CARE HOME ADULTS 18-65
Delos Community Ltd, 34 Park Road 34 Park Road Wellingbrough Northants NN8 4PW Lead Inspector
Mrs Helen Wilson Unannounced Inspection 17th November 2005 08:35 Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Delos Community Ltd, 34 Park Road Address 34 Park Road Wellingbrough Northants NN8 4PW 01933 222532 01933 276208 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Delos Community Limited Mr Simon Nicholas John Hardwicke Care Home 4 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (4) of places Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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 1 August 2005 Date of last inspection Brief Description of the Service: 34 Park Road is situated anonymously in a residential area close to the town centre of Wellingborough. The home is one of four homes operated by Delos Community Ltd and all are within easy walking distance of each other. A Day Centre in separate premises is run by the company and used on a sessional basis by some of the residents. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is on the outcomes for service users, and on their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 2 residents and tracking the care they receive through review of specific records, observations of them and care practices, and discussions with the care staff, The inspection took place during a morning over a period of 3 hours and was carried out on an unannounced basis. Communal areas were visited. A selection of care records and essential records of the home were reviewed and discussions took place with the Registered Manager and staff on duty. Most of the residents were spoken with and care practices were observed as part of the inspection process. What the service does well:
This is a well run and proficiently managed home that centres around the needs of residents. The home’s Policies and procedures were randomly checked and were clear, professional and offered good guidance to staff on care practices. Staff have had training in non-verbal forms of communication to assist and support specific service users. The home helps service users to share issues of a confidential nature via use of appropriate advocates and by talking through any issues with staff. The home has a robust procedure for resolving complaints that gives security and confidence to residents in bringing issues forward. Staff are trained to protect vulnerable service users and to identify any potential forms of abuse. The home is clean and homely and service users were relaxed and comfortable. Service users said they were very happy living at the home and had many outside activities that they enjoyed.
Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 Page 6 There were high levels of rapport with service users and staff were friendly and supportive. Clearly service users are relaxed and confident with staff. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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): 1,3 Service users are assured that the home can meet their assessed needs. EVIDENCE: The home’s Statement of Purpose document is currently being revised to show changes within the staff team and will be circulated once completed to service users and relevant parties. Staff have had training in non-verbal forms of communication to assist and support specific service users. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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): 10 Service users can be reassured that confidentiality is secured by the practices of the home. EVIDENCE: The home has a clear policy covering confidentiality of information held in respect of service users. The home helps service users to share issues of a confidential nature via use of appropriate advocates and by talking through any issues with staff. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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): 20 Errors in the medication system were a potential risk to the health of service users. EVIDENCE: From a check of Medication Administration Sheets it was clear that a supply of prescribed syrup medication had run out and was not obtained for some days; once obtained, the medication was not recorded as having been delivered and the medication then was not administered to meet the instructions of the prescribing General Practitioner. The home’s system for recording and administration of medication must be reviewed and staff practice monitored to identify further training needs. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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): 22, 23 The home has a robust procedure for resolving complaints that gives security and confidence to residents in bringing issues forward. EVIDENCE: The Registered Manager stated that there had been one complaint in recent weeks that had been resolved through discussion in a small group of residents and staff. No written documentation of this complaint was available in the home. The manager agreed to ensure complaint investigation details were recorded in-house and cross-referenced in individual case files. Staff are given basic induction training on the protection of vulnerable adults and additional training from an outside agency during a training programme set up to cover staff development needs. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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): 24,27,28,29,30 The home is comfortable, clean and well furnished and meets the needs of residents. EVIDENCE: The home’s lounge and dining room are bright airy communal areas. The kitchen is clean with normal domestic appliances suitable for the family style living at the home. Two well-fitted bathrooms are available; the extractor vent in the top-floor bathroom is very noisy and the Registered Manager will arrange it to be checked. There is no specialist equipment required by current residents. All parts of the home were clean and fresh. A new roof has recently been completed and the scaffolding has still to be removed by the contractors. No further large scale repairs are in progress. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 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): 31,33,34,36 The home has robust recruitment and staff supervision processes that give protection to service users. EVIDENCE: By interviewing two staff on duty and from staff files, it was evidenced that each person has a clear understanding of the home’s purpose, of their individual roles and where to obtain advice and guidance within the organisation. There were high levels of rapport with service users and staff were friendly and supportive. Clearly service users are relaxed and confident at this home. Staff files were brought to the home from the company’s head office to be inspected. There was clear evidence of thorough recruitment processes including interview evaluations, references and Criminal Record Bureau disclosure checks. Following this inspection the manager has agreed to ensure a summary staff file for each staff member is held at the home. Supervision is carried out on a regular two monthly basis with these sessions documented in the files held at the head office. To assist senior staff in monitoring actions planned with individual staff it was recommended that that this supervision paperwork be available at the home. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 This is a well run and proficiently managed home that centres around the needs of residents. EVIDENCE: Staff confirmed that the home is managed well by the registered manager and that guidance and leadership is offered in a positive and professional manner. There are processes for monthly in-house self-assessment to ensure service users needs are being met and a two yearly programme of receiving comments from questionnaires from service users and their families or interested parties. House and staff meetings were evidenced through the regular minuted notes seen. The home’s Policies and procedures were randomly checked and were clear, professional and offered good guidance to staff on care practices. The document relating to managing behaviour and challenge was particularly useful. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 Page 16 Service user information is now held on an individual basis and complies with the previous requirement made in August 2005. Food stocks for an individual service user are now generally within use-by-date and staff will continue to monitor this situation. The Registered Manager was pleased to state that the home has attracted increased fees for it services and has enhanced its staff group this year. Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x x Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x 3 3 N/A 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 x 3 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Delos Community Ltd, 34 Park Road Score x x 1 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 3 DS0000039663.V265788.R01.S.doc Version 5.0 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 12(1), 13(2) Requirement The home’s system for recording and administration of medication must be reviewed and staff practice monitored to identify further training needs. Timescale for action 15/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Delos Community Ltd, 34 Park Road DS0000039663.V265788.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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