Inspection on 19/01/06 for Deafway

This inspection was carried out on 19th January 2006.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Deafway 26/02/07

Deafway 01/02/05

Deafway 22/07/04

Similar services:

SignHealth

Mere Hall View

Beechfield Lodge

Christopher Grange (Rhona House)

Sense

Auden House

Sign, 100 Bowfell Road

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

CARE HOME ADULTS 18-65 Deafway Brockholes Brow Preston Lancashire PR2 5AL Lead Inspector Mrs Lynne Lynch Unannounced Inspection 19th January 2006 11:00 Deafway DS0000034696.V258013.R01.S.doc Version 5.1 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 Deafway DS0000034696.V258013.R01.S.doc Version 5.1 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. Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Deafway Address Brockholes Brow Preston Lancashire PR2 5AL 01772 796461 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) jjw@jjw-01.freeserve.co.uk Deafway Mr John Joseph Williams Care Home 34 Category(ies) of Sensory impairment (34) registration, with number of places Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service shall at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission 28th June 2005 Date of last inspection Brief Description of the Service: Deafway is a care home for adults, registered under the Care Standards Act 2000, to provide residential accommodation for thirty-four people who have a sensory impairment. The accommodation consists of four residential units amidst extensive gardens. There are several local shops and public amenities within walking distance of the home. A regular bus service to Preston city centre is close at hand. All residential areas within the home are equipped with environmental aids and equipment to meet the needs of people who are deaf. These include visual fire alarm systems, flashing doorbells and text phones. There is a cafeteria on site that offers a wide range of meals to suit all dietary needs and tastes. Residents are also encouraged to shop and prepare snacks and meals for themselves where facilities are available. The Preston Deaf Club is situated on site. All residents are issued with free membership to the club for the length of their stay at Deafway.The majority of staff can communicate in British Sign Language, which is the primary mode of communication within the home. Residents are encouraged and enabled to participate in community activities. Many attend college and pursue a range of vocational interests. Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on January 19th 2006 over six and half hours by two inspectors. An interpreter supported the inspectors to speak with people in the home whose first language was British Sign Language. The inspectors spoke with six residents, two staff, the activity co-ordinator and the deputy manager of the home. Documentation in respect of resident’s personal and healthcare support, complaints, protection, and risk management were viewed. The homes activity co-ordinator spoke with the inspectors about the many social and leisure activities made available to the resident’s in the home. Comment cards were distributed and at the time of the report one was received back from a General Practitioner. The inspection findings relate to the National Minimum Standards for Care Homes for Younger Adults (2nd edition). This home has been assessed against all the key standards over the course of the year. As such, those standards not assessed during this inspection, will have been assessed at the last inspection on the 28th June 2005. What the service does well: What has improved since the last inspection? The home is continuing with its major refurbishment plan. There has been further improvement to the furniture and decoration since the last inspection. Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 6 Deafway appointed a designated activities coordinator last year and this has made a great improvement to the social, leisure and educational opportunities for people living at the home. 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. Deafway DS0000034696.V258013.R01.S.doc Version 5.1 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 Deafway DS0000034696.V258013.R01.S.doc Version 5.1 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): None of the above standards were inspected at this visit. EVIDENCE: Deafway DS0000034696.V258013.R01.S.doc Version 5.1 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): 7 and 9 Staff support individuals to make decisions about their daily activities. Formal risk assessments, which are accessible to all staff, are required. EVIDENCE: Staff have good communication skills, as demonstrated during this inspection and clearly know the people living at the home very well. Individuals are supported to make decisions. Resident’s meetings are held monthly and are chaired by residents there was good evidence from the minutes that these are open an interpreter is available at these meetings. All residents are invited to attend their six monthly review meetings and also mid point meetings where they are consulted regarding their personal care and activity plans. The Care Plans, personal profile files and activity files for three residents were viewed. It was noted on two out of the three Care Plans that risks for individuals were noted however there were no risk assessments in place. The risk assessments viewed in the inspector’s opinion continue to be complex and lacking basic easily understandable guidance for staff, these assessments were only reviewed on an annual basis which is not frequent enough to address any changes. Staff spoken to all felt that the risk management system in place was Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 10 difficult to understand however they advised the inspectors that a new system was soon to be introduced and training had been given in respect of this. The intended system is much clearer and personal to the individual and if implemented correctly will give clearer guidance for the staff team. Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 and 16 Residents in the home are supported to maintain relationships and access social, leisure and educational opportunities. EVIDENCE: Deafway appointed a designated activities coordinator last year and this has made a great improvement to the social, leisure and educational opportunities for people living at the home. Every resident has an activity file, which contains his or her weekly programme of planned activities. Residents spoken with confirmed that they drew up these programmes with staff support. Activity feedback sheets are completed after each activity giving good information as to whether the activity was appropriate and enjoyed. The activity organiser advised that all activities are reviewed on a monthly basis and are also discussed at the resident’s general six monthly review. Activities take place both inside and outside the home and include budgeting, drama and current affairs groups, creative arts, bowling, going to the gym, cinema, museums, canoeing and shopping. One gentleman spoke about how he is being supported to find new employment after recently losing his job. There was good evidence of the home liaising with colleges and employment support groups. The majority of residents were very happy with Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 12 the support provided however one lady did say on occasions due to lack of staff she had not been able to complete her programme. The home has two vehicles to assist people to access the local area and several of the residents are able to access the good local transport networks. Religious services are held within the home on a regular basis and two residents attend church services external to the home were there is an interpreter provided. Through discussion and through viewing policies, the inspectors were able to determine that there are no undue restrictions in terms of times and frequencies of service users’ visits. There was evidence on several resident’s files of staff giving support to people to help maintain contact with friends and family. During the visit, several service users were observed to be receiving support in relation to daily living skills such as laundry and meal preparation. Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Staff provide personal care in the way individuals prefer. Excellent systems and practices are in place, which ensure that health care needs are met. EVIDENCE: Three residents files were viewed in respect of personal support and healthcare needs. Clearer guidance for staff in respect of some of the needs identified was required. Daily notes showed that staff follow any guidance given. A number of the current residents at the home have specific health needs. Records show good contact with other professionals such as district nurses, mental health professionals and specialist nurse input. Evidence of good multi disciplinary reviews of care was noted. Records are kept of all appointments and outcomes are noted with clear action taken in respect of this. Daily notes for one lady show good interaction from staff to support her mood in respect of her physical illness. One lady during the visit was in some discomfort due to a skin condition a staff member noticed this and assisted her to apply cream and a dressing to the area. Residents spoken with confirmed that staff support them if required with appointments or an interpreter is booked if they wish. One lady spoken to said she attends a women’s health group held at Deafway where she can discuss issues and get information. Another lady advised that she and her boyfriend attend a specialist centre for deafness and mental health support and are currently receiving support around their personal relationship, which Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 14 they find helpful. Several residents attend this unit for specific health support required, staff from the home and the unit liaise on a regular basis with good records of these visits being maintained. A thorough audit of the medication standard was conducted earlier this year the specific findings of the pharmacist inspection are available in a separate report. Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were inspected at this visit. EVIDENCE: Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were inspected at this visit. EVIDENCE: Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 17 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): 34 The home has a thorough and robust recruitment process, which is consistently applied in order to protect residents. EVIDENCE: The company operate a thorough structured recruitment process in order to protect residents. From observation of the staff member’s personnel file, it was evident that the policy and procedures in respect of staff recruitment had been followed. This included an application form; health questionnaire, formal interview, references and a Criminal Records Bureau clearance had been obtained prior to the applicant actually taking up post at the home. Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 18 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): 37 The manager is qualified, experienced and supported by the senior staff in providing clear leadership throughout the home. EVIDENCE: The registered manager has many years experience of managing residential care services for adults, he is a qualified RMN and holds the Diploma in Management Studies. The job description of the registered manager enables him to undertake responsibility for fulfilling the duties associated with the manager role. There are clear lines of accountability within the home and the wider organisation. The Deputy manager has recently taken on more responsibility for the day to day running with the probability that he will take over as the registered person. Staff spoken to felt well supported in their role and confirmed that they were happy with the level of training available. Residents spoken with were all aware of the lines of accountability in the home and felt able to make a complaint or raise their concerns. Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 19 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X X X X X Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 20 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 13(4) Requirement Care plans should be further developed and regularly updated to reflect current strengths and needs and formal risk assessments should be undertaken where a risk has been identified. Timescale for action 31/03/06 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 Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Deafway DS0000034696.V258013.R01.S.doc Version 5.1 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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