Inspection on 01/09/04 for Delos Community Ltd, 109 Great Park Street

Care Homes For Adults (18 ­ 65)Delos Community Ltd (109 Great Park Street)109 Great Park Street Wellingborough Northants NN8 4EAAnnounced Inspection1st September 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Delos Community Ltd (109 Great Park Street) Address 109 Great Park Street, Wellingborough, Northants, NN8 4EA Email address delos_community@talk21.com Name of registered provider(s)/company (if applicable) Delos Community Limited Name of registered manager (if applicable) Michael Brennan Type of registration Care Home (Personal Care) No. of places registered (if applicable) 3 Tel No: 01933 222532 Fax No: 01933 276208Category(ies) of registration, with (number of places) Learning disability (3), Mental disorder, excluding learning disability or dementia (3) Registration number H070000355 Date first registered 1st November 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 1st November 2002 yes NO 4th May 2004 If Yes refer to Part CDelos Community Ltd (109 Great Park Street)Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 31st September 2004 09:30 am Mrs Mary TimmsID Code138018Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionSimon HardwickeDelos Community Ltd (109 Great Park Street)Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementDelos Community Ltd (109 Great Park Street)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Delos Community Ltd (109 Great Park Street). The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Delos Community Ltd (109 Great Park Street)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 109 Great Park Street, also known as The Frogpond, is situated in a residential area close to the town centre of Wellingborough. The home is one of four homes within easy walking distance of each other. Supported by a Head Office and Day Centre in separate premises found within close proximity; the services offered are known collectively as the Delos Community. Further support services are provided within the organisation for those moving on into a more independent lifestyle. The home provides personal care and support for 3 service users with learning disabilities.Delos Community Ltd (109 Great Park Street)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an announced inspection visit by one inspector. The inspector interviewed one member of staff and the acting house manager. The care of the three service users was appraised for case-tracking purposes; through individual file audits assessing these and other record keeping against the National Minimum Standards and Care Homes Regulations 2001. The inspector also reviewed a selection of policies, procedures, and general records during this visit. Two service users were present during this inspection and one was attending a work placement. Whilst the inspector did talk with the service users present, communication was restricted due to the level of individual disability; consequently very little information was gained directly from service users to inform this report. Observations were made of service users interacting with staff and appearing relaxed during this visit. Not all standards were appraised during this inspection visit; these were appraised at the unannounced inspection, which was undertaken in May 2004. Choice of Home - Standards 1-5 Two met and three standards not appraised during this inspection visit. There have been no recent admissions to this home to enable the inspector to review any assessment of need undertaken prior to a placement agreement. However, the Acting Manager described how the organisation is developing an assessment framework to utilise both on admission and to ensure a current assessment of need is undertaken for all service users. The staff and Acting Manager interviewed demonstrated a broad knowledge and understanding of the care needs for this service user group. The home is supported by the wider Delos community organisation, including the Resource Centre, which provides daily structured activities for service users. The staff providing care have the experience, support and training necessary to undertake their role. Individual Needs and Choices - Standards 6-10 Four met and one not appraised during this inspection visit. The home has written confidentiality policies and procedures. Recordings were noted to be appropriate and appeared accurate; files were stored securely in a lockable cabinet. The inspector noted that a high level of information is made available to service users in a suitable format to aid their easy comprehension. Staff described to the inspector how a house meeting is structured each Sunday evening. Minutes taken during these meetings demonstrate that service users are consulted regarding the arrangements for the coming Delos Community Ltd (109 Great Park Street) Page 6 week, including activities and menus. The quality of care planning undertaken within this home is to be commended. Files are structured to include a Care Plan with sets out clearly the goals of the placement and care to be provided, a Person Centred Plan developed in consultation with service users sets out goals with required steps to reach identified targets. An Essential Lifestyle Plan is again developed in consultation with service users and reflects the service users perspective of their current needs and wishes. Lifestyle ­ Standards 11- 17 Six met and one not appraised during this inspection visit. Throughout the course of this inspection visit it was apparent to the inspector that staff are committed to supporting service users to access opportunities to develop their abilities in all areas. Observations were made of staff working closely with a service user to complete some set tasks. Each service user has an individual plan for daily activities. One attends the Resource Centre provided by the Delos Community, two others attend work placements. Records demonstrate that service users access a variety of local community activities and venues including a local theatre, bowling, swimming and pubs. Records demonstrate that family contact is encouraged and supported. The Delos community has been awarded the Heartbeat Award within the last year, which is a local presentation made by the environmental health department, to organisations demonstrating a commitment to following a healthy eating regime. Personal and Healthcare Support ­ Standards 18-21 Two standards met and two not appraised during this inspection visit. During discussion staff demonstrated that service users healthcare needs are prioritised, one service user confirmed that he has recently attended an appointment with his G.P. Information regarding specific health conditions was noted on individual files to ensure staff are aware of specific needs. One service user is currently convalescing after some recent surgery; the Acting Manager has confirmed that alterations to staffing ensure that care is always available to him during this time. Concerns, Complaints and Protection -Standards 22-23 Both All Standards met The organisation has an appropriate complaints procedure, the inspector noted this has been developed into an easily understood format and held within both the service user guide and the policy documents issued to individual service users. Staff confirmed that service users are able to raise `grumbles at the weekly house meetings or can talk to any member of staff. Advice was given to record such issues including actions taken to resolve any concern raised. The Delos Community has both a Whistle Blowing policy and an Adult Protection policy. The training plan for the staff team was noted to include training in the area of the protection of vulnerable adults later during this current year. Abuse awareness is also covered during the LADAF induction training undertaken by new staff within six weeks of commencing their care role. Environment Standards 24 ­30 Delos Community Ltd (109 Great Park Street) Page 7 Three met and three not appraised during this inspectionvisit. The home is of a domestic layout and found in a residential area close to the town centre of Wellingborough, in close proximity to the other provisions within the Delos Community this enables service users to easily visit other premises and for staff support to be readily available. Service users each have a single bedroom of appropriate size. The home has a domestic bathroom, which includes a shower fitted over the bath. There is a large lounge/dining area, which is comfortably furnished and decorated in a homely style; this room has open access to the kitchen area. The rear garden to the property is small in size however, appropriate to the needs of service users, this outside area appears well maintained. Staffing ­ Standards 31 ­ 36 All standards met Staff files hold copies of clearly defined job descriptions, terms and conditions of employment and a Code of Ethics. The home has a consistent staff team of four full -time and two part-time care staff. Records show a low turn over of staff and no use of agency staff in this home. The organisation uses the support of overseas volunteers; recently a training programme has been developed to ensure service users needs are appropriately met. Staff files viewed confirmed that robust recruitment procedures are operated within the organisation, and records demonstrate that formal supervision takes place on a regular basis. The inspector noted a commitment to the training of all levels of care staff, and the organisation is commended for the arrangements in place. Conduct and Management of the Home All standards met The inspector identified a commitment to promoting openness within the team, staff confirming they find management readily available for advice and direction. Staff described to the inspector a recent team day where staff spent time reviewing their roles and how services are provided. The home is commended for its detailed record keeping and the extensive areas of care planning undertaken. The Delos Community has recently undertaken a Quality Assurance project including questionnaires being sent to all significant Stakeholders, including service users. Feedback was very positive with 100 of service users stating they enjoy living at this home. A policy and procedure handbook is available for all members of staff. Staff are supported to development awareness and understanding of all documents during their induction period and through one-to-one supervision.Delos Community Ltd (109 Great Park Street)Page 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Delos Community Ltd (109 Great Park Street)Page 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 YA22 It is recommended that a record is kept of `grumbles raised by service users and the actions taken to resolve such issues.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSPage 10Delos Community Ltd (109 Great Park Street) The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES NO YES NO YES YES YES NO YES YES NO NO NO YES NO YES 2 0 0 YES YES YES YES 4 0 1/9/04 9.30 5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: Delos Community Ltd (109 Great Park Street) Page 11 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met(Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Delos Community Ltd (109 Great Park Street)Page 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 492.94 560.80 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Personal needs. Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.0Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? There have been no recent admissions to this home to enable the inspector to review the assessment of need undertaken prior to admission. However, the Acting Manager described how the organisation is developing an assessment framework to utilise both on admission and to ensure a current assessment of need is undertaken for all service usersDelos Community Ltd (109 Great Park Street)Page 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The staff providing care have the experience, support and training necessary to undertake their role. Observations were made of appropriate and assessed, communication methods being used within the home on the day of this inspection visit. Care plans have been developed to a high standard and in consultation with service users. The staff and Acting Manager interviewed demonstrated a broad knowledge and understanding of the care needs for this service user group. The home is supported by the wider Delos community organisation, including the Resource Centre providing daily structured activities for service users. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Delos Community Ltd (109 Great Park Street)Page 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 4 Key findings/Evidence Standard met?Delos Community Ltd (109 Great Park Street)Page 15 The quality of care planning undertaken within this home is to be commended. It was found to be of a high standard during the previous inspection visit, and since that time further development has been undertaken. Although some sections were still in the process of development the majority and structure was in place for the inspector to view. Each file has a Care Plan which sets out clearly the goals of the placement and the care to be provided, this includes guidance for staff as to `how care is be provided. This documents cross-references the reader to risk management strategies set out within risk assessment documents. Plans are also set out within a Person Centred Plan. This details in separate areas targets for individual development, a pathway to reach this target is also laid out. Staff confirmed these documents are developed in close consultation with service users. Where there are limitations to the ability of service users to participate the Acting Manager confirmed that consultation is undertaken with `significant others. Although there was no evidence viewed on this occasion this plan is apparently laid out in a format chosen by the service users and may use photographs, symbols, or drawings. One draft document showed a target of Independent work arrangement and the steps required to reach this goal. The Essential Lifestyle Plan is also being developed and the inspector viewed one under development. This Acting Manager described how this document sets from the service users perspective, who they are and how they would like to be viewed. This plan is developed between keyworker and service user. The Acting Manager informed the inspector that there is a dedicated member of staff who has undertaken some training for both Essential Lifestyle Planning and Person Centred Planning. This member of staff is working closely with keyworkers in the development of individual plans. Fully completed plans were noted to be signed by service users. The Acting Manager informed the inspector that Care Plans are always on the agenda for staff supervision meetings, and any required alterations identified and agreed. A multi-agency review takes place on an annual basis and an internal review on a six monthly basis. The Acting Manager confirmed that care plans are adjusted where there is an identified need.Delos Community Ltd (109 Great Park Street)Page 16 Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Staff described to the inspector how a house meeting is structured each Sunday evening. Minutes taken during these meetings demonstrate that service users are consulted regarding the arrangements for the coming week, including activities and menus. Some areas of planning for care provided have an inherent element of restriction for example service users identified as needing support and supervision whist away from the home. These areas of personal care and supervision are noted to be set out and agreed within plans. A member of staff and the Acting Manager described how service users are encouraged to become involved in both local and general elections.Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? A high level of information is made available to service users in an appropriate format to aid their easy comprehension. One service user showed the inspector his policy folder, which held several policies directly relating to the provision of care and the home, which had been reproduced using symbols. A recent development shown to the inspector was the use of a communication board. The daily routine for one service user had been set out on the board using symbols and photographs. Observations were made during this visit of a member of staff using this board with one service user to communicate the next activity they would be undertaking. Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Delos Community Ltd (109 Great Park Street)Page 17 Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? The home has written confidentiality policies and procedures for staff. Confidentiality is covered within the Induction programme prior to staff commencing their role. Learning Disability Award Framework (LADAF) Induction and NVQ Care modules undertaken by staff also address this area. Recordings were noted to be appropriate and appeared accurate. Files were stored securely. The inspector noted a document within the service users policy folder sets out how staff will respect service users confidentiality.Delos Community Ltd (109 Great Park Street)Page 18 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Each service user has a Person Centred Plan which highlights areas for personal growth, setting goals for individuals and plans to provide support where required, this document is developed in consultation with service users. Throughout the course of this inspection visit it was apparent to the inspector that staff are committed to supporting service users to gain opportunities to develop their abilities in all areas.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Each service user has an individual plan for daily activities. One attends the Resource Centre provided by the Delos Community, two others attend work placements. Service users also have the opportunity to attend a variety of evening classes, although at this time none are being accessed. It was pleasing to see that service users individual needs and choices are supported; evidenced by the variety of resources accessed.Delos Community Ltd (109 Great Park Street)Page 19 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Records demonstrate that service users access a variety of local community activities and venues including a local theatre, bowling, swimming and pubs. The inspector noted a display area holding information regarding local activities and interesting places to visit. As referred to in standard 7 a member of staff and the Acting Manager described how service users are encouraged to become involved in both local and general elections. On the day of this inspection visit one service user was supported by a member of staff to visit the bank and local shops. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Personal interests are set out within individual plans. The Acting Manager described how keyworkers are tasked with ensuring arrangements are put in place to meet requests for specific activities. Staff informed the inspector that service users frequently opt to go out together as a group; arrangements for activities are discussed at the weekly house meeting. The organisation has an ongoing arrangement with a service providing overseas volunteers; these support service users to attend leisure activities of their choice. The organisation as a whole also arrange from time to time activities for example a barbeque and an Easter `mad hatter party. One service user confirmed that he goes swimming regularly with members of staff. The cost of a basis one-week holiday is included within placement fees. However, service users may choose to contribute and take a more expensive holiday. The two service users spoken to during this visit informed the inspector that they are soon to go away on holiday. This was confirmed by staff.Delos Community Ltd (109 Great Park Street)Page 20 Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Records demonstrate that family contact is encouraged and supported. The Acting Manager described some current arrangements for supporting families and friends to visit service users in the home; this included transporting families unable to make their own arrangements. Family members are always invited to review meetings. Entries in the diary demonstrate that friends have visited for tea.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not appraised during this inspection visit.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The Acting Manager and staff confirmed that there are limitations to the service users abilities to make appropriate and balanced choices regarding dietary intake, however that staff plan a balanced diet in consultation with service users. The Acting Manager confirmed that he regularly checks the menus to ensure an appropriate diet has been followed. The Delos community has been awarded the Heartbeat Award, which is a local presentation made by the environmental health officers to organisations demonstrating a commitment to following a healthy eating regime. Through appraisal of records and discussions with staff it was evident that individual needs have been identified regarding diet and health needs, where appropriate health professionals have been consulted and advice incorporated into the planned menus, which are monitored, by keyworkers and the Acting Manager. The dining area within the home is domestic in layout and pleasantly decorated. On the day of this inspection visit a large bowl of fruit was available for service users.Delos Community Ltd (109 Great Park Street)Page 21 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Delos Community Ltd (109 Great Park Street)Page 22 Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? During discussion staff demonstrated that service users healthcare needs are prioritised. One service user is currently recovering after some recent eye surgery; he is not attending his usual daily activities on the recommendation of health professionals. The Acting Manager confirmed that alterations to staffing have been made to ensure that staff are always available in the home through this period of convalescence. A member of staff interviewed was able to describe how one service users is supported to partially manage the care of their diagnosed diabetes. Appointments are arranged for this service user to have the required regular blood tests with the diabetic nurse. All care staff have attended training regarding diabetic awareness and care. Information regarding specific health condition was noted on individual files to ensure staff have are aware of specific needs.Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? One service user self-administers their own insulin injections on a daily basis; this practice is supported by a risk assessment held on file. The insulin is stored appropriately in the home and is prepared by staff that have all been trained to do so. All staff are trained in the general administration of medication during their induction period.Delos Community Ltd (109 Great Park Street)Page 23 Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Delos Community Ltd (109 Great Park Street)Page 24 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X X X 3 Key findings/Evidence Standard met? The organisation has an appropriate complaints procedure the inspector noted this has been developed into an easily understood format and held within the service user guide and the policy documents issued to individual service users. Staff are made aware of the procedure during their induction week prior to starting work within the home. A relative responding to a pre-inspection questionnaire confirmed they were aware of the complaints procedure. Staff confirmed that service users can raise `grumbles at the weekly house meetings or can talk to any member of staff. Advice was given to record such issues including actions taken to resolve any concern raised.Delos Community Ltd (109 Great Park Street)Page 25 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The training plan for the staff team includes arranged training in the area of the protection of vulnerable adults later during the year. Abuse awareness is also covered during the LADAF induction training undertaken by new staff within six weeks of commencing their care role. The Delos Community has both a Whistle Blowing policy and an adult protection policy. The Acting Manager was able to demonstrate in discussion his awareness of appropriate reporting and notification of allegations of abuse, It was apparent during discussions that the he is aware of the recent amendments to recruitment requirements set out within regulations.Delos Community Ltd (109 Great Park Street)Page 26 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home is of a domestic layout and found in residential area close to the town centre of Wellingborough, in close proximity to the other provisions within the Delos Community, which enables service users to easily visit other premises and for staff support to be readily available. The premises are pleasantly decorated and furnished. The Acting Manager confirmed there is an annual renewal programme for the whole community. He also confirmed that should an unexpected issue arise funding is easily accessed to ensure needs are met.Delos Community Ltd (109 Great Park Street)Page 27 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total No. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total No. of wheelchair users accommodated for in rooms at least 12 sq.m Total No. of wheelchair users accommodated for in rooms less than 12 sq.m Total No. of shared rooms at least 16 sq.m Total No. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total No. of single bedrooms Number of single bedrooms with en suite Total No. of double bedrooms Number of double rooms with en suite Key findings/Evidence Service users each a single bedroom of appropriate size. A further double bedroom is available for the use of volunteers working within the community this is found in the basement of the property and has its own adjacent toilet. YES NO NO 3 0 0 0 Standard met? 3 3 00 0 0 0Delos Community Ltd (109 Great Park Street)Page 28 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Standard met? This standard was not assessed during this inspection visit. 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities, which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home has a domestic bathroom, which includes a shower fitted over the bath. A further toilet is available in the basement, this is apparently available to service users although rarely used as they choose to use the bathroom facilities. The inspector noted the lock has an over-ride system to use in the case of an emergency.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? There is a large lounge/dining area, which is comfortably furnished and decorated in a `homely style; this room has open access to the kitchen area. The rear garden to the property is small in size however, appropriate to needs of service users, this outside area is well maintained. There is no private area to receive guests however; staff and service users confirmed that visits could take place in private using bedrooms. This is a `no smoking home, anyone wishing to smoke must do so outside.Delos Community Ltd (109 Great Park Street)Page 29 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 9 Key findings/Evidence Standard met? No adaptation are required in this home at this time.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit, however all areas seen appeared clean and well maintained.Delos Community Ltd (109 Great Park Street)Page 30 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? Staff files hold copies of clearly defined job descriptions, terms and conditions of employment and a Code of Ethics. A member of staff interviewed was clearly able to describe her role and how this fits within the wider team. Staff showed an awareness of occasions when they should ask for support and advice, also aware of the Statement of Purpose including the aims and objectives of the home. All staff have been issued with standards of conduct and practice set by the General Social Care council. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The home has a consistent staff team of four full -time and two part-time care staff. Records show a low turn over of staff and no use of agency staff in this home. The organisation provides appropriate training for cares staff as detailed in standard 35. Regular staff meetings take place on a regular basis. The organisation uses the support of overseas volunteers; recently a training programme has been developed to ensure service users needs are appropriately met. Volunteers have limited responsibilities within home and undertake no areas of personal care.Delos Community Ltd (109 Great Park Street)Page 31 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total No. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X 3 X X 3 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X 117 Nursing X X X4X3 Key findings/Evidence Standard met? A requirement was made after the previous inspection visit regarding the use of untrained volunteers for some areas of care provision, and a shortfall in the arrangements for overnight care. Since then a meeting has taken place between the Commission and the provider organisation; confirmation has now been received that suitably trained staff will be available within the home overnight, also that a training programme has now been developed for the next intake of overseas volunteers due to arrive shortly. A volunteer co-ordinator has also been given the dedicated task of providing supervision for volunteer, the Acting Manager also will meet with them on a regular basis. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Staff files appraised confirmed that robust recruitment procedures are operated within the organisation. Files held a copy of application form detailing previous work history, two references, confirmation of I.D, including a photograph and confirmation that an enhanced criminal records bureau check has been undertaken. The Acting Manager is aware of recent changes to requirements within regulation regarding employment of staff. Delos Community Ltd (109 Great Park Street) Page 32 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 4 Key findings/Evidence Standard met? The organisation has developed a specific induction pack for new staff to work through, including management and staff signatures to demonstrate that all areas have been completed. All staff then progress on to a Learning Disability Award Framework-accredited (LADAF) induction training to be completed within six weeks. Two internal assessors are available within the organisation. Core training during the initial weeks of employment supports the requirements of the induction standards and the identified needs of the home. Including: - emergency first aid, food hygiene, moving and handling, fire safety awareness, general health and safety and diabetic care. The Acting Manager confirmed that staff then progress on to undertake NVQ 2 or 3 and LADAF Foundation training. A staff training plan was available for inspection and demonstrated a commitment to planning for training needs. The plan included Sign along, dementia care, protection of vulnerable adults, mental health, foundation equalities, and stress management., health and safety training. Individual training plans are also in place for each member of staff identifying specific needs. A member of staff interviewed stated that the training is fantastic and that where a need is identified then management will identify and arrange appropriate training. This member of staff described recent training facilitated by managers aimed at `team working, this was apparently very enjoyable and beneficial. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Records demonstrate that formal supervision takes place on a regular basis. The Acting Manager confirmed that key working and care planning is structured on the supervision Agenda. Staff interviewed confirmed they receive regular planned supervision and an annual appraisal of their performance and development. Also confirming that support and advice is readily available on a day-to-day basis.Delos Community Ltd (109 Great Park Street)Page 33 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES3 Key findings/Evidence Standard met? At this current time the position of Registered Manager remains with Mr Michael Brennan who is also the residential services manager for the whole of the Delos community. The homes direct manger Mr Simon Hardwicke has an application being processed with the commission regarding the position of Registered Manager. Both of these managers have extensive experience and appropriate qualifications to support the provision of care in this home. Advice was given during this visit to ensure that all members of senior management staff who may visit the home on a regular basis and have contact with service users should have a completed criminal records bureau check.Delos Community Ltd (109 Great Park Street)Page 34 Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? A member of staff interviewed was able to clearly describe her role within the home, and how this was integral to the overall provision of care. Staff described a recent team day where staff spent time reviewing their roles and how services are provided. Staff also confirmed that the Acting Manager is supportive and easily accessible for advice and direction.Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The Delos Community has recently undertaken a Quality Assurance project including questionnaires being sent to all significant Stakeholders, including service users. The information received in feedback has been reproduced into an easy to read format. Feedback was very positive with 100 of service users stating they enjoy living at this home. Service users were aware of the inspection process and have a copy of the latest report within the service user guide. The organisation has a rolling programme of reviewing policies and procedures. This is a shared project across this and the three other residential homes within the Delos Community. The inspector has been made aware that service users are involved in this process. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The home has a policy and procedure handbook, which appears to reflect the areas set out in Appendix 2 of the National Minimum Standards for Younger Adults. Staff are supported to development awareness and understanding of all documents during their induction period and through one-to-one supervision. There is evidence of regular reviewing of all policies and procedures. Managers across the organisation will review policies on a regular basis; staff and service users views are taken into consideration when making amendments.Delos Community Ltd (109 Great Park Street)Page 35 Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 4 Key findings/Evidence Standard met ? The home is commended for its detailed record keeping and the extensive areas of care planning undertaken. As detailed in standard six extensive care plans are developed for each service user. Risk assessments are cross-referenced to care plans, and monitoring sheets maintained for identified areas. Staff files were in good order with records of recruitment and individual development and training. All records required by regulation appear to be in place and well document records kept in all areas. Records are kept securely; service user and staff files were in good order, appeared accurate and up-to-date.Delos Community Ltd (109 Great Park Street)Page 36 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 4 Key findings/Evidence Standard met? The organisation demonstrates a commitment to promoting the health and safety of staff and service users and has been awarded two health and safety awards during the last few years. The organisation employees a member of staff dedicated to maintenance, renewal and health and safety procedures and requirements. This individual undertakes:· · A general check of the house on a weekly basis to identify any maintenance or health and safety requirements. Weekly checks of: smoke alarms, fire alarms, emergency lighting outside lighting, fire extinguishers, and first aid boxes.The dedicated member of staff referred to above is an approved trainer regarding moving and handling training and facilitates this throughout the organisation. Records demonstrate that all service users have been involved in a fire drill including evacuation of the premises. Staff undertake health and safety training and awareness as a part of their induction and refresher days as required in: food hygiene and safety, fire safety awareness, general health and safety awareness, medication administration, and emergency first aid. The Acting Manager confirmed that water temperature is restricted both within the boiler and with appropriate mixer valves, regular checks are undertaken by staff to ensure temperatures remain consistent. The Acting Manager confirmed that risk assessments are undertaken and recorded for any unusual activities or trips service users take part in. Cleaning materials are kept in a locked cupboard in the home with coshh safety sheets available in the home for emergencies.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? The Acting Manager confirmed that there is a financial business plan for the organisation which is kept under review. As this home is part of a larger provision of care the majority of budgets are held and managed centrally. The Acting Manager confirmed that where there is a realistic need identified then funds are made available. A certificate demonstrating the organisation has employers liability insurance was displayed within the home. Delos Community Ltd (109 Great Park Street) Page 37 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorMary TimmsSignature Signature SignatureRegulation Manager Hazel Hudson-Green DateDelos Community Ltd (109 Great Park Street)Page 38 Public reports It should be noted that all CSCI inspection reports are public documents.Delos Community Ltd (109 Great Park Street)Page 39 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 1st September 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Delos Community Ltd (109 Great Park Street) Page 40 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by the 28 day date of the covering letter, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Delos Community Ltd (109 Great Park Street)Page 41 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Ms Jeanne Steinhardt of 109 Great Park Street confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Ms Jeanne Steinhardt of 109 Great Park Street am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Providers comments and an Action Plan are available at the Area Office, where these have been submitted.Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Delos Community Ltd (109 Great Park Street)Page 42 Delos Community Ltd (109 Great Park Street) / 1st September 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000039664.V178083.R01© This report may only be used in its entirety. 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