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Inspection on 30/01/06 for Delos Community Ltd, 34 Finedon Road

Also see our care home review for Delos Community Ltd, 34 Finedon Road for more information

This inspection was carried out on 30th January 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Care is supported in a very homely atmosphere where some members have lived alongside each other for many years. The home is currently developing a wide range of new plans to support members care arrangements. Although not yet in place for all members, some of the files viewed held very good plans which fully reflected members needs, as identified by them and in a format they are able to fully understand.

What has improved since the last inspection?

The Registered Manager informed the inspector that all staff have either completed, are currently undertaking or are booked onto, the recommended NVQ level 2 and in some cases NVQ level 3 training.

What the care home could do better:

The practice of having only one member of staff on duty at certain times of day should be supported by a recorded risk assessment process setting out clear risk management strategies. The home should develop a written policy regarding the provision of work experience placements clarifying the restricted duties such workers can undertake within the home, and the level of supervision expected from other staff.

CARE HOME ADULTS 18-65 Delos Community Ltd, 34 Finedon Road 34 Finedon Road Wellingborough Northants NN8 4EB Lead Inspector Mrs Mary Timms Unannounced Inspection 30th January 2006 12.30 Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 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, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 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, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Delos Community Ltd, 34 Finedon Road Address 34 Finedon Road Wellingborough Northants NN8 4EB 01933 225197 01933 276208 info@delos.org.uk 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 Mrs Carrie Marian Harris Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7) of places Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 8th September 2005 Date of last inspection Brief Description of the Service: 34 Finedon Road is situated in a residential area close to the town centre of Wellingborough. The home is also known as Avonlea 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 seven members whose primary care need is due to having a learning disability. Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit lasting approximately three hours, made during the afternoon. Time was also spent prior to the visit reviewing previous inspection reports and the service history. This is the second statutory inspection visit to this home undertaken during the current inspection year, and readers will find that key areas not covered within this report were referred to in the September 2005 inspection report. All standards reviewed during the previous inspection were found as met and with no identified concerns arising since that time only the remaining key standards have been reported on within this document. The level of care provided was identified as consistent with the previous visit. The inspector spoke at length with the Registered Manager and interviewed the one member of care staff on duty. A member (resident) spoke briefly with the inspector on his return from his work placement. What the service does well: What has improved since the last inspection? What they could do better: The practice of having only one member of staff on duty at certain times of day should be supported by a recorded risk assessment process setting out clear risk management strategies. The home should develop a written policy regarding the provision of work experience placements clarifying the restricted duties such workers can undertake within the home, and the level of supervision expected from other staff. Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 6 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, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 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, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 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): These standards were reviewed during the previous inspection in September 2005. EVIDENCE: Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 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): Members are well supported and empowered to become involved in planning care arrangements. EVIDENCE: A selection of individual plans were viewed during this visit. Each file held detailed planning documents setting out individual needs, including guidance for staff. The Registered Manager informed the inspector that the staff team are committed to involving members in the development of their own plans. Where key-workers have attended the appropriate training they have developed both Essential Lifestyle Planning and Person Centred Plans alongside individual members. The plans were noted to be individual and in an easily understood and colourful format, fully reflected personal wishes and needs, future goals and agreed tasks. The member of staff on duty also confirmed that members are fully involved in planning arrangements. Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 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): Key standards were reviewed during the previous inspection in September 2005. EVIDENCE: Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 11 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): Key standards were reviewed during the previous inspection in September 2005. EVIDENCE: Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Member’s wellbeing and protection is treated as a priority within this home. EVIDENCE: On the day of this inspection visit three of the members of staff were attending Protection of Vulnerable Adults Training (POVA), the member of staff on duty confirmed he also has attended this training within the last year. It was apparent from discussion with the Registered Manager that the general welfare and safety of members is a main concern when developing arrangements for care. Delos Community has developed appropriate policies, procedures and monitoring systems aimed at protecting members living in all the residential homes. Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 13 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): Key standards were reviewed during the previous inspection in September 2005. EVIDENCE: Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34 Whilst members are well protected by the recruitment procedures operated in this home, the same protection is not offered in relation to individuals on work experience placements, which may potentially leave members at risk. EVIDENCE: The Registered Manager confirmed checks were undertaken with the Criminal Records Bureau (CRB) for all members of staff prior to them commencing work in the home. Two staff files were checked during this visit, one held all required documentation and confirmed an appropriate recruitment process had been followed. The second file related to a individual undertaking a work experience placement in the home under the New Deal Scheme, which eases unemployed individuals back into the work environment. The Registered Manager confirmed that individuals on such work placements are not recruited through the normal process, however they would not be providing any personal care and would be fully supervised at all times. Also confirming that CRB checks are completed prior to the commencement of such a placement. Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 15 It was identified during this visit that on occasions there is only one member of staff on duty with up to seven members. On the evening of this visit one member of staff was on duty from 2.30-10.30 pm supporting both an individual on work experience placement from 6.30-9.30 pm and seven members. It is unclear how this one member of staff would be able to fully support residents and supervise an individual on work experience. Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 16 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): 42 The quality of the service provided is reviewed regularly and well monitored within the organisation. Health and Safety is treated as a priority with good systems in place to protect members, staff and visitors. EVIDENCE: An external manager undertakes monthly visits to the home as required by regulation. Reports are produced setting out any issues identified or advice, copies are sent to the Commission on a regular basis. Policies and procedures are reviewed on a rolling programme by the management group within Delos Community. Work is currently underway to establish a process for members to become more involved in the reviewing of such documents. Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 17 Records demonstrate that the Registered Manager checks records in the home at least on a monthly basis. House meetings are facilitated on a regular basis. The member of staff interviewed described a culture where members are actively encouraged to comment around the service. Through discussion with staff, the Registered Manager and a review of records it was evident that staff are provided with a good range of appropriate health and safety training, including: fire safety awareness, COSHH (control of substances hazardous to health), medication administration, basic first aid, health and safety for carers, and manual handling all provided within the last twelve months. Arrangements are underway for further training in relation to food hygiene. Records demonstrate that required checks are made on fire safety systems and that fire evacuation drills are undertaken at regular intervals. It was noted that fire safety procedures are on display in symbol format to ensure all members are able to comprehend. An experienced and appropriately trained maintenance manager ensures the health and safety of the environment and facilitates a range of training for staff. A wide range of risk assessments are undertaken: The premises and practical issues relating to the use of the premises are risk assessed then individual risk assessments are undertaken in relation to any potential hazard arising for members. Health and safety was noted to be included within induction programmes for new staff. Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 18 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 X 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 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 X 33 3 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X 3 X X 3 X Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA42 Good Practice Recommendations Lone working within the home should be supported by a risk assessment, which reflects individual needs /vulnerabilities. This recommendation has been carried forward from the inspection reports from visits in September 2005 and December 2004. The Registered Manager agreed during this visit that this risk assessment would be completed by Friday the 3rd February. 2 3 YA31 YA33 Written policies and procedures should set out clearly the restricted role of individuals on work experience placements. The practice of Lone Working should be kept under review to ensure all needs can be fully met. Delos Community Ltd, 34 Finedon Road DS0000039665.V279400.R01.S.doc Version 5.1 Page 20 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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