Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 27/10/08 for Delos Community Ltd, 7 Poplar Street

Also see our care home review for Delos Community Ltd, 7 Poplar Street for more information

This inspection was carried out on 27th October 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

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

What has improved since the last inspection?

What the care home could do better:

CARE HOME ADULTS 18-65 Delos Community Ltd, 7 Poplar Street Willowtree House 7 Poplar Street Wellingborough Northants NN8 4PL Lead Inspector Ansuya Chudasama Unannounced Inspection 27th October 2008 10:00 Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.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, 7 Poplar Street DS0000039660.V373093.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, 7 Poplar Street DS0000039660.V373093.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 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) 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.V373093.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 June 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. The range of fees at the home start at £637 and increases depending on the needs of the person using the service per week. The inspector was informed that the Statement of Purpose had been reviewed but a copy was not available in the home. Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has one star rating and this means that the people using the service receive an adequate service We went to the home without telling any one on the 27th October 08. We spoke to the staff, the manager and some of people living in the home. We looked at information about policies and procedures, which tells the staff how to do things in the home. We looked at the training that they do to look after the people living in the home. We looked at three care plans of the people to find out how their needs are being met by the staff. This is called case tracking. We watched how the people and staff living in the home got a long together. The home sent us their Annual Quality Assurance Assessment (AQAA) when we asked for this and some of the information has been used in this report. What the service does well: Some of the people living in the home say they: • • • • • • • ‘Like living at the home’ They know who to tell if ‘I am unhappy’. They ‘go to the day centre’ ‘I like my room’ ‘I lay table’ ‘I like the food’ ‘I like staff’ The staff spoken to say: • • • • • • • That they ‘enjoy working at the home’. They are ‘attending lots of training’. They have meetings and supervision with their manager to discuss how they are getting on at work. They ‘help people look after themselves’ and ‘like to see them improve’. The ‘atmosphere is good at the home’ ‘It is relaxing at the home’ They are ‘happy with how things are’ DS0000039660.V373093.R01.S.doc Version 5.2 Page 6 Delos Community Ltd, 7 Poplar Street What has improved since the last inspection? What they could do better: Some of the things that the home needs to do better include: • • • • • • • • • • • Ensure all the radiators are covered up to protect the people from getting hurt. Ensure that the garden is accessible to all the people living in the home Provide the staff an office and a computer Ensure that regulation 26 visits are carried out by the organisation to monitor the home Ensure the people and their representative are involved in completing their care plans Ensure the people are not examined in communal areas Ensure peoples privacy, dignity and confidentiality is maintained Ensure all fire escape routes throughout the house are properly signed Ensure medication records are completed properly Ensure records are kept in the home from professional people Ensure documents are signed and dated and the name of the person completing the form is recorded Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 7 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, 7 Poplar Street DS0000039660.V373093.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.V373093.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people using the service are provided with information about the home prior to making a decision to stay. EVIDENCE: We examined three people’s files during the inspection and found that the people’s individual needs are assessed before they move into the home. We were informed by the manager that a new assessment form was developed and this document was going to be used when a new person was being admitted to the home. The manager also said that the home was going to reduce the number of people being admitted to the home. The manager needs to inform the registration team when this happens. The Statement of Purpose we looked at was completed in 2005 and the information about the home had changed since the document was produced. The manager informed us that the new Statement of Purpose was being updated by the organisation. When we were given a tour of the home and saw a copy of the Service User Guide in the people’s bedrooms. The documents were attractively put together with photographs to clearly illustrate the Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 10 information given. The individual guide was personalised by putting the name of the person living in the home. Consideration should be given to changing some of the photographs to actual pictures of the house and some of the amenities offered. The guide would also benefit from containing more details about the local facilities that the home accesses in the community. The people’s files seen also had contacts that were signed and dated by the manager and the person or their representative Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care planning process needed developing further to involve the people and their representative in implementing them to ensure that their views are taken into account to meet their needs. EVIDENCE: The three care plans that we looked at contained details on how people wanted to be supported and how this was going to be done. However there was no evidence to show that the people and their families helped compile the information. None of plans we saw were signed or dated by the person completing them. We saw copies of assessments the manager has recently carried out on all the people living in the home. They had done them in preparation of reviewing and Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 12 restyling the care plan’s to make them person centred. The manager talked about having review meetings so that everyone with an interest can have a say in what is included in the plan. The manager also said that the staff were beginning to attend training so they would have a better understanding of how to make care plans more person centred (PCP). The staff training information showed that 4 out of 13 staff had undertaken training on PCP in October 08. One file contained a communication book, which was very good and had detailed information about how to communicate with the person and how they were supported. The book had pictures and personal photographs and information about the special equipment they needed and some of the activities they enjoyed doing. Another file seen had a detailed health profile and had some very useful information. Unfortunately, on enquiry, we were told that the home had not produced either of these documents; these were brought with the person when they moved into the home. When reviewing and updating the peoples care plans it would be in the best interest of the people if the manager were to look at these formats. The people are given the opportunity to make decisions about their own lives regarding what they want to eat and wear and what time they go to bed. We observed the people being consulted by staff on what they wanted for lunch and several alternatives were selected. Risk assessments have been developed for day to day risks such as swimming and road safety. They had not been reviewed recently, however when they are updated, which will need to be in the near future, they would benefit from being more detailed and individual to the person involved. At present the risk assessments are generic and do not take into account peoples different needs, abilities or skill. The AQAA says the care plans and risk assessments are user friendly. This was not the case for the documents we had seen. The peoples files are kept locked in one of the small cupboards in the home. The AQAA said that all staff had risk management training but the training records showed that this was not the case. Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.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): 12,13,14,15,16,17, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people are offered a healthy diet and involved in choosing their meals with support to meet their needs EVIDENCE: We looked at the people’s files and read the diary and evidence showed that the people are given opportunities to develop personally and take part in a wide range of activities. Some of the people attend adult education classes, a day centre and are members of the local clubs. The people also attend church and use the local shops and public transport with support from staff. The cook told us that the home was having a Halloween party and there was going to be special food planed for this theme. The staff and the people were Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 14 going to wear fancy dress costumes and families and friends had also been invited to the party. Once a month the home had pampering sessions for the women. A beautician visits the home and offers a massage, and other beauty treatments. The visits are said to be popular with the people as they enjoyed being pampered. The charge for this service varied between £6 and £12. The tour of the home showed that only one of the bedroom doors had a lock. The others did not have handles and were opened by pushing the door and were kept closed by the automatic closure mechanism. It is important that people are provided with the choice to be able to protect their privacy by locking their doors. It was also equally important that the doors are kept locked when the people are not in the home so their possessions are protected. The information read in the AQAA said that the people are given keys to lock their bedrooms but only one door had a lock. We were told that the people are able to lock their doors from the inside of their rooms but it was said that if a person had an accident, and were not able to open the door, the staff would not be able to get into their room. This concern was demonstrated to the manager. It is required that locks are fitted to all the bedrooms. The lock chosen must be of the sort that will allow staff access to the room in the event of an emergency and a master key must be kept in a secure place that can be easily accessed by staff. We had lunch with the people in the home and the food was delicious, hot and wholesome. Lunch consisted of homemade soup or sandwiches and homemade cake or fruit. Some people had chosen something completely different to eat and the cook prepared it for them. The food was eaten in a relaxed atmosphere with staff supporting the people in a kind manner. The people are involved in choosing the menus and these were very good and offered a variety of food. The people and the staff said that the food was very good at the home. One person had a special diet and they had their own menu and the cook had worked hard to ensure that they had a variety of food on the list. The home has been given a four star award for food hygiene and a Northampton Heartbeat Award for offering a well-balanced and healthy menu. In a previous inspection it was suggested that the layout of the dinning room should be reconsidered because it was crowded and difficult to manoeuvre around the large table. Plans have been made to work out the optimum placement of the table and chairs and new furniture has been ordered. The diary gives details of the delivery being next week and the maintenance person told us about the arrangements they had made to dispose the old table. The dinning room was also being decorated. Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.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. 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. The arrangements for maintaining the people’s privacy and dignity are not satisfactory and therefore their needs will not be met in a dignified manner EVIDENCE: During this inspection we looked at three peoples personal files. The care plans we saw set out peoples needs but in a task led way. The manager talked about their plans to make them more person centred to allow people to tell staff about they would prefer to be helped with their personal care and other preferences. The records we examined showed that additional specialist support and advice is sought for people who need it, including speech and language and occupational health. The manager has recently arranged for an independent advocacy service to visit the home to offer support to the people. We were told that they would be Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 16 working with people individually and as a group by holding meetings to support them to discuss topics that are important to them. The first meeting was to take place in the early week of November 08. The care records showed evidence that people receive medical treatment as and when they need it, they contained details of doctor’s visits and records of specialist appointments such as dental, optician and audiologist. We also saw copies of psychology and psychiatric reports. Unfortunately during our visit a doctor called to see one of the people in the home. They were taken to the sun lounge where the person was sitting. The examination was conducted in the lounge with staff. This room has many windows open to the garden and the door in the room has glass panel and we were able to see what was happening in the room. The person’s privacy and dignity was not maintained. Examining people in public areas is very poor practice and must be stopped. Food and fluid intake charts were kept for one person because the carers noticed that they were not maintaining their weight very well. After a short period it was noted that interventions that had been put in place were working and the charts were discontinued. At the time of the last inspection the home was not managing the behaviours of one of the people living in the home. This caused a lot of disruption in the home. The person’s behaviours are better managed by the home due to increasing the staffing levels and ensuring that the persons care planning and health and special diet is being maintained. The medication records were inspected and evidence showed that some of the medication was kept in a fridge and the temperatures were being taken. The medication records showed that the staff were not always signing the MAR sheets when giving out medication. There was also coding used but did not state what this meant. The staff needs to write information at the back of the MAR sheet to explain any changes that are made to the medication. The manager had also recently carried out the in house medication audit on the 17/10/08 and stated that three signatures were missing and there was no continuity of bath oil that was being used. Information read regarding a visit to the home by management also stated that ‘medication system needs to be looked at immediately’. It was said that at present this was not adequate. There was no record of a date or when this visit had taken place or who had completed this form. Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.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. 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. Staff have understanding of safeguarding of vulnerable adults procedures to protect the people using the service EVIDENCE: We were provided with information to show that the staff had been on training courses on safeguarding of vulnerable adults procedures. The staff spoken to confirmed this. Examples were given of how they would be able to tell if a person who was not able to communicate verbally were unhappy. We were told that this was by understanding their behaviours and by getting to know the person. CSCI are being informed under regulation 37 of the Care Standards Act 2000 about accidents and incidents that were happening in the home. The manager said that they have not made any referrals to the social services safe guarding team. When we looked at the referrals we noted that none of these needed reporting to the safe guarding team. The people living in the home are provided with an easy to understand complaints procedure. We were told that most of the people in the home knew how to make a complaint if they were not happy with any thing. We spoke to the people who were verbal and it was confirmed by them that they would Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 18 speak to the staff. The people, who were not able to do this verbally, relied on staff and their family to understand when they were not happy. The manager said that the home had not received any complaints since the last inspection. The home is going to have advocacy support meet with the people using the service to listen to their views. Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment that is clean and tidy and there is evidence of improvement being made through maintenance planning to ensure that the needs of the people are met. EVIDENCE: We were told that management had visited the home and a list of priority tasks for the home was recorded. This was a very detailed list for things that needed doing in the home but the name of the manager completing the list and the date this was carried out was not recorded. There were not dates recorded when these items were to be purchased and completed. We were told that the two seat sofa for the small lounge was being replaced and being decorated. The main lounge settees were not being replaced but the room was being decorated. We were told that two chairs were purchased to meet the Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 20 needs of the frail people. The home was clean and tidy and a new cleaner had commenced working at the home. A staff member was also monitoring the cleaning in the home. At the last inspection we asked to see the occupational therapist assessment (OT) but we were told that they had not received this from the OT. We were told that a practical day assessment date was to be confirmed for some of the people living in the home. This was when the OT would come and assess the individual needs of the people living in the home. The manager informed us at this inspection that the OT had done the assessment but this was not available in the home. It was said that this was kept at head office. We asked for a copy to be sent to the CSCI but this was not received at the time of writing the inspection. The tour of the garden showed that the garden was uneven and therefore was not suitable to meet the needs of the people living in the home. We were told that management was looking into making the garden user friendly for the people. Some of the bedrooms have fire escape outside their rooms; it is accessed through a window by the use of two or three wooden steps. The steps do not have rails and would be difficult to use safely, especially in a hurry. We recommend that grip handles are securely fitted to the window frame so that people can steady themselves as they go up the steps and climb out of the window onto the fire escape. The layout of the home is complex with many twits, turns and corridors so it is not easy to find your way around unless you are very familiar with the layout. The fire doors are not identified and nor are the escape routes so in the event of a fire people will have to rely on their knowledge of the home to find their way out of the building. During a fire the visibility may be poor and people will be frightened and confused so they need to rely on clear and visible signs to show them the way to safety. The maintenance person assured us that the fire officer had agreed with him that signs would not be necessary and that they would spoil the homely appearance of the building. However under the Health and safety (Safety Signs and Signals) Regulations 1996 says signs must be used to help people identify escape routes and to find fire fighting equipment. Signs can be used sympathetically to keep in with a homely atmosphere but they must be used and remain visible. Advice can be fond on the Health and Safety Executive Website. The home did not have an office and we were told that the sleeping in room had a desk so confidential paperwork could be done in this room. On the day of the inspection we were using the dinning room to look at information and the staff were using the sun lounge to have their handover meeting whilst a person living in the home was in the room asleep. The communal areas in the home should not be used for staff meeting areas. As we are told that this is their Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 21 home. The organisation should consider using the outside flat, which is not being used as a bedroom. Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 22 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): 32,33,34,35,36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the peoples needs and this was evident from the positive relationships, which have been formed to meet their needs. EVIDENCE: The staff recruitment records are kept at the head office but the staff files we wanted to inspect were brought to the home. There was evidence that the home carried out CRB checks, obtained two references, and other pre employment information as required. This was confirmed by talking to a new staff that was recently employed by the home. We were told that the people using the service are involved in the interview process but it was not made clear if any of the people from the home had been involved. Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 23 A new staff spoken to stated that they were given an induction and this consisted of shadowing a member of staff and completing an induction booklet. It was also stated that they were given a job description and understood their role. We were told that the staff did not work on their own until they felt confident. Evidence showed that all new staff was completing the Learning Disability Qualification. The staff working rota was looked at and showed that the staffing hours had increased and the staff spoken to said that they were able to have enough staff on duty to go out with the people in the community. The cooks hours in the home had changed to working as a care staff in the mornings and doing the cooking in the afternoons. We were told that this worked very well and the staff enjoyed this new role. The staff working rota was better recorded with all the staff names and working times of the start and finish time were recorded. The training records inspected and staff spoken to say that they were doing lots of training and every thing was fine working at the home. The AQAA showed that there were 8 out of 15 staff who had NVQ level 2 or above Staff spoken to say that they were now receiving regular supervision and this was recorded in the diary. This was observed and a tick was made when the supervision was carried out. The manager needs to ensure that the staff receives at least six supervisions per year. They also said that they were having team meetings and it was lovely and relaxed to work at the home. They also said that they got more involved in the running of the home. Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 24 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): 37,39,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users benefits from a well run home and the manager is aware of where improvements needs to be made in the home to meet the needs of the people living in the home. EVIDENCE: The information recorded in the AQAA was at times difficult to understand and the information recorded in some sections did not relate to what was being asked for. Also the standards were mixed up for individual sections. In the future ensure that that the AQAA is completed properly and make sure that the information is recorded in detail of the changes that have happened in the Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 25 home. The AQAA states that the manager has 15 years experience of working in Health and Social care settings and has 8 years experience working in a managerial role. They also have a foundation degree in care management, and NVQ level 4 in care. The staff spoken to say that things in the home were much better and they were able to take people out for activities. We were told that the home had a team building day and this was good. At the last inspection the records of regulation 26 visits were not available in the home and one that was found was dated November 06. On this inspection we found that regulation 26 visit were had not been carried out since the last inspection and no reports were available in the home. Ensure that all documents are signed and dated so people know when these were written and by whom. The home must ensure that records such as the OT assessments are available for inspection and kept in the home. All information about the home should be maintained at the home and photocopies should be sent to the office. The medication records are not being fully completed by staff all the times The people’s privacy and dignity is not being maintained because an examination by a health professional was carried out in the communal lounge. The manager told us that questionnaires went out to families but did not know when this happened. We were told that an advocate completed the people’s questionnaires but it was not know when this happened. We were told that the quality assurance manager who is based at the office undertakes the analysis from the information received. The manager was not sure when this was going to be completed but we were told that they were waiting for three questionnaires to be returned from families. The home needs to ensure that all the staff are also asked to give their views of how the home is meeting its aims and objectives by completing the questionnaires. The last fire drill was carried out on the 8/7/08. The time the evacuation took place and the names of people involved needs to be recorded. The home must ensure that all staff are involved in a fire drill practice. The emergency lighting testing was being carried out on a monthly basis but the fire alarm testing was not happening on a weekly basis. The fire officer had visited the home on the 11th of June 08 and three recommendations had been made. Two recommendations were met and one for the fire risk assessment for the premises was being reviewed. We were told that the maintenance man was doing this. The home must cover the radiators in the home to protect the people from hurting themselves. Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 26 Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 27 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 2 2 3 3 X 4 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 3 X Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 28 Yes 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 YA10 Regulation 12-4 Requirement The people’s communal rooms must not be used for meetings when they are in the room to ensure their privacy is respected and confidentiality is maintained of people living in the home. It is required that people are not to be examined in public areas to ensure they can live their lives in a dignified manner. The medication records must be completed in full and comply with the homes medication procedures to ensure the people living in the home are protected Regulation 26 visits must be undertaken to monitor how the home is being managed. All fire escape routes throughout the house must be properly signed in accordance with the Health and safety (Safety Signs and Signals) Regulations 1996. Timescale for action 27/11/08 2 YA18 12(4)(a), 27/10/08 3 YA20 13-2 27/11/08 4 YA39 24(1), (2) &(3) 30/11/08 5 YA42 13 27/11/08 Delos Community Ltd, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 29 6 YA42 13 The radiators in the peoples room and in the communal areas must be covered up to ensure that the people don’t hurt themselves 31/12/08 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, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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, 7 Poplar Street DS0000039660.V373093.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!