Inspection on 28/11/05 for Danemere

This inspection was carried out on 28th November 2005.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Danemere 29/10/07

Danemere 23/08/06

Danemere 20/06/05

Danemere 08/02/05

Danemere 29/07/04

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

CARE HOME ADULTS 18-65 Danemere Dane Road Seaford East Sussex BN25 1DU Lead Inspector Kathy Flynn Announced Inspection 28th November 2005 10:00 Danemere DS0000021352.V269244.R01.S.doc Version 5.0 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 Danemere DS0000021352.V269244.R01.S.doc Version 5.0 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. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Danemere Address Dane Road Seaford East Sussex BN25 1DU 01323 890696 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) Freshford Care Consultants Mrs Tina Williams Care Home 1 Category(ies) of Learning disability (1) registration, with number of places Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of residents to be accommodated will be one (1) The people accommodated will be adults aged between eighteen (18) and sixty-five (65) years on admission 20th June 2005 Date of last inspection Brief Description of the Service: Danemere is registered to provide residential accommodation and care for one younger adult with an acquired brain injury. The home is a flat on the first and second floor of a semi-detached building. Situated in a residential area of Seaford, within walking distance of the town centre, public transport and the seafront, with GP and dentist surgeries easily accessible. The service users lounge, bedroom, shower room and kitchen/dining room is on the first floor, with staff rooms on the second floor, including a bathroom that the service user has access to. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and the home was informed of the date and time of the inspection several weeks before it was carried out. The standards not assessed in this inspection were assessed during the unannounced inspection in June. The information provided in the pre-inspection questionnaire, completed by the manager, and the comment card completed by a relative, was used to plan this inspection. The aims were to assess if the home meets the National Minimum Standards for Care Homes for Adults, identify how the service has improved since the last inspection and if the service could be improved for the service user. The inspection was carried out over three hours from 10.00am. It included a tour of the home, an examination of the care plan, risk assessments, records and policies. The service user was aware that the inspection had been arranged and the time it would start, she was happy for it to be carried out and spoke positively about the support she receives. The manager has been in place for over five years, there is low turnover of staff, with one new member of staff since the last inspection, which enables the team to provide consistent and skilled care. What the service does well: What has improved since the last inspection? There were no requirements at the last inspection. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 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. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 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 Danemere DS0000021352.V269244.R01.S.doc Version 5.0 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 and 5 The homes statement of purpose and service users guide does not include sufficient information regarding the services provided and how they meet the service users needs. EVIDENCE: The statement of purpose, which is also used as the service users guide, provides basic information about the services provided by Freshford Care Consultants. It does not include relevant information about the specific support and care that is in place for the service user, it therefore should be reviewed and updated so that it reflects the services provided by the home. A contract, an individual placement agreement, that involves the registered provider, relatives and social services is in place. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards not assessed at this inspection. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 10 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): 11 and 12. Links with the local community are good and support and enrich the service users social opportunities. The service user would benefit from a programme of educational and personal developmental activities. EVIDENCE: The flat is regarded as the service users home and she is encouraged to take some responsibility for keeping the flat clean and comfortable. The manager explained that the service user visits the town centre with one of the care staff on a regular basis, for shopping and meeting friends in the coffee shops or simply to post a letter. There is an attractive park nearby and during the inspection she enjoyed a walk with the carer. The service user is not taking part in any educational courses, although the manager advised during the last inspection that they would be looking for a suitable course in 2006. Appropriate courses at the local college are full so the manager will be contacting the college for advice about developing a suitable programme of education for the service user. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: Standards not assessed at this inspection. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: Standards not assessed at this inspection. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 13 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 The standard of decor within this home is poor with little evidence of improvement through maintenance or future planning. The home does not, therefore, present as a homely and comfortable environment for the service user. EVIDENCE: The service user’s flat is on the first and second floor of a semi-detached building and is kept clean and tidy. The manager advised during the last inspection that there were plans to replace the carpet in the lounge and redecorate this room, this work has not been carried out and the carpet continues to put the service user and staff at risk because it is split. The furniture in the lounge is large and dated, contemporary pieces of furniture would be more appropriate. The expectation following the last inspection was that a programme of repair and replacement would be in place, but there have been no improvements to the environment. The worn carpet in the bathroom is inappropriate, the stairs carpet is also worn, the kitchen requires updating and the flat should be redecorated throughout. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 14 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): 31, 34 and 36. The procedures for the recruitment of staff are not robust and do not provided the safeguards to offer protection to the service user. EVIDENCE: The team of staff providing support for the service user is made up of the manager and four care staff, they work together to provide 24 hour support and care. The manager explained that they all work together with the service user in planning and developing the service. There are handovers at the beginning of each shift, these are used to discuss the services provided and any changes in care need. The home has a recruitment procedure in place, a member of the care team has been working at the home since the end of September, however a POVA/CRB check was not completed until November. The requirement that all necessary checks should be completed prior to the employment of staff at the home was discussed in detail. The manager advised that she has a programme of supporting staff that includes formal supervision every six weeks, or more often if a problem has been identified. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 15 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): 39, 40, 41, 42 and 43. The environment at the home does not promote and safeguard the health, safety and welfare of the service user. There are a number of areas in the home that need to be improved for the benefit of the service user. There is no planning in place to show how these improvements are going to be resourced and managed. EVIDENCE: There is no quality assurance and monitoring system in place at the home and therefore no annual developmental plan for the home. The manager explained that she continually monitors the support and care provided at the home and makes any changes that she can and refers any other changes to the registered provider. Some policies and procedures are in place, these should be reviewed and additional policies developed as required. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 16 Training is provided for staff, including fire training and supporting people with epilepsy. Training in adult protection is included in the Induction programme and updated regularly with staff currently working through a challenging behaviour course. The manager is aware of the importance of making the flat secure to ensure the safety of the service user, however the poor state of carpets in the home, particularly in the lounge, put the service user and staff at risk. The provision of training in moving and handling was discussed and although the staff do not lift the service user they should have some understanding of moving people safely and the manager will arrange suitable training for all the staff. The manager is expecting to complete the Registered Manager Award in 2006, she has also completed a supervision and appraisal course. There are clear lines of accountability in the home. There was no evidence of a business and financial plan for the home, the manager advised that liability insurance is in place. Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 17 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 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 3 12 2 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Danemere Score X X X X Standard No 37 38 39 40 41 42 43 Score X X 2 2 2 2 3 DS0000021352.V269244.R01.S.doc Version 5.0 Page 18 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 Standard YA1 Regulation 4&5 Requirement The statement of purpose and service users guide to be reviewed and updated to reflect the services provided by the home. A suitable educational programme to be developed and introduced. A programme of maintenance and replacement for all parts of the home to be developed, to include timescales for completion of the improvements. The home to review, update and follow appropriate recruitment procedures. A quality assurance and monitoring system of the services provided to be developed and introduced. Policies and procedures to be reviewed and updated in line with the National Minimum Standards. Health and safety of service users to be reviewed and appropriate changes made to the environment. Timescale for action 04/04/06 2 3 YA12 YA24 12 (1)(b) 23 (2) (b)(d)(h) 06/02/06 06/02/06 4 5 YA34 YA39 19 (4)(b)(i) 24 12/12/05 06/02/06 6 YA41YA40 17 04/04/06 7 YA42 13 (4)(c) 06/02/06 Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 19 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 Danemere DS0000021352.V269244.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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