Inspection on 15/07/08 for Dean Park

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Dean Park 24 Park Lane Swindon Wiltshire SN1 5EL Lead Inspector Pauline Lintern Key Unannounced Inspection 15th July 2008 10:00 Dean Park DS0000071728.V366469.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 Dean Park DS0000071728.V366469.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. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dean Park Address 24 Park Lane Swindon Wiltshire SN1 5EL 01793 520922 01793 520922 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) Wardsign Limited Mr Robert Theobald Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (2) of places Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Learning disability (Code LD) - maximum of 5 places Mental disorder (Code MD) - maximum of 2 places The maximum number of service users who can be accommodated is 5. 2. Date of last inspection New service Brief Description of the Service: Dean Park is an adapted semi detached house in the Rodbourne area of Swindon. The home has recently seen a change in ownership. Dr Chetna Satra of Wardsign Ltd, now owns the home. Mr Robert Theobald is now the Registered Manager. Mr Theobald is also the manager of The Laurel, which is next door to Dean Park. Mr Theobald currently shares his time across Dean Park and the Laurel. The service provides care and accommodation to men and women between the age of 18 and 65 years. People have their own bedroom. The home is typically staffed with two people on duty between the hours of 8am and 7pm. There is no waking staff. One member of staff undertakes to sleep in at night and be available to meet any night time care needs or emergencies, as they arise. There is also an on-call system where a person can be contacted in an emergency. The model of care is relaxed and the supervision arrangements are unobtrusive. The fees for living at the home range between £450 and £865 per week, depending on need. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection took place over four and a half hours, and was conducted by two inspectors. Mr Theobald was available throughout the inspection. Feedback was given to Mr Theobald at the end of the visit. We were able to meet with three of the people using the service. However due to people’s limited verbal communication, we were unable to fully gain their views. The fourth person living at the home was out for the day; therefore we were unable to meet with them. The home currently has one vacancy. We were able to meet with the two staff on duty during the day, to obtain their views about the service. Time was taken to observe interactions between the staff members and the people using the service. As part of the inspection process, surveys were sent to the care home for distribution to the people using the service, their relatives, health care professionals and staff members. Three people living at the home (with staff support), one healthcare professional and one relative responded. Generally people told us they were happy living at Dean Park. Various records and documents were examined during the visit. These included care plans, risk assessments, health care and arrangements for managing medication, activities, complaints, staff recruitment and training. Systems such as health and safety and quality assurance were also examined. Both inspectors toured the building. The home sent us their annual quality assurance assessment (AQAA) when we asked for it. It was clear and gave us all the information we asked for. The AQAA included various improvements and the future plans for the service. During the visit all key standards were assessed. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people using the service. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose should be available at the home at all times. Care needs to be taken to ensure it contains clear information on what people living at the home can expect to be included within the fee. Consideration should be given to developing the Statement of Purpose in alternative formats. Each person using the service should have a copy of the Service User guide in a suitable format. More consideration should be given to people’s privacy and dignity. The Responsible Individual has confirmed that since our visit to the service, the practice referred to within the body of this report has now ceased. It would be good practice to have an activities plan available for people to refer to. Activities should be recorded and evaluated to identify if they were successful or not. Opportunities for a variety of activities and leisure pursuits should be explored. It is good practice to keep a complaints log in the home, so that any complaints or concerns are recorded, along with timescales and outcomes. The complaints policy needs to be updated. The radiator in the bathroom should be repaired to ensure it is at a safe temperature. All environmental risk assessments need to be reviewed and updated as necessary. Certain areas of the home would benefit from redecorating and refurbishment. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 7 The home currently does not have a system in place for obtaining the views of the people living there or their representatives. 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. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 8 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 Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 9 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): NMS 1,2,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Current information on the service was not found to be available within the home. People did not have a copy of the Service Users Guide. People using the service had received an assessment of their needs prior to moving into the home. EVIDENCE: We looked at the files of three people. Each of these people had had their needs assessed by a social worker before they moved into the home. Each person had a person centred plan, which contained assessment information about his or her needs. We saw that each of these three people had a contract with the home and the social services department. There have been no new admissions to this service since the change of ownership. We asked to see the Statement of Purpose, which was emailed to the home by Dr Satra. We recommended that a copy is kept in the home and is made available to visitors and the people using the service. We also recommend that Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 10 the statement of purpose be further developed in a more appropriate format to suit the needs of the people at the home. People did not appear to have a copy of the service user guide. This was discussed with Mr Theobald. He confirmed that he was planning to put them in place, using a Person Centred Approach, and in a format that suited each person’s individual needs. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 11 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): NMS 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s care plans and risk assessments need to be developed further to ensure that all their needs are met and they are protected from harm. EVIDENCE: We looked at three people’s personal files. Each person had a person centred plan, which had been developed by the previous owners of the care home. The plans were very long and complicated and not easy to read. The manager told us that he and the staff were developing new person centred plans for all the people who lived in the home. He told us that he wanted the plans to be working documents for the staff and to be kept up to date and reviewed regularly. One person had a new style plan called support guidance. When we looked at this we found that it contained sections about personal hygiene, activities and work, monies and finance, household, spirituality, communication, food and eating, drinks and drinking, sexuality, behavioural support and emotional Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 12 support. We noted that the sections on spirituality, sexuality and behavioural support had not yet been completed. The other sections were completed from the point of view of the person. They clearly showed how the person liked to be supported and how they were able to make choices. However, the guidance did not provide any information about the person’s diversity needs. For example how, as a person with a learning disability, they would be supported to integrate into the community, and how needs related to their sexuality, spirituality and culture would be addressed. There was information in the care plans about how people made choices for example choosing what to wear. A member of staff told us how people chose what clothes to wear each day. They also told us that people chose what time they went to bed. One person liked to go to bed between 9 pm and 9:30 pm while another liked to stay up until around 10:30 pm. The manager told us that people now had more choice about what time they went to bed because he had changed the staffing rota so that they could be supported later in the evening. We found little evidence of people making informed decisions about how to spend their time (see lifestyle.) There was a section about risk in the old style person centred plans. One person had a range of risk assessments, which focused on promoting their independence. These included shaving, using the kettle, crossing the road, riding a bicycle and self-medicating. They were last reviewed in May 2007 so needed further review. Two other people had risk assessments which were identical and included more general risks such as open windows, uncovered radiators, helping in the kitchen, moving round the home and going out in the community. One person’s risk assessments were reviewed in November 2007 and the other person’s were reviewed in March 2008. The manager told us that the risk assessments needed to be developed further. He planned to change the format of them and include the benefits and reasons why risks were being taken. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 13 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): NMS 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People would benefit from greater opportunities to various social activities both inside and outside of the home. Links with families and friends are promoted. Peoples’ rights are respected, although some people require more assistance from staff than others. EVIDENCE: As mentioned in the summary of this report, on our arrival at the home three people were at home. They were all sat in the lounge watching the television. They remained there, until lunchtime when they all walked to the Outlet Centre, in town, for lunch. It would appear that this is a popular location and the main focus of their activities. Diary entries show that activities usually involve a trip to the Outlet Centre for coffee, shopping or lunch, or a trip to another large superstore. Staff members report that day trips do take place occasionally and also trips to the pub, walks and trips to the park. Records Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 14 show little evidence of visits to places of interest, the seaside or one of the various leisure parks available. It is recommended that more choice and variety be offered with regard to activities. Mr Theobald reported that some times he brings in his guitar and they will have a music session. No one had an activities programme to alert them to what was planned for the week. It is recommended that this be developed. It was noted in the communication book that staff were reminded to complete ‘activity’ sheets. We discussed with Mr Theobald the need to ensure ‘activity’ sheets identify whether an activity had been a success. This should include what had been good and what may not have been so good for the person participating. Following our inspection the Responsible Individual provided us with Activity sheets that had been completed for the period of 7th April 2008 to the 8th June 2008. She explained that the sheets were being used more as a diary log to document activities carried out. She added that they are currently in the process of designing a weekly activity planner, which will be user friendly as well as organising some in house activities. Staff told us that one person using this service was very independent and regularly accessed the local community unaccompanied. On the day of the inspection they were out with a friend using public transport. Staff commented that they provide them with a packed lunch and a flask of tea when they go on days out. A cooked meal is then provided on their return if they wish. One person has been attending college, completing a drawing course. This course has now finished and staff were unsure whether the person would wish to attend another course next term. Records demonstrate that the people using the service are supported to make decisions where possible. One person’s care plan states that they will choose items they wish to purchase from the shop. It adds that they enjoy participating in some household tasks such as helping clear up after meals and making cakes. Another person helps staff to make their bed and tidy up. One care plan states that the person chooses not to do any household tasks. There is evidence to show that people are supported to maintain relationships. Friends and family are welcomed into the home. One staff member informed us that a BBQ has been planned for the weekend, and family and friends are invited. The statement of purpose states that ‘overseas trips are organised to give residents a wider choice of enhancing their knowledge.’ There was no evidence to indicate that this has happened. Mr Theobald reported that as far as he was aware this had not happened to date, although there are plans for a summer holiday. Minutes from the residents’ meeting on 12/5/08, record that the people living at the home had suggested staying in a hotel, with a kettle in the bedrooms. Consideration had also been given to the need for wheelchair Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 15 access. The Responsible Individual confirmed, after the inspection, that the people using the service had requested that their holiday takes place when the weather is cooler, therefore a seaside holiday is to be arranged for mid to late September. During the inspection we looked at the menus, which appeared varied and well balanced. Staff members told us that for people who are unable to verbalise their choices of food, pictures and photographs are used. They added that they have a good knowledge of people’s likes and dislikes. There appeared to be adequate supplies of food available. All open food in the fridge was labelled as to when it had been opened. Fresh fruit was available and refreshments frequently offered. Records indicate that a fair amount of meals are taken at the Outlet Centre or various supermarkets etc. Receipts show that the people using the service have paid for these themselves. The Statement of Purpose clearly states that ‘three meals are provided daily’. The Statement of Purpose must be amended to clarify what people are expected to pay for and what is provided by the home. If people are to be expected to pay for meals on day trips this needs to be clear within the statement. However, people living at the home should not be regularly paying for their main meals, these should be included within their fees. A copy of the amended Statement of Purpose has now been received. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 16 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): NMS 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s dignity and privacy were not wholly promoted. People’s immediate health care needs were being met. People were generally protected by the medication practices. EVIDENCE: As part of the inspection process we looked at three files. One person had new support guidance, which showed how the person liked to be supported. Each person had their own room and personal care took place in their bedrooms and/or bathrooms. One person had a bedroom with an en-suite shower. A staff member told us that they helped the person in the room next door to use this shower, so that they did not have to go downstairs to the shower room. To ensure that peoples’ privacy and dignity is upheld, we advised that this practice must cease. Since this report was completed, we have received confirmation that this practice no longer takes place. People were able to choose what to wear and had their own clothes in their rooms. The bedrooms were individually furnished and decorated. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 17 We saw information about health care in the personal files. Each person was registered with a GP and they saw other health care professionals as needed. Information about appointments was recorded. We saw that people had appointments with the GP, district nurse, dentist, optician, podiatrist, psychiatrist and other specialists as required. A record was made when the GP or psychiatrist reviewed medication. The manager told us that each person had a health action plan to ensure his or her health needs were met. We looked at one person’s health action plan and noted that they were not receiving regular health checks and screening. The manager told us that this person had been offered appointments but turned them down. The Responsible Individual later confirmed that everyone at Dean Park has an annual health check and that regular appointments are made with the GP or nurse as needed. Each person was prescribed medication. Three people had support with administering their medication and one person could manage their own. A monitored dosage system was used for most of the medication, although some medication was administered from original packaging. A record of medication received into the home, administered, and returned to the pharmacy was kept on a weekly medication audit sheet. Each person had a medication administration record. Staff signed these when they gave medication to people. We noted that one person who took their own medication had a record, which identified when their medication was received into the home. It had no signatures or a record of when or if the medication was taken. A member of staff told us that there were no controlled drugs. We noted that the medicine cupboard did not comply with the requirements for storage of controlled drugs in care homes if someone was prescribed them in the future. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 18 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): NMS 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place for recording any complaints or concerns, however this needs to be further developed. Greater care needs to be taken to ensure that people are safeguarded in relation to financial abuse. EVIDENCE: There is a copy of the complaints procedure within the statement of purpose. The procedure is in need of reviewing as it was last updated in 2003. There are forms available for registering a complaint, which were used by the previous owner. We discussed with Mr Theobald the need to develop a complaints log, which will provide timescales, actions taken and outcomes. The manager confirmed that he would action this. Staff members told us that they have seen a copy of the local protocols for safeguarding people, ‘No Secrets’. They confirmed that they understood the contents of the guidance and the ‘whistle blowing policy’. Staff confirmed that they had attended training in safeguarding people. As mentioned previously in this report, there needs to be greater clarity within the Statement of Purpose as to what is included within the fee of living in the home and what people can expect to pay for themselves. The home confirmed that they are amending their Statement of Purpose to provide clearer information. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 19 Some people have some of their personal monies held for safekeeping. We examined financial transactions, examined receipts and checked that cash within the personal money tins balanced with the records. Two people’s cash tins held by the home were sampled. Both cash and records balanced for both people. Receipts indicated that on some occasions one person had paid for their peer’s meals while they were out. The manager explained that this did happen and they took it in turns to pay for the meals. He added that this made it easier with regard to recording transactions. It is a requirement that this practice ceases immediately. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 20 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): NMS 24,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although the home is clean, tidy and comfortable, certain areas would benefit from being re-decorated and refurbished. EVIDENCE: Dean Park and the registered care home next door, The Laurel, are both owned by Wardside Ltd. Mr Theobald is the registered manager for both homes and works across both homes on a daily basis. Both inspectors toured the premises, accompanied by a member of staff. All areas of the home were found to be clean and tidy Provision had been made to ensure people had everything they needed in their rooms, such as television, personal items and music systems, if they wished. Some rooms are showing wear and tear and would benefit from being redecorated, as they were quite dark and oppressive. Another area in need of attention is the kitchen. Again, it is very dark and is in need of refurbishment. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 21 The manager told us that he would like to extend into the lounge area to make a bigger, lighter, open planned area. It was noted that one person’s bedroom windowsill had a piece of hardwood across it, which would benefit from being painted. The lounge does not appear to have been re-decorated for a number of years and would benefit from new lighting and redecorating. There is a very large plasma screen television in the lounge, which appears to be enjoyed by all the people using the service. However this does take up a considerable amount of room in what is a fairly small lounge area. Each bathroom and toilet was found to be clean and hygienic. Bacterial hand wash was available in these areas. One bathroom had an unguarded radiator, which was found to be extremely hot to touch. There did not appear to be a thermostat on the radiator to control the temperature. The staff member told us that the only person using this bathroom was very independent and would know not to touch it. We require that this radiator be repaired and a risk assessment put in place immediately. There is a separate laundry, which houses a washing machine and drier. Staff told us that there is a large drier in the garage. All toxic materials were found to be stored safely, although no accompanying data could be found. Data needs to be collated to ensure that staff knows how to respond in the event of an accident involving toxic materials. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 22 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): NMS 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People appear to be properly recruited, inducted and supervised. Staff have the opportunity to complete their National Vocational Qualification, however prior training in Learning Disability Award would further enhance their underpinning knowledge. EVIDENCE: We looked at the files of two staff who had been recruited by the new owners since they were registered. The staff had both completed an application form including a declaration that they had no convictions. One member of staff had some gaps in their employment record and the manager had made notes on their application form about the reasons for these. Both staff members had completed separate declarations identifying they were physically and mentally fit. Copies of their birth certificates and passports were being kept as proof of identity. Two written references, a protection of vulnerable adults (POVA) first checks and a criminal records bureau (CRB) check had been received for one member of staff before they started work. It was not easy to tell from the records what date this member of staff had started work. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 23 Two written references and a POVA first check had been received for the second member of staff before they started work. The manager told us that this staff member had started work on the day of the inspection and they were working with them until their CRB check was received so they would be supervised at all times. We also noted that the new member of staff had taken people out to lunch accompanied by another member of staff. We did not find an assessment of the risk to people who lived in the home of allowing this member of staff to work with people before their CRB check was received. The statement of purpose said that staff were given in house training up to National Vocational Qualification (NVQ) level 2. The first member of staff had an NVQ level 2 in health and social care. The new member of staff already had NVQ level 2 and had received a range of training in a previous job including prevention from abuse. The first member of staff was receiving an induction using the Skills for Care common induction standard. We noted that an induction booklet with the common induction standards was in the new member of staff’s file ready for them to complete. We did not see any evidence of Learning Disability Award training being used although there was a reference to it in the common induction standards. One member of staff told us that they would be attending Dementia awareness training in August, and they would also be starting their NVQ level 2 in Social Care at the same time. One staff member has an NVQ level 3. Staff members told us that they have recently attended medication training (level 2) in house. Dean Park staff team consists of five staff excluding the manager. The manager tends to work between 8am and 4pm and is therefore available if he is needed in either building. We noted when looking at the care plans that equality and diversity issues were not being addressed fully in the plans. More consideration needs to be given to people’s diverse needs, such as disability, sexuality, culture and spirituality. Staff would benefit from equality and diversity training so that they can recognise and record how to meet these needs. We saw supervision records in the file of the first member of staff. These showed that they had had supervision meetings with the manager about once a month since they started work. The supervision format covered training needs, performance and any issues relating to work. Action points were noted so that they could be followed up at the next supervision meeting. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 24 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): NMS 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the people living there. Systems need to be developed to capture the views of the people using the service and their representatives. Health and safety is promoted within the home, however greater consideration could be given to environmental risks. EVIDENCE: The registered manager is qualified and has many years experience within the care sector. He told us that he is aware of the areas in need of development and is working towards achieving this. Staff reported that the manager and new owner have settled in well. They added that they feel supported by both and could approach either person at Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 25 any time if they needed. They told us that the owner regularly visits the home to carry out management audits. An Annual Quality Assurance Assessment (AQAA) was sent to the home to complete as part of this inspection. The AQAA enables the manager/provider to assess their service and tell us what they feel they do well, what could be improved, what improvements have been made since the last inspection and what their plans for the next twelve months are. We received the AQAA a few days following our visit to the home. There are currently no systems in place for canvassing the views of the people using the service or their representatives. The manager reported that this is an area he will be addressing. He confirmed that he would be looking at each person’s communication needs and would incorporate these into his quality assurance system. Following the inspection we received confirmation from the Responsible Individual that the home plan to hold regular house meetings to ensure that the people they support are able to share their views and are provided with more choice. Records show that at one meeting, one person raised that they would like to have steak on the menu and another person said that they would prefer more ‘meat based’ meals. The last meeting recorded took place at Lydiard Park in May 2008. Overall health and safety checks are regularly carried out to ensure the safety of staff and the people using the service. This said, all environmental risk assessments should be reviewed and updated to safeguard people. Most checks relating to fire have been carried out regularly. Records show that staff have not received fire instruction for April to June 2008. This needs to be addressed. The home did not have a fire risk assessment in place. A requirement is set to ensure that this is rectified immediately. Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 26 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 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 2 X X 2 X Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 27 NO 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 YA18 Regulation 12(4) a Requirement The registered person must ensure that people’s privacy and dignity is upheld. To ensure this, the practice of a person using another person’s en-suite shower must cease. The practice of people purchasing meals for their peers must cease unless the person specifically wishes to do so. If this is the case this must be agreed and recorded in the care plan. The registered person must ensure a fire risk assessment is completed and kept under review. The registered person must ensure that all risks from hot surfaces are assessed and minimised where possible. The registered person must ensure that each person using the service has a copy of the service user guide. Timescale for action 15/07/08 3. YA23 13 (6) 15/07/08 4. YA42 23(4) 15/07/08 5. YA42 13 (4) c 15/07/08 6. YA1 5 (1) a to f (2) 15/10/08 Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 28 7. YA39 24 (1) a,b 8. YA42 13 (4) a The registered person must ensure quality assurance and quality monitoring systems are in place to take account of the views of the people using the service and their representatives. Data for all toxic materials should be readily available for staff reference. 15/10/08 15/09/08 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. 3. Refer to Standard YA6 YA6 YA9 Good Practice Recommendations Each person should have a new style care plan or support guidance. The support guidance should be developed further to include people’s diversity needs and promote equality of opportunity. The risk assessments should be reviewed and developed further to include the individual risks to each person, the reasons why people are taking risks and the benefits of risk taking. A cupboard, which complies with the requirements for the storage of controlled drugs in care homes, should be obtained so that if people are prescribed controlled drugs they can be stored safely. A checklist should be used to record when all recruitment checks are received and when a new staff member starts work. This will make it easier to tell whether all the recruitment checks have been made before a new staff member starts work to reduce the risk of people being cared for by unsuitable staff When a member of staff is employed following a POVA first check and before their CRB check, a risk assessment should be conducted to reduce the risk of people being cared for by unsuitable staff. All staff should receive equality and diversity training so they know how to recognise and meet people’s diverse needs. 4. YA20 5. YA34 6. YA34 7. YA35 Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 29 8. YA35 9. YA20 New staff should receive Learning Disability Award training as underpinning knowledge for NVQ’s. Each time the person who takes their own medication is given their supply of medication by staff, a record of the medicine and the quantity should be made on the medication administration record. The person should also sign this record to confirm that they have received it. The Statement of Purpose should clearly detail what people are expected to pay for. The Statement of Purpose should be available in alternative formats. A copy of the Statement of Purpose should be available to people in the home, at all times. A current activities programme should be developed and available to people. A greater selection of leisure activities should be offered, both internally and externally. A format for evaluating the success or failure of activities should be developed. A complaints log should be kept within the home to enable trends to be monitored. The complaints policy should be updated. Consideration should be given to re-decorating and refurbishing the areas in need of attention, as identified within this report. 10. 11. 12. 13. 14. 15. 16. 17. 18. YA1 YA1 YA1 YA12 YA13 YA13 YA22 YA22 YA24 Dean Park DS0000071728.V366469.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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