Inspection on 20/05/09 for Delos Community Ltd, 7 Poplar Street

This inspection was carried out on 20th May 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Delos Community Ltd, 7 Poplar... 27/10/08

Delos Community Ltd, 7 Poplar... 27/06/08

Delos Community Ltd, 7 Poplar... 16/01/07

Delos Community Ltd, 7 Poplar... 29/11/05

Delos Community Ltd, 7 Poplar... 08/02/05

Delos Community Ltd, 7 Poplar... 24/06/04

Delos Community Ltd, 7 Poplar... 08/01/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report CARE HOME ADULTS 18-65 Delos Community Ltd, 7 Poplar Street Willowtree House 7 Poplar Street Wellingborough Northants NN8 4PL Lead Inspector Judith Roan Key Announced Inspection 20th May 2009 11:00a Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Delos Community Ltd, 7 Poplar Street Address Willowtree House 7 Poplar Street Wellingborough Northants NN8 4PL 01933 222452 01933 677881 simonh@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) Manager post vacant Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10), Mental disorder, excluding of places learning disability or dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (10) Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC To residents of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD and Code LD(E) Mental disorder excluding learning disability or dementia - Code MD and Code MD(E) The maximum number of residents who can be accommodation is 10. 2. Date of last inspection 27th October 2008 Brief Description of the Service: 7 Poplar Street is situated in a residential area close to the town centre of Wellingborough. The home is also known as Willowtree House 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. The collective facilities are known as the Delos Community where people using the service are known as members. The home provides personal care and support for up to nine members whose primary care need is due to having a learning disability, but who may also have mental health problems. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people who use the service and their views of the service provided. This process considers the services 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 three people who use the service and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The Inspector also received questionnaires completed by four visitors/ relatives and health care professional. The questionnaires provided positive feedback of the quality of care and service. The homes registered manager also completed an Annual Quality Assurance Assessment (AQAA) a questionnaire required to be completed by CSCI. This was an announced inspection, which took place over the course of two days. We selected three people who use the service to ‘case track’ which involved reviewing the care they receive through review of their records, meeting with them and support workers. This inspection was announced and involved an expert by experience. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The views and experiences of people who use services are central to helping us make a judgement about the quality of a service so they should be fully involved in the inspection process. We use information from experts by experience to help us triangulate evidence and verify any issues. The inspection lasted 9 Hours. The range of fees at the home start at £637 and increases depending on the needs of the person using the service per week. What the service does well: Support plans are clear and detailed. There is a good choice of daily educational and leisure options Works well with healthcare professional in supporting people with their increased physical health care needs. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 6 Support workers are well trained and available in numbers to meet identified needs. What has improved since the last inspection? What they could do better: Risk assessments must be in place whilst radiators throughout the home are covered with a protective barrier. It is recommended that the acting manager extends their knowledge skills and experience in working with people with mental health needs through a period of extensive training. All incidents that affect the well being of people using the service must be reported to CQC. Exits from the building must be kept clear at all times. It is recommended that an alternative storage area is found for storing cleaning equipment when not in use. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 8 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, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 People using the service experience adequate quality outcomes in this area. Admissions to the service do not always take account of the compatibility of people presently using the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The service has a Statement of Purpose and service users guide, which are presently under review as the service is to move to providing a service for younger adults that high level needs and require a staff team with skills that can support people with behavioural support. Over the past twelve months the needs of all the present group living at the home have reassessed and for most alternative provision has been sought. The service does needs to develop a Statement of Purpose that clearly states and defines the service that the home intends to provide. This will support the assessment process and ensure that identified needs can be met. Evidence was found that people were assessed prior to admission but the diversity of needs of people living at the home did challenge the service in meeting all of the individual’s needs. There has been recognition by management of the issues facing the service and for this reason a plan of reprovision is being developed that will enable the service to meet needs. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 10 In talking with one person using the service and one person who was visiting on a planned admission they spoke about the new house that they would all be moving to when completed. Individuals have and continue to be involved with the process. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 People using the service experience good quality outcomes in this area. Support plans ensure that needs are met in a person centred service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The service under the management of the acting manager has improved over the past twelve months. Improvements continue to be made with clear support plans that take into account personal choice and preferences. Support needs are now underpinned by clear risk assessments. Management have reviewed the current records and are presently looking at alternative systems that will ensure that needs are detailed and inform the staff team on how these are to be met. It was evident that support plans are reviewed and updated as required. Records are kept securely in the records store with authorised access. In observation and in talking with people that use the service it was evident that support plans had been developed with their input and within their ability to do Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 12 so. Family representatives or advocates are used in situations where communication needs make the process more challenging. It is recommended that person centred plans are developed in accessible formats as they have been in other services within the organisation. In meeting with the expert by experience at the Day service centre three people agreed to be interviewed. They were asked if they would like a staff member to be present which they preferred. When asked if they could choose when to go out and where to go, one person said ‘she liked going for a walk’. Two others said ‘They can, only with the support from staff’. In asking if they could choose to bath or shower and who helped them with this? The expert by experience had the following response, ‘All three service users said that they could choose; only women help them at the moment and they want to keep it like this.’ On the question of house meeting the Expert by experience asked if they were invited to house meetings to put their ideas and grumbles across. One person said ‘once a month another said yes and the third person said sometimes.’ Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 13 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): This is what people staying in this care home experience: 12,13,14,15,16,17 People using the service experience good quality outcomes in this area. People using the service have a range of daily options to develop their skills or maintain there daily living skills. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People using the service have a range of day options within the Delos community. The day centre managed by Delos is opposite the home and people attend this provision on a daily basis or several times a week. One person due to health care needs only attended when their health permitted. At weekends the service promotes and supports people using the service to use facilities in their local community, like shops, library, cinema, pub, and theatre. When asked by the expert by experience what they did at weekends? Two people did not answer. The third person said ‘that she liked a lay in.’ Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 14 Meals are prepared at the house and people at the day service return to have their lunch. Most meals are freshly prepared or they go out for a meal on special occasions. The expert by experience asked two questions in this area firstly could choose their favourite food? One person said ‘that she could another said she could if she wanted to and the third person said that could change the menu if she wanted to.’ Secondly they asked if they ever went out to eat. Two people said ‘yes they did and the third person said that she went out to a carvery.’ Relatives and friends are most welcome at the service and staff support individuals to maintain contact. The AQAA confirms this by stating ‘We continue to actively promote family contacts for people, and to facilitate the creation and maintenance of friendships and other social relationships.’ The expert by experience also supports this fact by receiving the following replies, when asking if they could have friends in to visit. One person said ‘yes but not in my bedroom. Another said No as her friend lived to far away to visit. The third person also said yes.’ They were also asked about using the telephone one person replied by saying but that this was their choice.’ People using the service were also asked about going to church one person replied saying that ‘she went once a week. Another two said they could and the third person said she used to go to church but no longer wanted to go and that they did not go now.’ Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People using the service experience good quality outcomes in this area. The health care needs of people using the service will be identified and met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The changing healthcare needs of individual’s living at the home are now being met on a consistent basis with the support of visiting healthcare professionals. As a result of the reassessments undertaken over the last twelve months several people have moved onto more appropriate services where physical health care needs can be met. The needs of one person who presently lives at the service have increased significantly to the point where they needs bed rest throughout the day. The staff team have responded positively in meeting their needs and are working well with health care colleagues. A new service is being sought where they will have nursing care support in the future as their needs increase. There is evidence that plans have been made for every person who has moved onto a new service and that individuals had been involved in the transition. Risk assessment need to be in place in support of all activities and there is evidence that they kept under review. The service should not rely totally on Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 16 assessments and records made by visiting nursing staff to meet personal and health care needs of people using the service. Medication was seen to be stored securely and administered well within the service. Previous issues on recording were not evident on this inspection. Support workers have received refresher training and audits were being carried out by the acting manager and senior managers within the organisation. Facilities are available for controlled drugs and support workers were aware of the additional procedures that they would need to employ when administering medication in this category. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People using the service experience good quality outcomes in this area. Practices within the service fully protect people who use the service and ensure that they are listened to. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The service has comprehensive policies and procedures in relation to handling concerns and complaints. People who use the service were all clear about how to make a complaint saying they would speak with the manager or a member of their family. Support workers undertake abuse awareness training as part of their induction/foundation training. Several have completed this as part of their National Vocational Qualification. The inspector checked out their understanding during the inspection. The expert by experience asked the following questions of the three people they met during the inspection. ‘Do you feel safe living in the home? All three service users replied yes.’ They also asked if ‘They knew how to make a complaint? And if so who would they need to make a complaint to? All three service users said they would tell their key worker.’ The open approach of the registered manager enables people who use the service to feel comfortable if there was a need to make a complaint or express a concern. The AQAA confirms that there have been two complaints since the last inspection with one being upheld. The AQAA also states that ‘All service users are issued with an easy-to-read complaints booklet. The complaints Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 18 process is also easily viewable in poster form throughout the home. All members are aware of who they need to speak to make a complaint, or even to ‘grumble’ about a minor issue. Members are supported to go through the procedure by their key worker. We work in close partnership with advocacy Northants as a number of our service users no longer have family members who are able to advocate on their behalf if they themselves are not able to.’ In discussions during the inspection it was concluded that people using the service felt safe and that support workers had a good understanding of their role and were aware of policies and procedures. Accident records are completed and were available for inspection. Not all of these events had been notified to commission under regulation 37 of the Care Standards Act 2000. It is a requirement that providers notifies the commission of all incidents that affect the well being of people using the service. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People using the service experience adequate quality outcomes in this area. The home provides a warm family setting with individual space that is clean and hygienic but not totally meeting the needs of all the people that use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home is decorated to an adequate standard. There are sufficient rooms to enable everyone to have their own personal space. Several communal areas are used for joint activities and each bedroom has sufficient room for personal hobbies. Communal areas are comfortable and provide a range of areas where people can relax. Individual bedrooms are personalised they are comfortable and well maintained. A requirement made at the previous inspection to have radiators covered in areas where there is a risk for people using the service has not been complied with. In discussion with the acting manager they said that there are plans to Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 20 address this issue when the house is renovated as part of the service reprovision later in the year. Most of the people using service at present are maturing and their mobility needs are changing. In time the home will not be able to meet their needs. The organisation is being proactive and looking at the issues. They have prepared proposals that outline the needs and recommendations on how these will be addressed. The expert by experience established that people using the service have been consulted ‘All the service members I spoke to seemed anxious about the move to the new home. I spoke with the manager about this and she told me that they were all receiving counselling to address this issue. She told me she was monitoring the situation and keeping the area manager informed.’ The acting manager also confirmed that advocates were involved to assist people to make decisions. They also said in their report that ‘I was shown around the home by the manager and I thought that it looked clean and tidy. All the staff I met was warm and friendly. There was a board on the wall in the hallway that had the all of the service user’s photographs showing their choice of menu for the day. I thought this was a good idea.’ The garden is maintained and provides outdoor space when the weather permits. There are several seating areas where people using the service can relax. The uneven surfaces do however pose a risk to people with limited mobility. People spoken with during the inspection said that We like our own rooms and we have chosen how it has been decorated. Bedrooms seen during the inspection showed individuality and contained items to suit their lifestyles. They also said when asked if they helped with household chores. One person said that she washed up, another said she cleaned the tables and a third person said she did the hoovering and dusting Health and safety checks are carried out in accordance with the organisations procedures. Standards of cleanliness and odour control in all areas of the home were good. The storage of cleaning equipment remains an obstacle at the door into the garden and poses a risk in the event of an emergency evacuation of the building. The acting manager needs to find an alternative storage area that is safe. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 People using the service experience good quality outcomes in this area. Staff skills and recruitment practices ensure that the needs of people who use the service are supported and that they are protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Delos has a thorough recruitment procedure and files seen confirmed that required employment checks, application form, two references, criminal records bureau disclosures and interviews that involve people who use the service had been undertaken. The support worker team have a sound knowledge base about the needs of people that use the service. Through observation during the inspection they showed that they had a range of skills to support individuals and were proactive in developing everyday living skills. Support workers are offered a range of opportunities to train. Of the staff team of ten, seven people hold a National Vocational Qualification in care at level two or above with a further three undertaking the course at present. Support workers spoken to had a good knowledge of the needs of people using Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 22 the service and were committed to providing a good service. They have regular supervision, which is recorded. Support workers have access to a wide range of training; topics include Person Centred Planning (a system that identifies the individual needs, of people using the service), Epilepsy awareness, Mental Capacity Act, medication, Risk Assessment, Report Writing, Fire safety, Food Hygiene, Abuse awareness, health and safety, manual handling and more. Training records are kept within individual staff files. New support workers have to go through a detailed induction programme, based on the Skills for Care professional model and Learning Disability related. The AQAA states that ‘All new staff receive a thorough induction, using evidence based practice as well as theory to ensure they gain relevant skill sets. Support workers also undertake the LDQ (Learning Disability Qualification) induction and foundation qualifications within 6 months of beginning work for us.’ The expert by experience established that people using the service had key workers. And that when asked about staff the three people interviewed said ‘The staff were friendly and that they worked well with their key workers.’ Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42,43 People using the service experience adequate quality outcomes in this area. The home remains without a registered manager which is limiting the development of the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager is not qualified and to date has not been registered under the regulations set by Care Standards Act 2000. It is recommended that the acting manager extends their knowledge skills and experience in working with people with mental health needs through a period of extensive training and applies to become the registered manager. Management support is being provided by the organisation to ensure that the service is working towards meeting the regulations and National minimum Standards. The manager is aware of the need to keep up to date with practice and continuously develop management skills, but it has been difficult to find the level of course required. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 24 The manager is aware of the need to promote safeguarding and has developed a health and safety policy that generally meets health and safety requirements and legislation. The manager has highlighted areas where they need to make improvements and has an action plan for undertaking the work. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. More work is needed in this area so that assessments of need for people moving into the home ensure compatibility of people using the service. Records also need to improve so that staff are clear about the needs of people using the service and associated risks. Not all incidents had been notified to the commission which is required under regulation 37 of the Care Standards Act 2000. Quality assurance systems are in place and the AQAA confirms the range of activities undertaken, ‘The home has a range of quality assurance systems in place; service user surveys, 1-1 key worker meetings, members forum, periodic service review, regulation 26 visits, and of course the AQAA framework. The provider has undertaken all health and safety checks required. Clear records of all checks are well maintained. The AQAA also confirms the checks undertaken. Delos has robust financial checks of personal monies that require records of receipts, running balances and signatures. Monies are checked as part of management reviews. Health and Safety Policies and Procedures are in place and support workers are aware of these. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 25 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 3 2 2 3 X 4 3 5 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X 2 3 2 Version 5.2 Page 26 Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Are there any outstanding requirements from the last inspection? YES 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 YA41 Regulation 37 Requirement Timescale for action 31/07/09 2 YA42 13 3 YA42 13 All incidents that affect the well being of people using the service must be reported to CQC. This is to comply with regulation 37 of the Care Standards Act 2000 and to ensure that people using he service are protected. 31/12/09 Risk assessments must be in place whilst radiators throughout the home are covered with a protective barrier as part of the re-development programme in 2009. This is to ensure that people using the service are protected. The is a requirement made at the last inspection and not met within the timescale by 31/12/08 Exits from the building must be 31/07/09 kept clear at all times. This is to ensure that people using the building are kept safe and that accidents are minimised. Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 27 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 YA37 Good Practice Recommendations It is recommended that the acting manager extends their knowledge skills and experience in working with people with mental health needs through a period of extensive training. It is recommended that an alternative storage area is found for storing cleaning equipment when not in use. 2. YA42 Delos Community Ltd, 7 Poplar Street DS0000039660.V375605.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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