Inspection on 15/10/07 for Delrose House Ltd

This inspection was carried out on 15th October 2007.

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

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

Other inspections for this house

Delrose House Ltd 13/07/06

Delrose House Ltd 23/09/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Delrose House Ltd Delrose House Ltd 23 The Drive Ilford Essex IG1 3EZ Lead Inspector Mrs Sandra Parnell-Hopkinson Unannounced Inspection 15th October 2007 10:00 Delrose House Ltd DS0000063030.V353055.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 Delrose House Ltd DS0000063030.V353055.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. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Delrose House Ltd Address Delrose House Ltd 23 The Drive Ilford Essex IG1 3EZ 020 8518 0926 020 8518 0925 info@delrosehouse.co.uk www.delrosehouse.co.uk Delrose House Ltd 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) Andrew Paul Hayes Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD 2. Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 6 13th July 2006 Date of last inspection Brief Description of the Service: The home is a residential home for 6 adults with learning disabilities and/or associated mental health problems, providing a 24 hour service with waking night staff. The home is situated off The Drive, Ilford within the London Borough of Redbridge and is within easy access of shops and bus routes. All bedrooms are single and spacious each with an en suite, and two bedrooms have an en suite shower. There is a large lounge/dining area and a spacious kitchen/diner on the ground floor and a small smoking room on the first floor. All rooms are furnished and decorated to a good standard. There is disabled access to the front of the home. Access to the rear garden is from the lounge/dining room or from the utility room. The rear garden has a patio with a small lawn area and flower beds which are well maintained. Seating for residents to enjoy the garden is available. At the time of this inspection the fees ranged from £750 for mental health, £1047 for learning disabilities and dual diagnosis. These are the minimum fees and will vary in accordance with the assessment of need. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection which took place on the 15th October, 2007 from 11.30 a.m. The manager and the responsible individual were both present throughout the inspection. Questionnaires were sent out to residents, staff and relatives and 2 questionnaires were returned by relatives, 4 by staff but none from residents. However, on the day of the inspection the inspector was able to speak to all of the residents and staff members who were on duty. Telephone calls have also been made to several social workers to gain their views on the service. The inspection visit included talking to residents and staff, a tour of the premises, viewing maintenance records, staff files, training schedules, medication records and case tracking. Additional information relevant to this inspection has been gained from the Annual Quality Assurance Assessment (AQAA), monthly Regulation 26 reports and Regulation 37 notifications. The inspector had a discussion with both the manager and the responsible individual on the broad spectrum of equality and diversity issues, and both were able to demonstrate a good understanding of the varied needs around religion, sexuality, culture, disability and gender. People using this service were asked how they wished to be referred to in this report, and told the inspector that they would like to be called ‘service users’. What the service does well: The Annual Quality Assurance Assessment indicated that pre-admission assessments are comprehensive, and that prospective service users are enabled to visit the home prior to making a decision to move in. As part of the process of enabling service users to make the right choice for them, prospective service users are encouraged to have introductory visits accompanied by people they choose to support them in making decisions about their care. They are also encouraged to have an overnight stay and a longer trial period before making a final decision to move in. This was evidenced through the case tracking process, talking to a service user and a social worker. All service users have a comprehensive care plan together with any necessary risk assessments, and strategies are compiled with the service user, relatives if appropriate, the manager and other professionals. Service users are supported to remain as independent as is possible within a risk management framework, and are encouraged to participate in community activities. Service users are supported in maintaining strong links with family and friends. Encouragement is given so that service users take some responsibility for their Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 6 healthcare and they are supported in this and also in making and attending appointments. In talking to residents, one told the inspector “I like living here, and the manager is really nice.” Recruitment processes are robust and the management ensures that all prospective members of staff complete an application form, undertake an interview, provide two written references, proof of identity and a criminal records bureau disclosure is applied for, together with a check under POVA (protection of vulnerable adults) prior to employment. What has improved since the last inspection? What they could do better: Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 7 As identified in the AQAA, the service must continue to explore ways of ensuring that service users have even greater involvement in their individual care plans. The management to continue to explore the introduction of an easily understandable glossary of contract terms for service users, and to continue to explore different community based activities for the benefit of service users. The service will continue to improve energy efficiency and will be installing low-energy lights where appropriate. 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. Delrose House Ltd DS0000063030.V353055.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 Delrose House Ltd DS0000063030.V353055.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 and 5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. All prospective service users have an individual needs assessment, are given the opportunity to visit the home and are provided with a written contract or statement of terms and conditions, so that they are able to make an informed choice about where to live. EVIDENCE: The files of 3 service users were viewed and all showed evidence of a comprehensive pre-admission assessment, pre-admission visits to the home and a statement of terms and conditions. The management has invested a lot of time in ensuring that the contracts and statements of terms and conditions are in line with the guidance provided by the Office of Fair Trading, and have now produced a plain English version which benefits some of the service users who may have limited reading skills. The manager is working on a glossary of contract terms which he will produce in plain English, again for the benefit of the service users. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 10 Trial visits to the home are encouraged so that prospective service users can make an informed choice on where to live. The AQAA (Annual Quality Assurance Assessment) indicates that the manager is aware that there needs to be better recording of introductory visits to the home made by prospective service users and their supporters. The statement of purpose sets out the admission criteria, the needs that can be met and the support that can be offered. The service user guide has been produced in an easy to read format, with pictures, for those people with a learning disability and work has been done to provide other information, including menus, in easy to read formats for the service users at Delrose House. Delrose House Ltd DS0000063030.V353055.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, 8 and 9 People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Service users are very involved in the ongoing development of their care plan, and the management and staff ensure that service users are in control of their lives and that they direct the service. Service users are consulted on, and are encouraged to participate in all aspects of life in the home. The risk management framework enables service users to take risks as part of an independent lifestyle. EVIDENCE: Currently there are five service users accommodated at Delrose House, and 3 of these were case tracked. All of the files inspected showed clear evidence of a comprehensive assessment of need, and personal goals for each had been reflected in their individual care plan. There was evidence on the files that the service users had been involved in the development of the care plan, and this was confirmed in a discussion with one of the service users. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 12 Through training staff have developed the skills to support, engage and encourage the individual service user to be fully involved in their care. When necessary one to one support is given, and the care plans are up to date so that all staff are aware of the current needs and wishes of the individual service users. From viewing the records, observation, discussions with the manager, staff and some service users, it was evident that the service adopts a positive attitude to care and risks are managed in a way that enables service users to lead the life they want. Obviously there are some limitations on freedom and choice, identified through a risk management process and in consultation with the individual service user and health professionals. These are always in the best interests of the individual, are fully documented and reviewed on a regular basis and discussed and agreed with the service user. An example of this is around the right of a service user to manage his own finances in accordance with his wishes. Whilst the manager has reservations about this, this was discussed thoroughly with the service user, social worker and the consultant within the framework of the Mental Capacity Act 2005, and it has been mutually agreed that the individual can manage his own finances. This will be monitored and is being kept under review. Regular meetings are held with the service users to consult them on how the service runs, and they are able to influence decisions in the home. A service user was involved in the development of the revised care plan format, so that this is now clearer and easier to read. During the inspection several of the service users returned to the home on their own having after going out for shopping, a walk or other community activities. The inspector was told by one of the service users “I like living here, everyone is nice and I can come and go provided I let someone know where I am going. Another service user needed support when leaving the home due to identified risks around road safety, and this was very clearly documented within his care plan. During discussions with the manager and the responsible individual, it was clear that sexuality had been addressed in the care plans, together with other areas of equality and diversity such as religion, culture and diet. Robust emergency systems are now in place, together with the ability to employ additional staff if needed for emergencies or if a service user required support when leaving the home. Delrose House Ltd DS0000063030.V353055.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): 11, 12, 13, 15, 16 and 17 People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Service users are able to take part in age, peer and culturally appropriate activities, are part of the local community and are encouraged to maintain appropriate relationships with family and friends which is to the benefit of all parties. Service users’ rights are respected and responsibilities recognised in their daily lives. A healthy diet is offered so that service users can enjoy meals and be assured that their dietary and nutritional needs are being met and monitored. EVIDENCE: From talking to several of the service users, to staff and from viewing records, it was evident that the home’s aims and objectives are to ensure the promotion of the individual’s right to live an ordinary and meaningful life within the home, and as part of the general community with all the rights and Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 14 responsibilities of citizenship. The manager is very aware of the importance of enabling service users to achieve their goals, pursue their interests and participate in community life in a way required by the individual. One service user who has a brain injury has been enabled to attend Headway, which is specifically for people with a brain injury. This was the result of much negotiation by the manager with the funding authority, because it was felt to be in the best interests of the service user. Another service user attends an adult education centre and is doing creative writing. Another service user is being encouraged and supported to find out about employment opportunities. Due to mobility difficulties, the manager has been proactive in enabling a service user to obtain a motorised scooter. This has meant some changes to the environment so that the scooter can be recharged when necessary, and the management has worked with the service user to ensure that this has happened. All service users have a key to their own bedrooms, and it was apparent that their privacy is respected by all staff. During a tour of the home, it was observed that staff always knocked on bedroom doors and waited for a service user to respond before entering. Routines within the home are very flexible, are service user focused and can be quickly changed to meet an individual’s changing needs, choices and wishes. All service users are encouraged and supported to be independent and involved in all areas of daily living in the home. This includes being involved in areas such as shopping, meal planning and preparation and household chores such as cleaning and washing up and laundry. Menus were viewed, including the kitchen cupboards and refrigerators, and it was evident that the food provided was nutritional and catered for varying dietary needs of the service users. Plenty of fresh fruit and vegetables are always available. Service users can make drinks or snacks at any time. From talking to several service users, and from viewing documentation, it was also evident that individuals are supported in developing maintaining family and personal relationships. Birthdays and other festivals are celebrated in the home, and family and friends are always invited and made welcome. One relative commented “my son has his own phone. At the moment the home seems to help my son be a happier person, and he seems to be well fed.” Where applicable, service users have a freedom pass or a blue badge (to enable the person to park in a bay for people with a disability). In view of the frequent theft of the blue badges, the management has provided the service user with the mobility scooter with a security holder which can be fixed to the steering wheel of any vehicle he is travelling in. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 15 As identified in the AQAA the manager will be ensuring that all service users are registered to vote. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 16 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 and 21. People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Service users can be sure that they will receive personal support in accordance with their wishes. Their physical, emotional and health care needs will be met by the involvement of themselves and that of the appropriate professionals where necessary. Service users will be encouraged to retain, administer and control their own medication within the protection of a risk assessment framework, staff training and the home’s medication policies and procedures. When necessary, service users can be assured that the ageing process, illness or death will be handled with care and respect and in accordance with the wishes of the individual. EVIDENCE: From viewing the care plans, talking to service users and staff it was evident that individuals receive effective personal and healthcare support using a person centred approach. As the current service users have either mental health problems, a learning disability or a dual diagnosis, staff have received training in all three areas and the manager has a registered nursing qualification in mental health, a degree in psychology which included Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 17 management and counselling modules, a post graduate module in neuropsychology and an ENB 998 (teaching and assessment in clinical practice). In discussions with some staff it was evident that they are very aware that they manner in which support is given is of great importance to the service user. They ensure that care is in accordance with the wishes of the individual, is flexible, consistent and is able to meet the changing needs of the service users. If personal care is required, then the service user’s choice of either a male or female care worker is respected. It was evident from viewing the files, and from talking to some service users, that they are encouraged and supported to manage their own healthcare in all aspects. One service user who requires monthly blood monitoring due to medication, visits the clinic unaccompanied. Another service user is being encouraged and supported to take eventual responsibility for his own administration of medication through a planned programme of gradual responsibility. Other service users are very involved in various programmes to monitor various aspects of their behaviour. All service users are registered with a GP of their choice, and have regular check ups, and all have access to National Health Service facilities including dentist, optician and chiropodist. The manager views all appointments made for service users as important with the necessary systems being in place to ensure that such appointments are kept by the individual. Several of the current service users are on Section 117 discharge, and regular reviews within the CPA (care programme approach) are held with the service user and the relevant health professionals. Comprehensive reports are compiled by the manager, with the involvement of the individual. As evidenced from case tracking, the weights of all of the service users are monitored monthly and any concerns are addressed immediately with the service user, with appropriate referrals being made to either a dietician or nutritionist where necessary. It has been possible to speak to several healthcare professionals, and all were complimentary about the care being delivered at the home. One healthcare professional told the inspector “my client has made really good progress whilst living at Delrose House. The manager and staff appear to be very supportive and on the ball.” Through observation, the inspector was pleased to note that there was a good relationship between staff and the service users. Staff appeared to be very alert to changes in behaviour and the general well-being of the service users, and were able to respond appropriately. Medication records (MAR) were inspected and were found to be in good order. Since the last inspection the management has developed a more detailed selfDelrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 18 medication policy, as the aim for all of the service users is for them to eventually be able to manage their own medication. However, this may not be possible for some service users. The management has a very good relationship with the local pharmacist, and the manage is planning to ask service users if they would like the pharmacist to attend one of their meetings to discuss issues relating to medication. Several of the service users currently smoke, but it was evident from the care plans that the manager and staff are endeavouring to work with these service users to support them in giving up smoking. Notices on ‘stopping smoking’ are displayed in the smoking room on the first floor. Within the revised care plan documentation is an area for the inclusion of end of life issues. These issues are gradually being introduced and discussed with the individual service user, at a pace and time determined by him/her. End of life issues are also discussed with staff who would have continuous support and opportunities to discuss any areas of anxiety and concern. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 19 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 and 23 People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Service users are assured that their views are listened to and acted upon, and that they are protected from abuse, neglect and self-harm through a robust recruitment procedure, policies and procedures and staff training. EVIDENCE: From viewing the complaints record it was evident that the manager and staff are aware of the importance of listening to service users, and taking their views seriously. Concerns and complaints are promptly dealt with and are viewed in a positive manner so that the service can be improved for the benefit of the service users. A simplified copy of the complaints procedure is made available to all of the service users within the service users’ guide, and a copy is also available within the home for visitors. The inspector asked several service users if they were not happy would they know how to complain? One service user told the inspector “I would complain to him, (pointing at the manager), because he listens to me.” Another service user told the inspector “I like it here and don’t have any complaints, but if I did I would tell Andy.” Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 20 Staff were able to demonstrate an awareness of safeguarding adults; they have received training and were au fait with the policies and procedures of the service. Because of concerns around a possible abusive financial situation with a service user and people external to the service, the manager made a referral to the local authority’s safeguarding adults team. This resulted in meetings with the service user, health and social care professionals and the manager of the home. A conclusion has been reached which is in accordance with the wishes and choices of the service user, and within the framework of the Mental Capacity Act 2005. The situation will be monitored by concerned and interested parties. Where possible service users manage their own finances independently but with support where necessary, and all have their own bank accounts. Staff demonstrated an understanding of restraint and the alternatives to its use in any form are always looked for. Training has been given in dealing with challenging behaviour to all members of staff. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 21 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, 25 and 30 People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment which encourages independence. EVIDENCE: A tour of the home was undertaken and all areas were found to be clean, hygienic and well maintained. All of the bedrooms are for single occupancy and have either an en suite toilet/handbasin or shower, toilet/handbasin. The communal toilets and bathroom/showers provide sufficient privacy to meet the individual needs of all of the service users. Provision has now been made for the storage and recharging of a service user’s electric mobility scooter. Bedrooms have been decorated and furnished to a good standard, but it was evident in talking to service users, and in viewing several bedrooms, that they Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 22 are encouraged to personalise their rooms in accordance with their own wishes and choices. All service users have a key to their own bedrooms. In view of the newly introduced legislation around smoking, a small communal room on the first floor has been designated as a smoking room with the necessary external window being in place together with an extractor fan. The room is in accordance with the legislative requirements. There is a large lounge/dining room which is well furnished and decorated and a new flat screen television has recently been purchased for the benefit of the service users. Also to assist some of the service users in adopting more consistent practices in hand hygiene, a small handbasin has been installed at the dining room end of the lounge/dining room. Whilst this may not be aesthetically pleasing, it has been beneficial for some of the service users. Service users view the home as their own and it has very good access to community facilities and services including transport links to other areas. The kitchen is large and can also be used as a dining area. The kitchen was clean and well maintained and a recent visit by the local authority’s environmental health officer confirmed that the facilities were kept to an excellent standard. The management has now adopted an environmental policy. As a result of this water butts, other water saving devices, light sensors and composters have been introduced. The home also received an award from the London Borough of Redbridge for recycling. The service is now looking at improving energy efficiency. There is now a fire risk assessment in place in line with new fire regulations introduced in October, 2006 and all deficiencies identified at the previous inspection have been addressed. There is disabled access to the front of the building and to the rear garden which is well maintained with a patio area, lawn and flower beds. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Service users are supported by staff who have, and are receiving training and regular supervision. Recruitment procedures are robust in accordance with the Regulations and staff have a job description and employment contract. EVIDENCE: Staff files were inspected and all were found to be in good order with the required two references, application form, interview notes, criminal records bureau disclosure, copy of employment contract and supervision contract. All members of staff are given a copy of the General Social Care Council’s code of conduct, and for staff who have English as a second language such information has been made available to them in their mother tongue as well as in English. The manager and the responsible individual recognise the importance of having an effective recruitment procedure to ensure that good quality services are being delivered. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 24 In discussions with some staff and from returned questionnaires, it was evident that ongoing training is available, and recently staff have undertaken training in dealing with challenging behaviour, medication administration, moving & handling, food hygiene, first aid, mental health certificate level 2, Mental Capacity Act 2005 and safeguarding adults. The service uses both internal and external trainers, and is now able to access ‘Train to Gain’ and EU (European Union) funding for training through membership of the Redbridge Learning Collaborative. New staff have to complete the common induction standards. Current staff have attained or are undertaking a qualification at NVQ level 2 and the manager has nearly completed the Registered Manager’s Award. From observation and from discussions with some service users, it was apparent that staff promote a war and homely atmosphere. Staff are very respectful of the rights and privacy of the individual service users. Rotas showed that there are always sufficient numbers of staff on duty to ensure that the needs of the service users can be met. Supervision is being undertaken by all staff with the appropriate records being retained on file. Supervision is now in place for the manager. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 25 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, 38, 39 and 42. People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Service users are assured that the management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a competent manager and organisation. EVIDENCE: The manager has a registered nursing qualification in mental health, a degree in psychology which included management and counselling modules, a post graduate module in neuro-psychology and an ENB 998 (teaching and assessment in clinical practice). Currently the manager, as an additional qualification, is in the final stages of completing the Registered Manager’s Award. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 26 Both the manager and the responsible individual were able to demonstrate a sound knowledge of both strategic and financial planning and how these dovetailed into the operational and business plans for the service. According to the AQAA (Annual Quality Assurance Assessment), the service offers value for money by providing the best quality of care and support for service users and through the maintenance of a pleasant and homely environment without compromising on standards for the sake of economy. This was demonstrated during the inspection and through discussions and other feedback from service users, relatives, staff and healthcare professionals. One service users who was on an initial six-month placement has had his placement made permanent at the request of the service user and his social worker. Letters were seen from consultants, social workers and relatives which all complimented the service being delivered. Due to the effective management of the service, there is good staff retention and all full-time staff are working towards nationally recognised qualifications in health and social care. Currently all of the service users enjoy good mental health and have not had any relapses, or needed to be admitted to hospital since living at Delrose House. It was apparent that a clear vision of the home, based on the values of the service, is communicated to service users, visitors and staff. The company’s assessment procedure uses validated tools such as HONOS (Health of the National Outcome Scales), and only service users are admitted whose needs can be met. This is supported by the fact that the service has taken some time to fill beds, in spite of referrals being made. The management and staff were able to demonstrate an effective understanding of the broad range of equality and diversity issues. Staff from differing ethnic minorities spoke very positively about the support and training being given by the management. Policies and procedures are regularly reviewed and updated in line with changes in legislation or other identified good practice information. Service users have access to their records whenever they wish, and the home has efficient systems to ensure the effective safeguarding and management of an individual’s money where this is required. However, wherever possible service users are supported and encouraged to take control of their own finances. Appropriate insurance cover is in place and all maintenance records such as regular checking of fire alarms, water, gas and electrical appliances and services were viewed and in good order. Systems are in place to regularly Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 27 review and update health and safety systems in line with experiences within the home and external developments. The responsible individual undertakes the monthly quality visits required under Regulation 26 of the Care Home Regulations 2001, and a copy of these reports continue to be sent to the Commission to inform the inspection process. Where necessary, the manager sends notifications under Regulation 37 of the Care Home Regulations 2001 to the Commission. Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 28 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 3 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 4 ENVIRONMENT Standard No Score 24 4 25 3 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 3 4 X LIFESTYLES Standard No Score 11 4 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 4 4 3 X X 4 X Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Delrose House Ltd DS0000063030.V353055.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Delrose House Ltd DS0000063030.V353055.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. 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