks are taken regularly. One service users spoken with while she enjoys getting away a recent trip to Paris, which took place on the spur of Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 10 the moment, was not successful. It was not clear how much input she had in choosing the destination. Service users are encouraged to take reasonable risks and are involved in the running of the home. One of the service users has a family wedding coming up and was taken shopping to chose her outfit. The home must explore more imaginative ways to encourage the service users to communicate with staff. Other service users have regular breaks with family or arranged by staff. Cheshire Drive DS0000039939.V343531.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This would have been good if more care had been taken to ensure mealtime is more enjoyable. The life styles of the service users has improved and work is being done to ensure all the service users have a lifestyle which represents their choice and reflects their abilities to live as independently as possible. EVIDENCE: A great deal of work has been done to improve the atmosphere at the home. Training of staff has resulted in service users recognising boundaries this has helped to create a much calmer atmosphere. The noise levels have dropped and the quality of live of the service has much improved. The staff are trying to obtain work for two of the service users who are starting the preparation for more independent living. The both work on a voluntary basis at the moment on one or two days a week the aim is to extend this. As already stated, the home has started the process of preparing two service users for independence. Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 12 The home welcomes visitors at all reasonable times. Families play a big role in the lives of most of the service users who live there. The rights of the service users are protected and where possible the service users live without restrictions. The inspector observed the evening meal. Service users are served at different times and one service user had finished before all the staff had sat down. Two of the staff sat with the service users who chose to eat in the dining room. One member of staff took a phone call in the dining room this detracted from the shared experience. The home would benefit from a more structured mealtime where service users were served together and ate together. Cheshire Drive DS0000039939.V343531.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users receive personal support in a manner that is preferred and required. Risk assessments must be carried out on the storage of the medication. EVIDENCE: Service users are receiving their personal support in a manner that respects and promotes dignity and privacy. In an effort to enhance this, the home has moved the service user’s medication into their rooms, where it is stored in small locked cabinets. This was not accompanied by a risk assessment. Two of the service users have very complex needs and have exhibited extremely challenging behaviour in the past, which could render this method of storage dangerous for the service users and the staff. One service user is extremely overweight is taken to his GP on a regular basis to ensure his health is not affected, he goes to the gym one or twice a week this is beginning to show results and he is losing weight slowly. Families have a good deal of involvement in the lives of the service users. Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 14 Until more work has been done with two service users who are being prepared for more independent living it is not possible to say if all the service users emotional needs are being met. Cheshire Drive DS0000039939.V343531.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with in an appropriate manner. Service users are protected from abuse. EVIDENCE: There were no complaints since the last inspection. The home has a robust complaints procedure. Staff were aware of adult protection procedures. Cheshire Drive DS0000039939.V343531.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is clean and fresh. The upstairs needs to be re-decorated and the stair carpet is showing signs of wear and tear. EVIDENCE: The downstairs area of the home is looking very nice and homely. It is kept clean and odour free. The stair carpet is showing signs of wear and tear and must be replaced. The service users bedrooms do not reflect the same standard as the downstairs area. The rooms, while clean and tidy, are not inviting and need to more reflect the personality and cultural beliefs of the service users. The upstairs corridor is very dark and would benefit from improved lighting. The electrical lighting in the dining room is not working properly leaving the room very dark and dreary. There was a requirement to improve this lighting at the last inspection, it has not been met. One of the service users is moving from her room upstairs to one downstairs leaving a free room upstairs. Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 17 The Registered Manager is planning to create a quiet room here where service users can go to have one to one time with staff or to watch television on their own. There are systems in place to ensure hygiene and infection control. Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is adequate. This outcome would have been good had a Criminal Records Bureau check on a staff member been audited. This judgement has been made using available evidence including a visit to this service. The home is staffed by trained staff and that the needs of the service users are being met in a professional manner. The recruitment records were not available for inspection. EVIDENCE: Staff recruitment files are stored at the home’s head office and therefore were not available for inspection. Paper work relating to Criminal Records Bureau checks are kept in the home. One staff member’s CRB check showed that he had driving offences but there was not an audit trail to show that this had been picked up and discussed with the employee with judgements made as a result of these discussions. Staff indicated that supervision takes place monthly records supported this. Staff records and conversations with staff indicate that staff are trained to meet the needs of the service users. This is also evident in the drop in the number of incidents that must be reported under The Care Standards Act 2000. Cheshire Drive DS0000039939.V343531.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is improving and this is having a positive benefit for service users and staff. EVIDENCE: The atmosphere of the home is much improved and progress has begun towards meeting the needs of all the service users. However, the paperwork on care plans is not up to date and there were issues over a CRB clearance. Risk assessments were not carried out on the storage of service user’s medicines in their rooms. The home has a quality assurance system and involves the service users as well as their families and friends in how the home is run and how the needs of the service users are met. Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 20 Monies of the service users was checked and found to be in order. There are safe working practices in place to ensure the health and safety of the service users. Cheshire Drive DS0000039939.V343531.R01.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 X 2 X 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 2 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X X 3 X Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation Requirement Timescale for action 31/07/07 12(1)(a)(b) The Registered Manager must ensure that the home is managed in a manner that ensures the mix of service users doesn’t prohibit the development of all the service users particularly those who are less dependent. 23(2)(b) Some work has started on this. The Registered Provider must ensure that the carpet on the stairs is replaced as it shows signs of wear. The Registered Provider must ensure that the rooms of the service users reflect the personality of the service user. The Registered Manager must ensure that risk assessments are carried out on the storage of medicines in service users rooms The Registered Provider must ensure that the electrical lighting in the home is suitable. The registered Manager must ensure that care plans are up to date regarding plans on future care of residents DS0000039939.V343531.R01.S.doc 2. YA24 30/09/07 3. YA26 16(2)(c) 30/09/07 4. YA20 13 (2) 15/06/07 5. 6. YA24 YA17 23 (2) (b) 14(2)(b) 29/07/07 29/07/07 Cheshire Drive Version 5.2 Page 23 7. YA37 37(1)(e) The Registered Manager must ensure that all incident forms are available for inspection. Registered Manager must ensure that all Criminal Records Bureau checks where convictions are shown have an audit trail of interviews held with the member of staff. 15/07/07 8. YA34 7,9,19. Schedule 2 20/06/07 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 Cheshire Drive DS0000039939.V343531.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Cheshire Drive DS0000039939.V343531.R01.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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