Inspection on 05/03/07 for Daubeney House

This inspection was carried out on 5th March 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Daubeney House 16/10/07

Daubeney House 24/01/06

Daubeney House 20/06/05

Daubeney House 18/11/04

Daubeney House 24/06/04

Similar services:

1 Marten Road

Three Gables

Aldwick House

49 Glendale

The Springs Community

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

CARE HOME ADULTS 18-65 Daubeney House Bersted Street Bognor Regis West Sussex PO22 9QE Lead Inspector Ms B Tye Unannounced Inspection 5th March 2007 09:00 Daubeney House DS0000039774.V331325.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 Daubeney House DS0000039774.V331325.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. Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Daubeney House Address Bersted Street Bognor Regis West Sussex PO22 9QE 01444 459517 01444 453413 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) Sussex Oakleaf Housing Association Limited Ms Lynda Peggy Strange Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of one (1) person in the category MD(E) (mental disorder excluding learning disability over 65 years). 24th January 2006 Date of last inspection Brief Description of the Service: Daubeney House is a care home registered to provide accommodation and personal care for up to ten people between the ages of eighteen and sixty five years who have mental disorders. The registration provides for one of the ten persons to be over the age of sixty five. The service is provided by Sussex Oakleaf Housing Association Ltd, and the Registered Manager is Mrs Lynda Strange. The Responsible Individual operating on behalf of the organisation is Mrs Tracey Faraday-Drake. The property is a large detached house, situated in a quiet residential area near to the town centre of Bognor Regis. Accommodation for residents is on ground and first floors. A second floor provides additional office space and staff sleep-in accommodation. All resident’s rooms are for single occupancy only and have en-suite facilities. A TV lounge, quiet lounge and open plan dining room/kitchen provide communal space for residents at ground floor level. There is a spacious garden to the rear of the house and an enclosed garden area in the centre of the building. Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the inspection all relevant information and correspondence relating to the home was examined. During the course of the inspection the inspector spoke to some of the people living in the home, interviewed staff and spoke at length to the manager. A tour of the premises was undertaken. The inspector observed lunch being served and staff interaction with residents. Three care plans and staff files were examined alongside the homes records including, staff training and supervision, fire, incident and accident reports and all those relating to health and safety. This is the first inspection of 2006/2007. This is called a key inspection and will determine the frequency of visits/inspections hereafter What the service does well: What has improved since the last inspection? Since the last inspection the manager has implemented risk assessments for self medication and individual medication profiles, which have been agreed and signed by the residents. This information provides outcomes to show why some residents are deemed unsafe to take control of their own medications. Daubeney House DS0000039774.V331325.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. Daubeney House DS0000039774.V331325.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 Daubeney House DS0000039774.V331325.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 good. Prospective residents and their families can be confident that current information regarding the home will be made available, their needs will be assessed and visits to the home are encouraged. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide for the home are in place and accessible for prospective residents. Files examined showed that each resident’s needs had been thoroughly assessed in relation to all aspects of care. There have been no new residents admitted since the last inspection visit. At that time pre-admission assessments and contracts were seen to be in place. Daubeney House DS0000039774.V331325.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 good. Care plans and risk assessments detail the personal and emotional needs of each person. Residents know that their individual care plans reflect their assessed and changing needs as well as their personal goals. The staff team offer choice regarding personal care issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a plan of care in place for each person living in the home and information is updated on a daily basis and reviewed six monthly or more frequently if required. The plans include any specific arrangements agreed with residents about their day-to-day activities and care as well as any specialist arrangements. Care plans seen now include the individual resident’s consent to medication in addition to detailed risk assessments. Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 10 Care plans, which include assessments of need, risk assessments, daily living plans and personal routines are very comprehensive and information is well laid out. This enables staff members to access information easily about the personal and background details of the people they are supporting. Detailed risk assessments held on each care file promote the residents independence in daily living within agreed limitations, to ensure their safety and welfare. All care plans and risk assessments seen are signed by the residents and their key workers. The members of staff spoken to showed an awareness of the support needs of residents and any changes are communicated at shift handover times and through the daily communication sheets. Staff practice was observed, and showed residents were treated kindly and with respect. It was clear that staff were knowledgeable about resident’s needs and how to communicate appropriately with them. Daubeney House DS0000039774.V331325.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 good. There is a choice of activities available for residents to participate in. Residents are supported to keep in touch with family and friends. Residents have their nutritional needs assessed and are offered a variety of fresh, home cooked meals. The daily routines and house rules promote independence and individual choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An activities file is kept at the home to demonstrate the choice of outings and activities offered. Residents are supported to pursue interests and hobbies in line with their care plans. They are supported and encouraged to get involved in daytime activities but the final decision about participation is theirs. Residents meetings are held on a monthly basis to involve people in the decision making processes within the home. Minutes of these meetings are Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 12 held on file. A community notice board in the kitchen area displays information about local community events and activities held in the home. The kitchen/dining area provides a clean and homely environment for residents to sit and talk throughout the day. All residents have access to hot drinks and snacks as required. Menus were seen and these are planned on a five-week rotating basis. They showed that meals provide variety and a healthy balance as well as a daily alternative to the main meal. Residents usually have a snack style lunch of their choice and a main cooked meal in the evening. Residents are supported to cook in a separate ‘training kitchen’ as part of the rehabilitative process, which promotes more independent living. Residents also assist with preparation of house meals and the weekly house shop as part of developing independent living skills. Residents asked, said that the ‘food is good and they had a choice’. Staff provide support and encouragement where special diets are needed. The final decision as to whether diets are adhered to rests with the individual. Daubeney House DS0000039774.V331325.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): Quality in this outcome area is good. Healthcare needs are met including access to a number of healthcare professionals. Medication is well managed and staff members receive relevant training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Healthcare needs are assessed and recorded in detail on residents care plans. These are reviewed on a six monthly basis or more frequently if required. There is evidence from records and from speaking to the staff team that the home works with a variety of healthcare professionals to meet residents healthcare needs. These include community based Psychiatrists, Psychologists, Community Psychiatric Nurses, Social workers and GP’s. Each resident has a community based link worker who liaises with the home about on going care planning and reviews. Residents also have access to services such as dentists, opticians and chiropodists. Staff support residents to attend appointments as required. Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 14 Residents are supported to take control of their own medications where appropriate. Since the last inspection, risk assessments have been undertaken in respect of whether or not individuals should take control of their own medication. These risk assessments are held on file in conjunction with detailed medication plans and medication profiles for each resident. Medicines were seen to be stored securely in a locked cupboard and records maintained to provide an audit trail from the time they are received until disposal. Staff receive annual refresher training in the safe handling of medicines. All medicine administration records seen were in good order with no gaps or errors. This confirms staff are working in line with the homes policies and procedures. Daubeney House DS0000039774.V331325.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): Quality in this outcome area is good. Working practices and staff training are designed to protect residents from risk of abuse. Residents know how and to whom they should complain. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure in place, which is displayed within the home. A copy is also included in the Statement of Purpose and Service User Guide. The complaints book showed that no complaint s had been received since the last inspection. A resident said, “the staff are very nice. I can talk to them if I am not happy about something’ The home has a “whistle blowing” policy and staff members receive training in the protection of vulnerable adults from abuse. Records show all staff undergo CRB checks prior to employment at the home. Staff members were observed treating residents in a kind and caring manner. Daubeney House DS0000039774.V331325.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): Quality in this outcome area is good. The home’s premises are suitable for its stated purpose, accessible, safe and well maintained This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is conveniently situated within walking distance of the town centre and local bus routes. The premises were found to be clean, well maintained, bright and spacious. The home was warm and comfortably furnished with good quality furnishings in all areas. Residents are able to have their own furniture and personal possessions around them if they wish and this was very evident in the rooms seen. They also have the opportunity to choose their own décor. The home meets the requirements of the local fire service and environmental health department and there are reports to verify this. Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 17 The laundry is suitably sited away from areas where food is prepared or served. The equipment was seen to be suitable and residents are able to use the facilities themselves with staff support if required. The area was clean and tidy and there are hand-washing facilities provided. Outside a courtyard area with seating has been provided and the area is pleasant and easily accessible. Building works are to commence in the downstairs corridor to treat an area of damp. Once this is completed the area will be decorated. The home has a maintenance man who attends the home on a weekly basis. All fire and safety checks are completed by staff members and monitored by the manager. Records seen on file were well maintained and up to date. The home has policies and procedures in place for the control of infection. The staff team have all recently completed infection control training. Daubeney House DS0000039774.V331325.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): Quality in this outcome area is good. Residents in the home are supported by a committed, caring and well-trained staff team and recruitment records are in good order. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are sufficient staff to meet the assessed needs of the current service users in the home. The people on duty were kind and caring in their dealings with residents and were seen supporting people to be as independent as possible and offering choice. Residents stated that the staff team were kind and caring, one person said, “they are all good to us” New staff undertake an induction at the start of their employment in addition to the completing the annual training programme offered at the home. All staff have completed the National Vocational Qualification Levels 2 & 3. The manager has completed Level 4 and the Registered Managers Award. Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 19 Each staff member has a training record in place and there is evidence that a variety of courses are undertaken including medication and the protection of vulnerable adults from abuse. Training in mental health related topics is also provided. Relationships between staff and residents appeared to be very relaxed and there was a happy and warm atmosphere in the home. Staff spoken with said that they very much enjoy working in the home. They were observed to speak to the residents as equals and clearly had a good understanding of each resident’s needs. Staff members confirmed that they received regular supervision sessions from either the manager or her deputy. Records of the sessions are held on file and reflect that supervision is held every 4-6 weeks, which is above the requirement of the standards. Staff spoken to stated they were clear about their roles and responsibilities and receive clear direction and support from the manager. All staff presented as being well motivated and committed to providing the best possible care for the residents. Overall the staff members are long standing providing consistency of care to the residents. There has been one member of staff recruited since the last inspection. The recruitment file of a new staff member contained all the required documentation. The recruitment files were in excellent order and information regarding each staff member from interview to completion of induction was detailed and easily accessible. Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. A confident and competent manager is in place, staff are well supported and records are in good order. The safety and welfare of the residents is paramount within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home was available through the inspection process. Two staff members were interviewed and both were very complimentary about her commitment to the home and her supportive management style. A member of staff said that the team ‘really worked well together. Everyone did more than what was needed because they really cared’ Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 21 Staff meetings are held on a regular basis. During these meetings there is discussion around care issues and how quality of practice could be improved within the home. Records for the running of the home were seen including finance, health and safety, recruitment, incident, fire checks and maintenance records. All were current and in very good order. All accidents and incidents are recorded and reported to the appropriate Bodies as necessary. The home has a comprehensive health and safety policies. Risk assessments are in place relating to individual residents and to the home’s premises and work practices. Quality Assurance reviews are completed by the manager, on a monthly basis for ten months of the year. For the remaining two months head office completes the audit. This information is collated on an annual basis and available in the home for perusal. Overall, the inspector concluded the running of the home and supported administrative systems were in excellent order and best served the interests and welfare of the resident and staff group at the home. Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X 3 X 3 X 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000039774.V331325.R01.S.doc LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Daubeney House Score 3 3 3 X 3 X 3 X X 3 4 Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 Daubeney House DS0000039774.V331325.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Daubeney House DS0000039774.V331325.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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