CARE HOME ADULTS 18-65
Delos Community Ltd 109 Great Park Street 109 Great Park Street Wellingborough Northants NN8 4EA Lead Inspector
Ms Sarah Jenkins Unannounced Inspection 13th June 2006 07:45 Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Delos Community Ltd 109 Great Park Street Address 109 Great Park Street Wellingborough Northants NN8 4EA 01933 222532 01933 276208 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) Delos Community Limited Mr Simon Nicholas John Hardwicke Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The home may only admit service users aged 18-65 No person falling within the category MD may be admitted to the home unless that person also falls within category LD - I.e. dual disability 14th February 2006 Date of last inspection Brief Description of the Service: 109 Great Park Road is situated in a residential area close to the town centre of Wellingborough. The home is also known as The Frogpond and is one of four registered homes within easy walking distance of each other, supported by a Head Office and Day Centre in separate premises. Further support services are provided within the organisation for those moving on into a more independent lifestyle. The collective facilities are known as the Delos Community where residents are known as members. The home provides personal care and support for up to three members whose primary care need is due to having a learning disability. The environment is that of a family house. Members have their own bedrooms but there are no ensuite facilities. The range of fees at the home is £650-£1660 per week. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting 2 service users and tracking the care they receive through meeting with the service users, a review of their records, discussions with the care staff and observation of care practices. The Inspector visited during the early morning period to observe practices by staff and to meet with members. Members have Learning disabilities, and may have additional mental health needs, but current members were able to communicate effectively with the Inspector. The Inspector also undertook observations of care practice, and members’ relationships with staff to establish their levels of contentment with their lifestyles and routines. The Inspector spent two periods in the home, 7.40am-9.00am and 10 15am11.30am and a further hour (approx) in the Organization’s Central Offices, meeting with the General Manager and reviewing the staff records and quality audit processes. One completed comment card was received from a Social worker expressing general satisfaction. What the service does well:
Members are well supported by staff, as individuals and as a group. The ethos of the home is to promote members rights as individuals and to ensure that they are enabled to lead active and satisfying lifestyles and where they wish, to achieve their potential for independence. The atmosphere of the home is calm and nurturing, and conducive to members’ happiness and wellbeing. The staff at the home are well supported by the organization (The Registered Owners, Delos Community), which shows a commitment to professionalism, development and good outcomes for members. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 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. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 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 Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Members’ admission to the home is supported through thorough and flexible processes that ensure that members will benefit from the placement and that the home can meet their needs. EVIDENCE: There have been no recent admissions to the home but procedures were discussed with the staff. These evidenced that a professional and sensitive process are followed regarding preadmission assessment and admission, which leads to good outcomes for members. Policies and procedures support effective communication from the outset and the Service Users Guide, in the process of being updated, is enhanced by illustration. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Members are enabled to enjoy a full and stimulating lifestyle with a variety of choices available to them. They are enabled to take reasonable risk in pursuit of their independence. EVIDENCE: Members talked to the Inspector about the things that they were supported to do and their enjoyment of these activities Service Users are enabled to take reasonable risks in pursuit of their independent lifestyle choices but there is a need to revisit at least one members risk management programme to ensure that it is updated appropriately and reflects the situation currently practiced by staff. Members are empowered to take responsibility in the house and to be involved in the management and were observed to answer the front door and the telephone. Inherent risks in such activities need to be properly recognized and managed.
Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Members are very happy with their various lifestyles, which are active and stimulating. EVIDENCE: Members talked to the Inspector about their hobbies and the things that they were supported to do and showed their enjoyment of these activities. Members participate fully in the local community and activities include regular daytrips and/or holidays according to their choices. Members are supported to look after their pets and there are two well-loved cats resident in the house. One member spoke to the Inspector about their retirement but had support to attend activities of her choice, and was planning to go out with staff during the morning. Members spoke of, or showed their enthusiasm for their day placements.
Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 11 Members are encouraged to maintain and develop good relationships based on mutual respect and consideration. Visitors feel warmly welcomed to the home. Members said that they enjoyed the food provision at the home, and there is an informal routine of participation in the shopping and preparation. Staff told the Inspector that healthy eating options have been implemented. One member has been supported to join a Healthy Eating/Lifestyle group. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and healthcare support is good, and members’ physical and emotional needs are well met. EVIDENCE: Members expressed general content with the way in which they were supported in personal and healthcare routines, and said that they were happy with the help they got to see their doctors and attend appointments. Interviews with staff and details on records of staff training demonstrated that proper emphasis is put on the principles of care (privacy, dignity, respect). Records demonstrated a good response to members needs. Community healthcare teams are appropriately accessed with or on behalf of members. The inspector observed the early morning routine in relation to the administration of medications. The staff member had received appropriate training and followed the correct procedures; medication was seen to be well managed and recorded. Members take responsibility for their own medicines when appropriate.
Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 13 Advice has recently been given to the organization that there should be evidence that the hand copying of prescription details onto Medication Administration Sheets has been checked by a second person to safeguard against mistakes being made. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 14 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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Members are protected by the quality of professionalism and the observation and listening skills of staff. EVIDENCE: Members said that they could approach staff or the Manager with their problems and showed confidence that they would be listened to and taken seriously. A member was seen to raise concerns confidently to the senior on duty about one of the homes procedures, which the member felt had not been followed properly. There is no document on premises enabling members to have their complaints written down. Formal quality concerns and complaints are held in a file at the main office. There is an ethos of empowerment at the home and this is supported by a policy for staff to familiarize themselves with. There is a prompt response to issues arising. Allegations are taken seriously, and due process followed. Staff have had training in the Protection of Vulnerable Adults.
Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 15 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): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The members’ house is homely, clean, comfortable and well maintained, suiting their needs and lifestyles. EVIDENCE: The home was seen to be comfortable, homely and clean at this early morning visit. Members showed pride in their house and in their individual bedrooms and said that they had chosen the decoration and some of the furnishings. Those who showed the Inspector their rooms expressed satisfaction with the provision. There are no ensuite facilities at this home. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 16 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): 32,33,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Members are generally well supported by trained experienced staff. EVIDENCE: There were no staff on duty when the Inspector arrived at the home although there was a sleep in volunteer who lives on the premises. No support was available for members at this time and the Inspector raised concerns about this and related safety issues with the General Manager of the organization later during the morning. The rota was inaccurate, showing a staff member sleeping in, this was apparently a possibility if the volunteer had not been available but had not been altered to reflect the staff cover accurately. The staff member who arrived on duty at 08:00 was spoken with and showed them self to be fully competent in their role and aware of their responsibilities. This staff member was lone working but was able to get immediate back up if necessary from another home and after 09:00 from the central office. The risk assessment in relation to lone working at this home was not reviewed at this inspection.
Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 17 Recruitment process were discussed at the organizations central office and found to be fully professional, properly recorded and reflected in policies and procedures. Staff training is ongoing. Staff expressed full content with the levels of training they were offered. One staff member commented that they thought the training on offer to the staff was exceptionally good and very regular, staff being given opportunities both to undertake necessary training and to choose from special interest areas. Records on staff files were well organized, fully met the standards and showed good levels of training and supervision of staff. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management of the home is effective and responsive and members thereby benefit from a well-run service. EVIDENCE: There was a good level of organization within the home, and the confidentiality of records was properly safeguarded despite there being no “office” within the home. It was evident from discussion with the staff and members that the management of the home is being effectively undertaken. A member expressed confidence that members’ views were included in the running of the home and informed the inspector that they were involved in interviewing new staff. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 19 Staff expressed full confidence in the Registered Manager and felt that they were able to approach him with any issues or problems and they would receive a very positive response. Quality Audit processes are full and thorough and the Organizations response to issues raised is very good. Policies and procedures of the organization demonstrate that positive outcomes for members are the focus of the service and that the principles of good care are adhered to. Health and Safety is properly promoted. The Inspector advised the senior on duty that it would be good practice to have disposable hand towels in communal areas to safeguard against the spread of any infection. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 1 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA33 Regulation 18 Requirement Staffing levels must be reviewed in relation to the early morning period to ensure adequate cover to protect and support members at all times. The outcome of this review must be forwarded to the inspector, together any relevant risk assessments. Timescale for action 10/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA9 YA33 YA42 Good Practice Recommendations Risk identification and management should be revisited to ensure all reasonable action is being taken to protect members whilst preserving their independence and rights. The rota should accurately reflect the hours worked by staff. Disposable towels should be provided in communal areas to safeguard against the spread of infection. Delos Community Ltd 109 Great Park Street DS0000039664.V294488.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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