Inspection on 29/01/07 for Cheshire Drive

This inspection was carried out on 29th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Cheshire Drive 15/06/07

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 29th January 2007 10:00 Cheshire Drive DS0000039939.V330378.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.V330378.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.V330378.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.V330378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th December 2006 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 ambulent 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.V330378.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 by one inspector. The Registered Manager was not present. This report includes details of the recent random inspection. When the inspection started one service user was present. Later in the afternoon the remaining four service users returned from day care. Service users and staff who were available were spoken with. At present the home offers is registered for six places the home has voluntary reduced the number of service users to five. The Registered Manager and the Registered Provider recognise that if the numbers were to be increased to six again the staffing establishment would have to be reviewed and increased. What the service does well: What has improved since the last inspection? The behaviour of one service user has improved and there are fewer incidents of unacceptable behaviour. Staff have received training in delivering his care in a manner that does not raise his anxieties and defusing and potential violent outbursts. A new care plan has been drawn up for him. Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Cheshire Drive DS0000039939.V330378.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.V330378.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): This standard was not inspected as there have been no new admissions to the home since the last inspection. EVIDENCE: Cheshire Drive DS0000039939.V330378.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): 6,7,9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service uses needs and choices are being identified and are starting to be met. EVIDENCE: The home has made efforts to ensure that the service users needs are being met. The challenging behaviour of one service user had improved and the staff and manager of the home are now working as a team to meet his needs. A uniform approach has been adopted and staff spoken with now feel that the service user has responded to strict boundaries set out in his plan. One female service user wanted to change her room from upstairs to downstairs. This was tried and not found to be in her best interests, as staff could not keep her safe. (She used her window to leave the home without staff knowing her whereabouts and invited visitors to her room using the window again for access putting her at risk). It was decided for the present that she needed to go back upstairs while arrangements were made to attempt to change the windows. The Registered Manager has approached the housing association to Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 Page 10 ask if they can accommodate this. Attempts are being made to try to secure employment for the same service user. Four of the five service user were away for Christmas and staff took a male service users abroad before Christmas. Cheshire Drive DS0000039939.V330378.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): Quality in this outcome area is adequate. 12,13,15,16,17. This judgement has been made using available evidence including a visit to this service. This would have been good had all the service users been given a structured week. Staff endeavour to ensure service uses have a life style appropriate to abilities and aspirations. EVIDENCE: As already stated staff make efforts to ensure service users needs and aspirations are met. Holidays are arranged and one service user works away from the home and staff are endeavouring to find employment for another. Local facilities are used and the service users who want to go the local public house and shops. Families play a big part in the lives of all the service users at Cheshire Drive and at least two of the service users go home for very frequent breaks. On the day of the inspection staff were assisting one service users to get an outfit for a family members wedding where he had a part to play in the ceremony. On the day of the inspection four of the five service users spent the day at a day centre. One service user had no structure to his week and his useful occupation is on a casual basis. More care must be taken with this as his occupation could be dependant on the will of the staff. Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area good. 18,19. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One service users appears to be putting on weight and appears to be obese, care must be taken to monitor the effect of this on his health. Service users spoken with said that they were happy with the care given to them. A complementary therapist arrived during the inspection the service users was taken to his room to receive his therapy. He later told the inspector that he enjoyed it. All the service users present were given the choice of having a treatment. All service users have health plans and regular health checks. Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 Page 13 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): These standards were not inspected, EVIDENCE: Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This judgement would have been good if the lighting was adequate. The home was clean, fresh, homely and comfortable. The electrical lighting in some of the rooms was found to be dull. EVIDENCE: Every effort is being made to meet the needs of the service users. The home has voluntary decided to limit the number of service users to five rather than the six it is registered for. The registration would have to be reviewed if the home should decide to make any changes to this arrangement. On the day of inspection the home was clean bright and fresh. The electrical lighting in the dining room is very dim and should be reviewed. The home is comfortably furnished and is domestic in style. All service user’s rooms are comfortable and are personalised to reflect the their taste. Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 Page 15 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): The Registered Manger was not present at the inspection making inspecting staffing files impossible. EVIDENCE: Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 Page 16 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 mix of service users and the lay out of the home makes managing it very difficult. EVIDENCE: The home has made considerable progress in meeting the needs of the service users living at Cheshire Drive. The lay out of the home and the mix of service users makes this home difficult to manage. The home retains the problem of meeting the needs of more able service users combined with the needs of service users with complex needs. One service user does not have structured day care and his day to day occupation is left to the discretion of staff on duty. The home is now attempting to find employment outside the home for one young female service user. The number of incidents with one service user appears to have decreased due to the combined efforts of the entire workforce. It is not possible to say for definite if the home will be able to meet the needs of all service users in the future to ensure they all have optimum life enhancing Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 Page 17 opportunities. A new deputy has been appointed and will take up her post in the near future. Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 Page 18 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 X 23 x ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X x 2 X 3 X X X 3 Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 Page 19 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 YA6 YA7 Regulation Requirement Timescale for action 31/03/07 2. YA12 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. 12(2) The Registered Manager must re-asses all service users to demonstrate that all their needs are being met. 23 (2) (b) The Registered Provider must ensure that the electrical lighting in the home is suitable. The Registered Manager must ensure the diet of the service user who is overweight is monitored and his diet is reviewed. 31/03/07 3 YA24 29/01/07 4 YA17 14(2)(b) 29/01/07 Cheshire Drive DS0000039939.V330378.R01.S.doc Version 5.2 Page 20 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.V330378.R01.S.doc Version 5.2 Page 21 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. 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