Inspection on 04/11/05 for Deja Vu.

This inspection was carried out on 4th November 2005.

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

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

Other inspections for this house

Deja Vu. 20/09/06

Deja Vu. 07/07/05

Deja Vu. 22/11/04

Deja Vu. 08/06/04

Deja Vu. 11/02/04

Deja Vu. 08/10/03

Deja Vu. 10/03/03

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

CARE HOME ADULTS 18-65 Deja Vu 14 - 16 Liphook Road Lindford Hampshire GU35 0PX Lead Inspector Marilyn Lewis Unannounced Inspection 4th November 2005 10:00 Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Deja Vu Address 14 - 16 Liphook Road Lindford Hampshire GU35 0PX 01420 477863 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) Robinia Care Limited Mrs Clare Michelle Morris Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users not to be admitted under the age of 18 years Date of last inspection 7th July 2005 Brief Description of the Service: Déjà vu is a care home for seven younger adults with learning disabilities. The home is situated in a residential area of Lindford, Hampshire, within easy reach of the local shops. All residents are accommodated in single bedrooms. One bedroom has en-suite facilities and the remainder are provided with hand basins. The home has a large, enclosed rear garden and patio area. The home is owned and operated by Robinia Care Limited, an organisation that has been a care provider since 1995. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 4th November 2005. The inspector toured the home and met with the seven residents, two staff members and the registered manager. Care plans were sampled for two residents and records were seen for medicines, staff recruitment, staff training, fire safety and fire drills. What the service does well: On the day of the inspection all the residents were at home in the morning. Good interaction was observed between the staff and residents and there was a calm relaxed atmosphere in the home. Prospective residents will know that the home can fully meet their needs and aspirations. The individual care plans provide staff with good information, allowing them to fully support the residents. Residents are supported to make decisions about their lives and participate in all aspects of life at the home. Residents are able to attend education or resource centres and can participate in a wide variety of leisure activities of their choosing, both in the home and the community. Residents physical and emotional health needs are met and they are protected by the home’s clear procedures for dealing with medicines. Residents are protected by staff awareness of abuse issues. Residents benefit from the home’s robust recruitment procedures and staff who are supervised and have clear job descriptions. The home is well run and residents benefit from the open approach to management operated by the registered manager. Residents know that their views will be taken into account when decisions are made about life in the home. The health, safety and welfare of the residents are promoted by the safe working practices operated at the home. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Prospective residents would know that the home could meet their needs and aspirations. EVIDENCE: Since the last inspection the home’s Statement of Purpose and Service User Guide have been updated to include the qualifications of staff employed at the home. The registered manager has the qualifications and experience necessary to run the home and the deputy manager also has experience in providing care for people with learning disabilities. The registered manager said that a full needs assessment would be undertaken for anyone being considered for a place at the home to ensure the home can fully meet their care needs. Staff receive training in all aspects of care and specific topics relevant to the service such as epilepsy. Advice is sought from the GP and other health professionals including the community physiotherapist, community behaviour support team and the speech therapist. The services of advocates are accessed for residents who require them. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 9 One resident who wishes to attend church social mornings is supported to do so. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 10 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): 6, 7, 8 and 9 Care plans provide staff with good information on the needs of the residents, who are encouraged to make decisions about their lives and who participate fully in all aspects of life in the home. EVIDENCE: Individual care plans were seen for two residents. The care plans are very detailed and contain information on all aspects of care needs, including personal care, communication and socialisation. The care plans had been reviewed regularly and the plans had been discussed with the resident’s parents or representatives. The registered manager said that care planning was now following a person centred planning approach that provides plans that are based on the goals and aspirations of the resident. The registered manager and the deputy manager have received training in person centred planning and other staff members were due to attend training sessions in the near future. The residents’ likes and dislikes were recorded in their plans including the time they would like to get up and go to bed, toiletries they preferred when washing and bathing and for food items. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 11 An assessment of expressive skills has recently been included in the care plans. The assessment provides staff with information on the resident’s communication methods including body language and assists them in supporting the resident to make decisions about their daily lives, for example if one resident wanted to spend time alone they would indicate this by going and sitting on the stairs. It was evident during the inspection visit that residents were able to make decisions with support from staff. One resident went into the kitchen and indicated she would like a drink. A staff member showed the resident tea and coffee to help her make a decision about which drink she would like. Residents were able to choose which activities they wished to participate in with some residents involved in drawing and colouring, while another sat quietly in the lounge. Records seen for one resident said that the resident had gone to the cinema to see a film of their choosing and on another occasion had shopped for food items for a meal they wished to cook. Residents participate in all aspects of life in the home. Pictures and photographs are used to assist residents to make decisions about food items to be purchased each week and some residents go with staff to do the shopping. Prospective new staff members are asked to spend a day at the home prior to be offered a position so that residents can meet the person and give their opinion about employing them. The registered manager said that if the home had a vacancy and a new resident was being considered for a place at the home, they would also visit to meet the permanent residents. Risk assessments for all daily living and leisure activities were included in the care plans. A risk assessment is completed for all new activities prior to starting the activity. One care plan stated that the resident liked to sometimes sit on her own when eating out in a café. A risk assessment said that the resident’s wishes should be respected but staff were to stay close and ensure the resident was safe. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13 and 14 Residents are able to participate in a wide range of leisure activities, both in the home and the community. EVIDENCE: Four of the residents attend sessions at education or resource day centres. Sessions attended are varied and include cookery, art and crafts and communication. One resident does a small job at the resource centre for a few hours a week. Daily programmes are in place in the home for the residents. The programmes are based on the needs of the individual and records of the activities are contained in their care plans. The residents receive support from staff to develop independent living skills and they are encouraged to participate in household activities such as helping to lay the table, loading the dishwasher and tidying their room. Residents are offered a wide range of leisure activities both in house and in the community. A system has been started to record whether the activity session programmed was completed and the resident’s enjoyment of the activity. Records for one resident showed that an activity session had been changed at the request of the resident who asked to help with the grocery shopping. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 13 On the day of the inspection one resident was attending sessions at the resource centre in the afternoon and another resident was going out to the pub for lunch. Residents remaining at home were involved in a number of activities, with some colouring, one tidying her room and one sitting quietly in the lounge. While touring the home the inspector was shown name plaques that the residents had recently made for their room doors. Records seen indicated that residents attended events in other local care homes such as birthday parties and barbeques. Staff had taken three of the residents on visits to a nightclub in London that specialises in providing entertainment for people with learning disabilities. Staff had also supported two residents to go to see a band at a local pub. Records seen indicated that some residents went out with relatives for meals and trips into local towns. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 14 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): 19 and 20 Residents receive support to ensure their physical and emotional needs are met and are protected by the home’s good procedures for dealing with medicines. EVIDENCE: Care plans seen indicated that residents were seen by their GP as required. Advice and support was sought from other health professionals when necessary. Records seen indicated that one resident was being supported by the Community Behaviour Support Service and another had received visits from a community physiotherapist who had taught staff members a programme of physiotherapy exercises for the resident. The home has good procedures in place for dealing with medicines. Only staff who have received training in the administration of medicines are allowed to give out the medicines. Medication records seen had been completed appropriately. The GP for the residents reviews their medication regularly and has signed to confirm the use of some homely medicines for the individual residents. The GP also provides training for staff in epilepsy and staff treat the medicine, Epistat, used for epilepsy, as a controlled drug, with two staff members required to sign the records. A new system for the disposal of unused medicines has been introduced and staff were aware of the up dated procedures. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 15 At the time of the inspection there were no residents who self administered their own medication. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 16 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): 23 Residents are protected by staff awareness of abuse issues. EVIDENCE: The home has procedures in place to be followed should abuse be suspected. The registered manager said that abuse awareness had been discussed during resident meetings and information was available in symbol/picture format for residents. Two staff members spoken to during the inspection were aware of the procedures for reporting suspected abuse. Staff receive training in abuse awareness. Six of the eleven staff members had received training in abuse issues and four were due to attend training sessions at the end of November 2005. One staff member had attended training in child protection. Since the last inspection the system for charging residents for using the home’s transport has changed. Records are now kept for each individual journey and the resident is charged for the distance travelled. Residents also receive £1.50 towards meals taken when away from the home for example when going out for lunch at a pub. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 17 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): EVIDENCE: These standards were assessed as met at the inspection dated 07/07/05. On the day of this inspection the home looked clean and homely with cheerful communal rooms and homely, personalised bedrooms. Since the last inspection the windows of a bedroom, for a resident who would not tolerate curtains or blinds, had been covered with a fine film that reduced the ability of people outside the home to see into the room. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Residents are protected by the home’s robust recruitment procedures and are supported by an effective staff team. The cancellation of training sessions and the lack of NVQ training could result in the residents needs not being fully met. EVIDENCE: The home employs a registered manager, a deputy manager and eight support workers. One person is employed as a part time cleaner and she also works part time as a support worker. Since the last inspection additional one to one hours have been approved for two of the residents, providing additional support time. Staff members are provided with a clear job description when starting work at the home. The registered manager said that staffing levels are flexible to allow for additional staff when support is required for leisure activities. One of the support workers holds an NVQ level 3 and the deputy manager is due to complete NVQ level 3 later this year. One support worker is currently doing a nursing degree. The registered manager is aware of the need for fifty percent of care staff to have obtained or are studying for NVQ level 2 or above. The registered manager said that staff members who were due to attend training sessions in Communication level 2, had to wait until the new year as Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 19 the courses they had been booked on were cancelled and all the remaining training sessions were fully booked. Records were seen for two staff members who have recently been employed at the home. The records contained all the information required including proof of identity and two written references. Criminal Records Bureau and Protection of Vulnerable Adult checks had been completed for both staff members before they started work at the home. Staff receive formal supervision on a regular basis. The supervision meetings cover all aspects of the provision of care for residents, training requirements and the strengths and weaknesses of the staff member. The supervision meetings are recorded. The registered manager is supervised and supported by the area manager. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 The home is well run and residents benefit from the registered manager’s open door approach to management and they know that their views will be taken into account when decisions are made about changes to life at the home. The health, safety and welfare of the residents are protected by the home’s safe working practices. EVIDENCE: The registered manager is in the process of completing the NVQ level 4 and the Registered Mangers Award. Mrs Clare Morris has experience in providing care for younger adults in a residential setting. Staff spoken to during the inspection commented on the support they received from the registered manager and it was evident during the visit that there was an easy, relaxed relationship between the registered manager and the staff and residents. The registered manager operates an open door approach to management. Resident meetings are held monthly in the home and these meetings are recorded. Minutes of the meetings are provided in symbol format suitable for Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 21 the residents. Some residents also belong to a forum and join residents of other local care homes operated by Robinia Care Limited for meetings. During one of the forum meetings residents had asked if they could raise money for a charity. A sponsored walk had been organised and residents from Déjà vu raised the most amount of sponsorship money for the charity chosen by the forum. The home has developed a system for discussing changes to staffing. Cards have been produced to hold the photographs of the staff member who is leaving the home and a simple message is written for them to say goodbye. A similar card system is in place for new staff members starting work at the home. The registered manager said this new system has helped residents to understand when changes have taken place. The system will also be used if a resident leaves the home. Staff meetings are held once a month at a time that is convenient for both day and night shift workers. At the time of the inspection the kitchen looked clean and in good order. Food was stored appropriately and temperatures of the fridge and freezer were monitored and recorded. Temperatures were also recorded for cooked foods before serving. Hazardous substances such as cleaning fluids were stored securely. Records for fire safety training and attendance at fire drills was available in the home. The records indicated that all but two staff members had received fire safety training. Fire safety training had been arranged for the two staff members but it had been cancelled and was now rearranged for the 7th December 2005. The registered manager had arranged for a fire drill to take place when a staff member, who had not attended drills, to be on duty. Following the inspection the registered manager confirmed that all staff had attended fire drills. Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x x Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Deja Vu Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 3 x DS0000011567.V261228.R01.S.doc Version 5.0 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Deja Vu DS0000011567.V261228.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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