Inspection on 02/03/04 for Delos Community Ltd, 109 Great Park Street

Care Homes For Adults (18 ­ 65)Delos Community Ltd, 109 Great Park Street109 Great Park Street Wellingborough Northants NN8 4EAAnnounced Inspection2nd March 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) Type of registration Care Home No. of places registered (if applicable) 3 Tel No: 01933 222532 Fax No:Category(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 If Yes Refer to Part CDelos Community Ltd, 109 Great Park StreetPage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 32nd March 2004 09:30 am Mrs Mary TimmsID Code138018Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Mike Brennan the time of inspectionDelos Community Ltd, 109 Great Park StreetPage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. 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: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementDelos Community Ltd, 109 Great Park StreetPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) 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 NCSC in respect of Delos Community Ltd, 109 Great Park Street. The inspection findings relate to the National Minimum Standards (NMS) for Care Home 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 NCSC 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 · Report of the Lay Assessor (where relevant) · 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 and the Children Act 1989 as amended. 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 StreetPage 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 StreetPage 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 is the first time 109 Great Park Street has been inspected as an individual home, previously the whole community would have been inspected as a `whole. This was an announced inspection visit made by one inspector. The inspector spoke individually with staff and service users, toured the building and reviewed some policies and procedures, recording systems, and appraised the service users files. The inspection of this home was undertaken a day prior to 34 Park Road, a separate Delos residential care home. Some findings from one inspection visit inform the other report, as many of the policies and procedures are overarching and staff interviewed work in both homes. Choice of Home - Standards 1-5 Four standards met and one unmet A Statement of Purpose details the services provided within this home. A service user guide is personalised for each resident, with much of the information reproduced in an appropriate format to aid service user understanding. Assessment of service users needs appear to be ongoing with alterations to plans as required. Prospective service users visit several times prior to any new placement. Contracts are in place however; full terms and conditions should be detailed within this document prior to obtaining service users signatures. Individual Needs and Choices ­ Standards 6-10 All five standards met Very detailed plans were held within files, reflecting care management and health professional assessments. There was evidence of service user participation in the day to day running of the house. Service users choose the menu and identify house and individual activities during a weekly meeting. Where restrictions are place on service users, there is evidence to support this need, and plans in place to improve or manage the risks identified. Staff demonstrated a good understanding of the written policies and procedures around confidentiality. Lifestyle ­ Standards 11 ­17 Six standards met and one unmet Detailed planning supports the development of new experiences and opportunities for personal growth. Each service user has structured plans for education and leisure activities. There is evidence within records of various social activities and community facilities being accessed by service users. Service users have unrestricted access to communal areas of house and gardens, one service user confirmed they had their own key to bedroom. Service users choose the menus and are encouraged to participate in meal preparation.Delos Community Ltd, 109 Great Park StreetPage 6 Personal and Healthcare Support Standards 18 ­ 21 Of the three standards appraised two were met and one unmet Service users are registered with local G.P, and there is evidence of a wide range of health professionals being accessed by service users, including annual health checks. One service user is supported to administer their own medication. Advice was given to ensure consent is held on file from service users for the administration of their medication by the home. Policies and procedures have recently been developed to ensure service users wishes and needs are appropriately met, regarding ageing, illness and death. Concerns, Complaints and Protection ­ Standards 22 ­23 Both standards met A complaints procedure is available, and has been further developed into an appropriate format to aid service user understanding. Staff and service users were able to relay to the inspector the procedure they would follow if dealing with a complaint. Environment - Standards 24-30 the six standards appraised were all met. The premises and environment were seen as appropriate to its stated purpose; all areas were noted to be clean and well maintained. Each service user has their own bedroom with communal areas appropriate in size to the number of service users. A delegated member of staff is employed within the organisation, who ensure health and safety requirements are met and deals with minor maintenance works. Staffing - Standards 31 ­ 36 - three standards appraised as met and two unmet There appears to be clearly defined roles within the staff team. Service users and staff were able to relay the line management responsibilities within the home. Robust procedures are in place for the recruitment of staff generally confirmed by the Staff files examined. However, there were some areas where required information was not held on file. The Induction Training program undertaken by new staff is diverse and ensures staff are aware of service user needs. However, this program must be extended to include areas of Adult Protection including, recognizing and reporting abuse. Staff records show staff receive ongoing training and it was noted that Adult Protection is planned for future training. Staff spoken to confirmed they were able to request specific training. Staff files and discussion with staff members confirmed that supervision is regular and appropriate. Volunteers working at the home are recruited via an agency have duties restricted to a support role with no responsibility for personal care. Conduct and Management of the Homes - Standards 37-43 Of the two standards appraised all were met. There is evidence that policies and procedures are monitored and reviewed on a regular basis, including service user and staff input. A member of staff has particular delegated responsibility for the monitoring of health and safety requirements, including staff training and minor maintenance works.Delos Community Ltd, 109 Great Park StreetPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY 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. No. Regulation Standard Required actions Timescale for actionAction is being taken by the National Care Standards Commission 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 StreetPage 8 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 and recommendations 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, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 5 (c) YA5 The Registered Person must ensure terms and conditions are fully detailed within contract/agreements with service users. The Registered Person must ensure consent is obtained and held on file, for the administration of individual service users medications. 17th May 2004213YA2017th May 20043Schedule 2 YA34 18 1917th May All information detailed within Schedule 2 must be held for staff working within the home 2004 Competent staff must be available within the home at all times day and night, to ensure service users immediate needs are met. 17th May 20044YA33RECOMMENDATIONS 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) No. Refer to Good Practice Recommendations Standard ** 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.Delos Community Ltd, 109 Great Park StreetPage 9 PART BINSPECTION METHODS & FINDINGSThe 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 YES NO NA YES YES YES NO YES YES YES NO NO YES NO YES 3 0 0 NO NO YES YES 5 X 2/3/04 9.30 7Delos Community Ltd, 109 Great Park StreetPage 10 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards 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: 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 StreetPage 11 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, 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. 478.58 560.00 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Holiday contribution, activities, public transport, personal needs (books, magazines, shampoo etc) 3 Key findings/Evidence Standard met? A Statement of Purpose was viewed during this inspection. The document contains detailed information around the care provided within this home. The Registered Manager informed the inspector this document is regularly reviewed to identify areas of further development. A Service User Guide is available which is personalised for each resident on admission. The guide utilises a system of symbols to promote user understanding and contains the previous Inspection Report.Delos Community Ltd, 109 Great Park StreetPage 12 Standard 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? Care Management Assessments are on file for service users admitted recently to the community. Application forms are sent to families and/or previous placement to gather information such as; likes and dislikes, general welfare and behaviour patterns. Placement plans are developed utilising information within referral paperwork. Detailed planning appropriately supports necessary restrictions identified through the assessment process. 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 statement of purpose and service user guide set out the care to be provided within this home and how this care will be facilitated. The staff team collectively have training and skills to ensure service user needs are met. There is a depth of knowledge and expertise, within the wider community that supports an understanding, of service users needs and current good practice in provision of care. All care provided is monitored by the House Manager and the Registered Person. 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. 3 Key findings/Evidence Standard met? Service users visit several times prior to a placement commencing, visits include overnight stays. Staff confirmed they are involved in feedback from such visits and the decision as to whether the home is able to meet the prospective service users needs. Service users are able to see their room and where possible have some choice as to which room. Service users are admitted on a three month trial period. This home does not offer emergency placements. 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. 2 Key findings/Evidence Standard met? Written placement agreements have recently been produced. These were on file for the service users within this home. However, although signed by service users, the costs were incomplete. The inspector advised the Registered Manager to be specific as to; what was and was not included within costs.Delos Community Ltd, 109 Great Park StreetPage 13 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? All three service user files were appraised during this inspection. Each file contained various detailed plans. · · · · · · A Care Plan - overall purpose to placement A Person Centred Plan ­ which details areas of personal development . Personal Care Needs Planner ­ detailing level of support required in all aspects of personal care Day Centre Planner Weekly schedule ­ including all regular appointments Health Profile ­ detailing how health needs to be met.Detailed risk assessments were held on file, identifying some restrictions placed within plans, also guidelines to reduce risks. There was evidence on file of plans and reviews, being reproduced in an appropriate format to aid service user understanding. The registered person confirmed that service users are involved in all stages of planning and reviewing. Each service user has a key worker. A member of staff informed that key workers meet oneto-one with service users, to reflect on plans, assess newly identified needs also to support service user involvement in the planning process. Plans are reviewed on a six monthly basis, and monitored between by keyworker and house manager.Delos Community Ltd, 109 Great Park StreetPage 14 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? Detailed risk assessments are held on file for the three service users in this home. Where restrictions are made ­ such as service users not able to leave home without staff; there are clear reasons evidenced. A Senior member of staff confirmed that service users are all aware of these restrictions as are Care Management authorities. Staff interviewed gave examples of personal choice - weekly house meetings are facilitated during which menus are selected, residents decide which household tasks they will undertake during the next week, activities and outings are discussed and decided on. Staff discussed how they are working with one service user, actively encouraging them to make more personal decisions. A family member manages one service users finances. Two service users are supported by staff, to manage their personal spending.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? As referred to above there are House Meetings on a weekly basis, during this decisions are agreed between service users and staff, and service users can make suggestions. A Senior Care worker informed the inspector, that these meetings are recorded and outcomes used for future planning. Service Users confirmed they feel they have some involvement, in the running of the home. It was noted that service users are, encouraged to take some responsibility, for household tasks and participate in the preparation of evening meals. The Delos Community has secured the involvement of an external service in the development of communication aids for service users. Pre-inspection questionnaires were developed into an appropriate format for their service user understanding.Delos Community Ltd, 109 Great Park StreetPage 15 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. 3 Key findings/Evidence Standard met? From discussions with staff and the Registered person there is evidence of a commitment to promoting independence whilst at the same time managing risks. One service user is being supported to use a bus to her Day Centre placement. One Risk Assessment identified hazards for service user within the kitchen environment, plans were developed to support access to the kitchen in a safe way. When appraising the Day Centre timetable it was noted there are sessions on road safety and other areas of personal safety. 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? There is a confidentiality policy and procedures for staff. Confidentiality is covered within the Induction programme prior to staff commencing their role. LADAF Induction and NVQ Care modules undertaken by staff, also address this area. A member of staff interviewed was clearly able to outline his responsibilities in this area and showed a good awareness good practice. Files were noted to be held securely within the home.Delos Community Ltd, 109 Great Park StreetPage 16 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? A Person Centred Plan has been developed, in conjunction with and for, each service user. These plans highlight areas for personal growth, promoting opportunities for social and emotional development. Staff confirmed that service users were fully involved within the planning process. The daily routines within the house and timetable appraised for the Day Centre, supported by observations made by the inspector; endorse the commitment within the Statement and Purpose to support each service user to attain their goals, dreams and ambitions. 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 a fully structured week Monday ­ Friday. They attend either the Delos Day Centre or other local resources, identified as appropriate to met their needs. Service Users have the opportunity to attend various evening classes or groups. One service user currently attends a dance class during the evening, whilst another attends an evening class organised by Life Long Learning.Delos Community Ltd, 109 Great Park StreetPage 17 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? Service users are noted to use local shops, library, theatre, cinema and pubs. As previously stated they attend sessions within Day Centre, focusing on personal safety, which supports their ability to undertake these outings more independently. The Senior member of staff interviewed confirmed there is a good relationship with immediate neighbours. Although there are sometimes restrictions on the availability of staff to support service users, one-to-one, there are several community volunteers working within the organisation, who are available, in a planned way, to support in this area. 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? One Service user particularly likes singing and dancing and now attends an evening class to support this interest, another attends an evening class organised by Life Long Learning. The inspector was informed by staff, that although service users will access leisure activities outside the home there is sometimes a general reluctantance. On the day of the inspection one service user appeared content knitting whilst another was colouring with a member of staff, the other watching television ­ this is apparently typical of an early evening. The organisation arrange various social events through the year and currently there are plans for a March Party advertised on the notice board. Evidence of service users having holidays last year was noted on files, one to the Isle of Man and one to France.Delos Community Ltd, 109 Great Park StreetPage 18 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? Only one service user has regular contact with family member, this occurs on a weekly basis with family involvement in all aspects of planning and reviews. There was evidence within one file of staff being proactive in encouraging family involvement and participation in the care of service user. Staff confirmed that families are welcome to visit the home and can see service users privately within their bedrooms. Service users have the opportunity and are encouraged to develop links into the wider community to enable them to develop social relationships, however, at this time service users do not have friends outside of the community.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). 3 Key findings/Evidence Standard met? Service users have unrestricted access to the communal areas of the house and grounds, except where hazards are identified and staff support required ­ an example would be one service user must be supported by staff when using the kitchen areas. One service user confirmed they have a key to their bedroom. The registered person described a very inclusive ethos operating within all the homes. Staff and service users working alongside each other. The inspector observed appropriate interactions between staff and service users.Delos Community Ltd, 109 Great Park StreetPage 19 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. 2 Key findings/Evidence Standard met? The menus are chosen by the service users a week ahead, during the weekly house meetings. The main meal is in the evening during the week and service users are encouraged to participate in some way, according to their abilities. One service user has some restrictions on her dietary intake due to a medical condition, this is apparently easily facilitated in a sensitive way. The current practice of recording menus is for this to be detailed within daily diary. The inspector advised that it would be beneficial to record on a menu format, to enable the monitoring of nutritional content with diet. Monitoring should be evidenced.Delos Community Ltd, 109 Great Park StreetPage 20 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 procedure 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.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) XX3 Key findings/Evidence Standard met? There is evidence on files of service users health being monitored within the home. Records show that a wide range of health professionals have been accessed, as required, including prompt attendance with G.P. to ensure health needs are met. Regular annual health checks are undertaken.Delos Community Ltd, 109 Great Park StreetPage 21 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. 2 Key findings/Evidence Standard met? One service user is supported to administer their own medication for diabetes. There is extensive information for staff on file and plans in place to support service user with self medication. Although detailed information was available, advice was given to ensure a risk assessment in line with the format used within the home, was available on file within the risk assessment section. An appropriate medication administration system is in place for prescribed medication. Consent is obtained from G.P to administer `homely remedies it is recommended any such medicines are always recorded when administered and stock controlled as per prescribed medications. Advice was given to ensure service user consent is held on file, for the home to administer their medications. 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. 3 Key findings/Evidence Standard met? The organisation has recently developed a policy on the support and care of service users who may be terminally ill. Guidelines for staff are available including good practice around cultural or religious rituals.Delos Community Ltd, 109 Great Park StreetPage 22 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 times-scales 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 NCSC Percentage of complaints responded to within 28 days X 0 X X X X X 3 Key findings/Evidence Standard met? A Complaints procedure is available; the service user complaints procedure has been reproduced in an appropriate format. This is also held within the service user guide, which is supplied to families on service user admission. Staff are made aware of the procedure during their induction week prior to starting work within the home. Service users confirmed to the inspector their knowledge of this process.Delos Community Ltd, 109 Great Park StreetPage 23 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 whistle blowing procedure was appraised. The inspector discussed with the Registered Person that this seemed to be quite `wordy and agreed this would be further developed to ensure easier comprehension. The home has robust recording and reporting procedures in this area. Service Users financial records were appraised and found to be in order.Delos Community Ltd, 109 Great Park StreetPage 24 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 was noted to be suitable for its stated purpose. Décor is pleasant with homely furnishings throughout, areas were clean and appeared well maintained. All communal areas are accessible to service users, including a small well-maintained garden. The home is close to the town centre of Wellingborough all local facilities are within easy reach. The home has to date received no visits from an Environmental Health Officer. There were no obvious health and safety hazards noted during this visit.Delos Community Ltd, 109 Great Park StreetPage 25 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 YES NO NO 3 X X X Standard met? 3 3 XX X X XEach service has their own bedroom which is of appropriate size.Delos Community Ltd, 109 Great Park StreetPage 26 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. 3 Key findings/Evidence Standard met? The inspector accompanied by individual service users, viewed each bedroom. Rooms were pleasantly decorated and furnished. Both personalised and containing belongings brought in by service user. Bedding curtains and flooring all appeared of good quality. Bedrooms are not fitted with wash hand basins, which should be reflected within the Statement of Purpose. One service user confirmed to the inspector that they have her own key to their bedroom.Standard 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 one main bathroom of a domestic style shared by the three service users, who also have the use of a further toilet. Bathroom is lockable and staff confirm there is an override device if required.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 is 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, visitors can meet with service users, in their bedrooms. This is a `no smoking home, anyone wishing to smoke must do so outside. Two further bedrooms converted from cellar space are found underneath the ground floor, also a toilet and washbasin. These rooms are used by community volunteers (overseas) who live there for the duration of their placement within the Delos Community.Delos Community Ltd, 109 Great Park StreetPage 27 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 adaptations necessary 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 inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The premises appeared clean, hygienic and free from offensive odours on the day of this inspection visit. All facilities are of a domestic layout within this small care home. The organisation employs a member of staff who has responsibility to monitor all areas of health and safety, make recommendations and provided training for staff.Delos Community Ltd, 109 Great Park StreetPage 28 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? Clearly defined job descriptions were found on file for the staff records appraised during this visit. The organisation has an inclusive, community-based ethos, which all staff are aware of, and work to promote. All policies and procedures are incorporated within the induction period, for new staff. On the day of this inspection visit observations were made of positive interactions between staff and service users. Staff were able to verbalise to the inspector a good knowledge of individual service users needs. Overseas volunteers work in various ways within the organisation and do have restricted roles with the service users within this home.Delos Community Ltd, 109 Great Park StreetPage 29 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. 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 X X X X 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 X Nursing X X XXX3 Key findings/Evidence Standard met? Records show evidence of a good level of training to support staff competency. There is a mix of very experienced staff working closely with less experience staff and volunteers. Volunteers have limited responsibilities within home and undertake no areas of personal care. The Senior Care worker within this home, has completed; Learning Disability Awareness Framework accredited induction level programme, and is registered to commence the Foundation level. Also NVQ III care award. Staff training and supervision records show; a wide range of appropriate training continues after the induction programme.Delos Community Ltd, 109 Great Park StreetPage 30 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. 2 Key findings/Evidence Standard met? The home provides care for three service users, current practice is for one member of staff to be on duty, supported if required from staff from the other Delos homes. Staff confirmed they feel safe and well supported in this practice. Feedback from staff was that on occasions they feel unable to meet all requests from service users, however, their welfare needs are always met. Service users also confirmed to the inspector they feel well supported by staff. Staff are not directly available overnight, leaving at 10.30pm and returning at 7.45 am, the community volunteers that live in the lower ground floor are tasked with calling for staff working in the nearby homes; should any need arise. Service users were able to relay to the inspector that they know where to go if they need help. No staff have resigned from work in this home within the last year. The organisation is apparently usually able to support internally with sickness absences. No agency staff, have been used recently within this home. 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. 2 Key findings/Evidence Standard met? Files were checked for two members of staff and two volunteers. Both volunteers were recruited through the Inter Cultural Youth Exchange. The Delos organisation has been using this scheme directly for four years and previously other similar schemes. The Registered Person informed the inspector of many benefits they have found from this scheme, including the sharing of cultural experiences by service users. Two references and a police check undertaken in the country of origin are provided for each volunteer from the Agency. These documents were held on file for the two volunteers directly involved with this home. Only one reference was on file for one member of staff, and photo I.D for another, this was discussed with the Registered person and advice given that all information detailed within Schedule 2 of the Care Homes Regulations 2001 must be held for each person working within this home. All other documentation appeared in order, including CRB checks completed on all staff working in this home.Delos Community Ltd, 109 Great Park StreetPage 31 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. 3 Key findings/Evidence Standard met? The home has a training plan for the next year, development targets for the staff team and individual training goals for each member of staff. The Delos organisation has the benefit of support management working locally, from the Head Office, staff there have the delegated responsibility for developing training resources to meet identified needs. A robust induction programme is operated for new staff, including structured training, shadow shifts, one-to-one with senior staff and handbooks for personal learning. Training was noted to reflect the Statement of Purpose for this home. 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? Supervision records were appraised and content noted to be appropriate and supportive of staff development. The senior care worker interviewed informed the inspector, there has been some occasions within the last six months when supervision has fallen behind, frequency, still however, meets the standard recommendation of minimum of six times yearly. Plans have already been made to address this. Annual appraisals also take place within this home. Staff informed the inspector that regular staff meetings take place and these are beneficial and supportive. Terms and Conditions of employment were noted to contain the grievance and disciplinary procedures. Staff undertake training in dealing with challenging behaviour and risk assessed planning was noted on individual service users files. There is a shortfall in the level of supervision for the community volunteers. There is no system in place for regular one-to-one supervision at this time. The house manager has apparently provided some occasional group supervision in the past. The shortfall was discussed with the Registered Person.Delos Community Ltd, 109 Great Park StreetPage 32 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 or equivalent. X 0Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.Delos Community Ltd, 109 Great Park StreetPage 33 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. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection visit.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 Younger Adults. 3 Key findings/Evidence Standard met? The home has a policy and procedure handbook, which reflects 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 four policies each month; staff and service users views are taken into consideration when making amendments.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. 0 Key findings/Evidence Standard met ? This standard was not assessed during this inspection visit.Delos Community Ltd, 109 Great Park StreetPage 34 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. 3 Key findings/Evidence Standard met? There is a member of staff employed within the organisation with the dedicated responsibility to ensure health and safety requirements are maintained and improved. Weekly checks are undertaken of smoke alarms, emergency lighting, fire alarms, first aid boxes. Records checked by the inspector confirmed this practice. Health and Safety training is undertaken by staff during their induction period with further development courses provided on a rollingprogramme 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. 0 Key findings/Evidence Standard met ? This standard was not assessed during this inspection visit.Delos Community Ltd, 109 Great Park StreetPage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateMary Timms Hazel Hudson-GreenSignature Signature SignatureDelos Community Ltd, 109 Great Park StreetPage 36 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Delos Community Ltd, 109 Great Park StreetPage 37 PART EE.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 2nd March 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the NCSC in response to provider comments: Delos Community Ltd, 109 Great Park Street Page 38 Amendments to the report were necessaryYESComments 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 accurateYESYESNONote: 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. E.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 YESAction plan was received at the point of publicationYESAction 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 planNOYESNOOther: enter details here NODelos Community Ltd, 109 Great Park StreetPage 39 E.3.2 I Ms Jeanne Steinhardt of Delos Community 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 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. 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