Inspection on 04/09/07 for Delos Community Ltd, 109 Great Park Street

This inspection was carried out on 4th September 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Delos Community Ltd, 109 Great... 21/09/08

Delos Community Ltd, 109 Great... 13/06/06

Delos Community Ltd, 109 Great... 14/02/06

Delos Community Ltd, 109 Great... 01/09/04

Delos Community Ltd, 109 Great... 04/05/04

Delos Community Ltd, 109 Great... 02/03/04

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

CARE HOME ADULTS 18-65 Delos Community Ltd, 109 Great Park Street 109 Great Park Street Wellingborough Northants NN8 4EA Lead Inspector Sarah Jenkins Unannounced Inspection 4th September 2007 08:00 Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.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.V342032.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.V342032.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 677881 mikebrennan@delos.org.uk www.delos.org.uk Delos Community Limited 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) 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.V342032.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 13th June 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 en-suite facilities. The range of fees at the home is £650-£1723 per week. This fee does not cover the full cost of individual holidays arranged with the home, nor personal toiletries or clothes. Details about the home including the Statement of Purpose and Service Users Guide are available from the Registered Manager and some information is available in user-friendly formats. The most recent inspection report is available through the home or on the Commission for Social Care Inspection website. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.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 meet with members and staff. Members have Learning disabilities, and may have additional mental health or communication difficulties. Establishing their choices and informed decisions is dependant to some extent upon the consistency of staff, service users relationships with staff, and the quality of communication. The Inspector undertook observations of care practice, and members’ relationships with staff to establish their levels of contentment with their lifestyles and routines. The Inspector spent approximately five hours in total on the site visit; some of this time was spent at the Organization’s Central Offices meeting with the Registered Manager and reviewing the staff and maintenance records. No comment cards from visitors or relatives had been received at the time of the inspection but the Inspector had an opportunity to meet with a visiting relative at the home. 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.V342032.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. The summary of this inspection report can be made available in other formats on request. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.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.V342032.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. 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: A prospective new member is currently going through the admission and assessment process and it was evident from records and from discussion with staff that this is being done with proper understanding of the new members rights and choices and with sensitivity to their needs and the needs of the other members of the household. Arrangements for preadmission visits to the home are fully flexible according to need, and the professionalism of the process leads to a gradual introduction and good outcomes for all concerned. Policies and procedures support effective communication from the outset and the Service Users Guide, recently updated, is enhanced by illustration. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their feelings, needs and choices are recognized as central to the care planning process and that they will be treated with respect and involved in the running of the home. EVIDENCE: Members care plans are full of relevant information and the information gathering, and updating process is clearly full and thorough. Advice was given that information could be clearer and more accessible for staff. (see also comments under Healthcare – medication) Members are enabled to take reasonable risks in pursuit of their independent lifestyle choices. They are empowered to take responsibility in the house and Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 10 to be involved in the management. Regular house meetings are held but members do not always feel a need to attend as communication between members and staff is constant and ongoing. Members were observed to be comfortable in their environment and with staff, and were able to confidently assert their feelings and needs appropriately. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Members are very happy with their various lifestyles, which are active and stimulating. EVIDENCE: Members spoke positively about their lifestyle choices and the support that they received. On the day of the inspection members were engaged in or planning activities of their choice. The Inspector discussed daily life and activities with the staff member on duty and it was clear that staff give constant consideration to how best to support members, to involve them in all aspects of the home, and to enhance their skills and understanding. Members are enabled to go on holidays and day trips and regular outings and there were photographs that demonstrated their enjoyment of such activities. Members’ diverse needs are considered and supported at all times, for example Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 12 members attend religious festivals in accordance with their choices, or may choose not to attend any. Members are enabled to receive visitors, and a relative called at the home to visit during the Inspection. This relative expressed general positive feelings about the members’ lifestyles at the home. Members are part of the local community, visiting the local facilities, which are conveniently close, and can also share activities with their friends who are members in other homes owned by the organization. Members are encouraged to maintain and develop good relationships based on mutual respect and consideration. Visitors feel warmly welcomed to the home. Members choose their menus with some guidance from staff towards healthy eating options. The menu was seen to have a selection of nutritious and appetizing food, and a member expressed full satisfaction with the food provided. Food stocks were seen to be hygienically stored and staff and members access a shop, which is only minutes away, if they need anything that is not in stock. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall members’ personal and healthcare needs are met but there is a need to improve the quality of the records evidencing this and review and refine shortfalls in the medication system. EVIDENCE: A member 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. From discussion with staff it was apparent that service users healthcare needs are observed and responded to appropriately, and members are supported to access healthcare professionals appropriately. It was not possible to fully cross check the overview of members’ healthcare as records were not consistent, and some records appeared to be missing. Some information had been inappropriately entered in the staff communication book Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 14 instead of the care notes and the Inspector advised on data protection and confidentiality issues regarding this. Although no serious risk to members was identified at the time of the inspection, the medication system needs review. There did not appear to be any breech in the medication actually given at the time of the inspection as members’ medications were sealed by the pharmacist in cassettes, checked by staff and found to match the prescriptions. However, medication administration sheets are handwritten and were found to be inaccurate in one instance. Staff had been signing these sheets and had not picked up the inaccuracy. The directions for medications that were prescribed PRN (as required) did not detail the minimum period between doses or the maximum dosage in 24 hours. At least one such medication was being administered on a regular basis. There was no detail in the service users care plan as to how this medication should be used, and advice was given that this should be properly reviewed with the member and with their General Practitioner. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 showed that they could approach staff with their problems and showed confidence that they would be listened to and taken seriously. There is an ethos of empowerment at the home and this is supported by policies and procedures for staff to familiarize themselves with. There is a user-friendly symbolic guide for members in relation to complaints and protection. There was evidence at this Inspection that a member had raised a concern about the attitude of a staff member and that this had been fully and thoroughly investigated and followed up. The Commission for Social Care Inspection have not received any complaints about the home since the last inspection. 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.V342032.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. There is a pleasant garden area, which is being developed by a staff member with horticultural experience, alongside members to enable them to grow some of their own vegetables and herbs. A member who showed the Inspector their room expressed satisfaction with the provision. There are no en-suite facilities at this home. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 17 Records of maintenance and standard checks on equipment were well maintained, and there were up to date risk assessments, which were monitored and reviewed by an officer of the organization. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are caring and appropriately knowledgeable and members can be confident that their life at the home will be well supported by people who have their best interests at heart. EVIDENCE: Both members and the visitor to the home felt that staff at the home are “kind”, “nice” and “helpful”. Relations between members and the staff member on duty were seen to be working positively to promote members’ interests and independence. Staff generally work on their own in the home but this is risk assessed and updated as needed. When the support needs of members increases or there are new admissions to the home, the staffing levels are increased accordingly. The Inspector reviewed the staff training records and found that training is undertaken appropriately although there were shortfalls in qualified first aiders and not all shifts throughout the 24 hour period are properly covered in this respect. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 19 Recruitment processes are full and thorough and records evidence this. The staff member on duty at the time of the inspection described a thorough induction process, and felt well supported by the training and supervision at the home. Staff members each meet with the Registered Manager once a week for supervision, which covers issues directly relating to the work with members, and a range of relevant developmental areas. The Registered Manager described an effective and thorough supervision process. The staff member interviewed also showed confidence in the robust “on call” system whereby staff can be called to the home at short notice, and a manager of the organization is always available. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the management of the home generally reaches a high Standard. The Registered Manager is well supported by the organization, which has wellorganized systems, checks and Quality Audit. Records need to evidence the general quality of provision. 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. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 21 It was evident from discussion with the staff and members that the management of the home is being effectively undertaken, and that there is confidence in the Registered Manager. 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. There are good systems and records to show the overview of premises issues, and staff files are well organized with the relevant information easily accessible. (These are held at the head office) Members care files are not maintained so well and this shortfall has prevented the Inspector from being able to verify the quality of care in all areas. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 2 33 x 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 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 1 x 3 x 3 x 2 3 x Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13 Requirement Timescale for action 14/10/07 2 YA20 13 The medication system must be reviewed to ensure the accuracy of the records and to ensure that members receive the medications that are prescribed for them. Medication Administration Sheets 14/10/07 must reflect the General Practitioners prescription, to protect service users from receiving wrong medications. 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 Refer to Standard YA20 Good Practice Recommendations Instructions on records of PRN (as required) medications should show the minimum time between doses, the maximum doses in 24 hours and the purpose of the medication. Where PRN (as required) medication is given for emotional or behavioural support, the criteria for administration of the medicine should be clear on the medication administration sheet or on the care plan. DS0000039664.V342032.R01.S.doc Version 5.2 Page 24 2 YA20 Delos Community Ltd, 109 Great Park Street 3 YA20 4 YA19 YA42 Medication profiles should be updated and accurate. Details of the administration of medicines on profiles should match the Medication Administration Sheets and the General Practitioners prescription. Records of members’ healthcare should be recorded fully and consistently and in accordance with The Data Protection Act guidelines. Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Delos Community Ltd, 109 Great Park Street DS0000039664.V342032.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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