CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65
Deafway Brockholes Brow Preston Lancashire PR2 5AL Lead Inspector
Mrs Christine Marshall Unannounced Inspection 26th February 2007 09:30 Deafway DS0000034696.V299350.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 Deafway DS0000034696.V299350.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 Older People and 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.V299350.R01.S.doc Version 5.2 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) stuart.richardson@deafway.org.uk Deafway Stuart Richardson Care Home 34 Category(ies) of Sensory impairment (34) registration, with number of places Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 34 residents to include:*Up to 34 residents in the category of SI (Sensory Impairment) 19/01/06 Date of last inspection Brief Description of the Service: Deafway is a care home for adults, registered to provide residential accommodation for thirty-four people who have a sensory impairment. The accommodation consists of four residential units amidst extensive garden areas. There are 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 adaptations 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. 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. At the time of this visit (25/2/07) the fees charged at this home were from £655.00 to £1050.00 with various extra costs for personal toiletries, interests and some activities. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced visit, which took place over a full day. Two British Sign Language (BSL) interpreters accompanied and supported the inspector, to speak with people in the home. Comment cards were received from the residents before this visit, as was a pre-inspection questionnaire from the registered manager; this information helped in the planning of the visit. The management, staff and residents were spoken with and administration records were looked at. A tour of the home included looking at bedrooms, lounges and dining areas, toilets and bathrooms. This was to assess whether the home provided a comfortable, homely environment for the enjoyment of everyone, and to ensure the residents’ safety. What the service does well: What has improved since the last inspection?
Risk assessments for each resident, for their personal lives and for their environment, had been developed to ensure the safety and welfare of the people who live there. Deafway DS0000034696.V299350.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. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home gathers enough information about prospective residents, so that their needs can be met. EVIDENCE: There were pre-admission assessments and these made sure that the prospective residents’ strengths and needs were identified, and that the home could provide the care that was needed. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 9 One resident said that they did not have a pre-admission assessment because they were taken to the home from hospital. The manager confirmed that this person was an emergency admission and that all assessments and information about the home were completed within the first week. Staff were able to confirm that residents were welcomed on visits before they moved in. Generally all residents were assessed by the same tool, thus promoting equality of assessment and care provision. It was noted that the residents’ religious preferences were not recorded. The manager said that religious ministers visited the home and some residents did go to church if they wished; however this would be addressed and recorded in future. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning and risk assessments reflected each person’s preferred way of life, and health and welfare needs were met. EVIDENCE: Care plans are written records that describe the care that is given to each person living at the home.
Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 11 Each resident had an individual plan of care, based on a person centred approach, which helped staff to get to know each person’s needs and wishes. These reflected the complexity of his or her needs and detailed how these were to be met. Aims for care, including communication and coping strategies were clear, as were any limitations, risk assessments and the reasoning behind this. The ethos of the home is to improve each deaf person’s quality of life, and promote independence and social inclusion. The care plans that were looked at were recorded on a fairly new system, and those records that had been transferred to this system were updated regularly; the manager agreed that the member of staff who was completing these plans, and the residents or their relatives, should make sure that they sign the plans to clarify agreement. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 13 Standards 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home are supported in maintaining relationships and accessing social, leisure and educational opportunities. EVIDENCE: Residents and staff worked together to promote practical skills such as cooking, shopping and household chores and the residents’ choice was positively promoted. Staff said that visitors were made welcome and they encouraged and enabled residents to keep in touch with family and friends. Residents said that they enjoyed a variety of individual hobbies and interests. These included going shopping, scuba diving, swimming, going to the pub, church and cinema, keep fit, walks, day trips and holidays. College courses were also available. Records showed that staff supported residents in something of their choosing most days. On the day of the visit, a member of staff was holding an environment/recycling class and the residents joined in and contributed to the discussion. Residents had privacy in their own bedrooms if they wanted, with the option of holding their own keys. Daily routines were flexible and restrictions on lifestyle choices were minimal; each person’s care plan had a formal risk assessment and those resident who were spoken to understood this as being in their best interests. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were supported in all aspects of daily life and treated with dignity and respect. EVIDENCE: Staff ensured that residents’ choices about personal routines, such as getting up/going to bed times, bathing, clothes choice and going out were respected. Personal care needs and strengths were recorded in care plans and staff
Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 15 helped accordingly. Staff monitored healthcare needs. GP, outpatient and other medical check visits were planned and recorded, and residents were supported to attend clinic appointments. Residents said that they were supported in their daily lives and could “please themselves”. The pre-inspection questionnaire gave information to the Commission that there were safe medication storage, recording and administration policies and procedures in place. The Commission’s pharmacy inspector had visited the home within the last twelve months and there were no issues or shortfalls noted. Staff had undergone accredited medication training. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected through organisational policies and procedures and staff training programmes. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 17 EVIDENCE: The pre-inspection questionnaire that was sent to the Commission before this visit gave information that there was a complaints procedure in place. There had been one allegation levelled against the home since the previous inspection visit and this had been referred to the Social Services under the Adult Safeguarding Procedures. An investigation was undertaken and the home had responded quickly and appropriately. The home had an adult protection procedure and a copy of “No Secrets in Lancashire”. Staff said that they knew about this. Most of the staff had also received training in protecting the residents, those who had not, were to be included in the planned training schedules in the near future. Although the staff were given copies of the General Social Care Council Code of Conduct for Carers, some staff said that they could not remember or describe this; the manager said that he would offer reminders to any staff who needed it. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were provided with a homely environment that was basically suitable for its stated purpose. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 19 EVIDENCE: Although there are long-term plans to move the site of Deafway, to a purpose built establishment in the Preston area, the home is continuing with its ongoing refurbishment plan. Two residents gave permission for the viewing of their rooms. These proved to be comfortable and personalised and the residents said that they were quite proud of their rooms and personal possessions. The lounge areas around the home were comfortable and kitchen areas were clean and hygienic. There are policies and procedures in place for the Control of Substances Hazardous to Health (COSHH) and laundry and domestic staff knew about these. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team understood their roles and responsibilities, and met residents health and welfare needs. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 21 EVIDENCE: Staff were seen to be confident in their abilities and demonstrated good understanding of their roles. Staff had undertaken induction and foundation training in care, support and the needs of deaf people. There are ongoing training plans and programmes for the staff, however there remains below 50 with National Vocational Qualification (NVQ) at level 2 or above. The manager said that when the staff who were currently doing their NVQ had completed the course, then the home would have the required level of 50 NVQ trained staff. There were satisfactory staff recruitment procedures in place and the administrator was in the process of updating the files, making sure that each file held a photograph, as proof of the identity of each person. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 23 Standards 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is satisfactorily managed and service users health and safety is monitored and supported. EVIDENCE: The new registered manager is experienced in managing residential care services for adults, and there are clear lines of accountability within the home and the wider organisation. Residents spoken with were mostly aware who the manager was and felt able to make a complaint or raise their concerns if necessary. The home has recently achieved accreditation with the Investors in People (IIP), which is a quality standard. Yearly surveys are put to the resident, their relatives and visiting professionals and there are plans for the results of these surveys to be posted on the home’s notice board for all of the stakeholders to see. The pre-inspection questionnaire that was forwarded to the Commission before this visit, gave full information confirming that all health and safety procedures were updated, and relevant safety certificates were current; thus promoting the safety and welfare of the residents and staff. Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 X 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Deafway Score 3 3 3 X DS0000034696.V299350.R01.S.doc Version 5.2 Page 25 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 YA32 Regulation 18 Requirement 50 of staff must have NVQ level 2. A written plan to ensure this should be produced. Timescale for action 06/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA2 YA6 Good Practice Recommendations Prospective residents’ religious preferences should be recorded. The resident or their representative, along with the member of staff undertaking the care plan development/review should sign the records. Actual times of report writing should be included in any daily reports about the residents’ care. The manager should remind the staff about the General Social Care Council Code of Conduct for Carers. The recruitment files should be checked for proof of identity of all staff. Quality survey results should be made available for all stakeholders. 3 4 5 YA23 YA34 YA39 Deafway DS0000034696.V299350.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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
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