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Inspection on 23/09/05 for Delrose House Ltd

Also see our care home review for Delrose House Ltd for more information

This inspection was carried out on 23rd September 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 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

The premises were new build within an existing house in Ilford. All fittings, and furnishings were new, including equipment. All bedrooms were en-suite and the kitchen was newly fitted. The home has a clean slate on which to build a delivery of service, with new staff team, new policies and procedures and appropriate service users.

What has improved since the last inspection?

This is the first inspection since the home was registered.

What the care home could do better:

This was the first inspection. It was identified during the inspection that the home had a number of duplicate policies and procedures, some of which were repetitive which could cause confusion. The deputy manager acknowledged this and was in the process of filtering out the policies and procedures that will not be used, leaving only those that will be used at the home. The home will need to ensure their recruitment procedures are strictly adhered to, for example proof of identity must be clear.

CARE HOME ADULTS 18-65 Delrose House Ltd Delrose House Ltd 23 The Drive Ilford Essex IG1 3EZ Lead Inspector Mrs Denyse Lillington Unannounced Inspection 23 September 2005 10:00 Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 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 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) Delrose House Ltd Kulvinder Kaur Swalli Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the first inspection since registration was approved. Brief Description of the Service: The home is a residential home for 6 adults with learning disabilities, providing a 24 hour service with waking night staff. The home has been registered since 29/6/05, and has had one service user for an overnight stay since that date. The providers are hoping to admit service users within a short period of time now that they are open. There is a registered manager in post and a deputy manager. The manager of the home was not working at the home at the time of inspection but the deputy manager was available throughout the inspection and had the day to day responsibility at the time of inspection. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home is in a central position, close to Ilford town centre and local bus routes. The home had just opened for business when the inspector carried out the inspection and there had been one service user staying overnight, the night prior to the inspection. The proprietor met with the inspector and the deputy manager was available throughout the inspection. The policies and procedures at the home were being fine tuned by the deputy manager, who had the time to do this whilst organising prospective service user visits and stays. There are a number of different policies and procedures, which had been put together by various managers prior to registration and since registration. What the service does well: What has improved since the last inspection? This is the first inspection since the home was registered. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Prospective service users have the opportunity to ‘test drive’ the home prior to admission. The home were able to offer an assessment process and admission criteria which would ensure the needs of service users are met. EVIDENCE: At the time of inspection a prospective service user was waiting to be escorted from the home after an overnight stay. The service user had spent a day at the home the previous week to the inspection and had spent a night at the home the night prior to the inspection. This was part of a trial ‘test drive’ for the service user. The service user told the inspector that they had enjoyed their stay and had a ‘good nights sleep’. The Service user said the staff were really nice and the home was very nice. The service user’s file showed detailed assessments carried out by professionals able to do so. The deputy manager at Delrose House had completed an assessment of need, which was comprehensive. The home has a care plan format which details a pen picture of the service user and then more detail about mental and physical needs, personal care, domestic home life, work/social activities, relationships, culture and religion, risk assessments and more. Both assessments and care plans to be used at the home had space for regular reviews to be undertaken and recorded accordingly. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9. Service users are supported to take risks as part of an independent lifestyle. The assessment and care planning process were in place to record specific risk needs. EVIDENCE: The one service user file available at the home evidenced clear abilities and limitations for the safety of the service user, which provided guidance for the expectations of the home. The statement of purpose sets out in the admission criteria, the needs that can be met, including area’s of risk and the support which can be offered. Areas of risk identified, such as road safety were clear in the assessment provided. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13 and 16 . The registered persons demonstrate that they have the ability, through their policies and procedures, to promote personal development, that service users will be able to take part in the local community and that service users rights are respected. EVIDENCE: The statement of purpose philosophy of care discusses promoting a positive image for people with learning disabilities. The statement of purpose says, ‘We believe that service users must be involved in all aspects of their care and they will be encouraged to work with their key workers to make individualised care plans, with goals that are both realistic and achievable in order to facilitate their development and realise their full potential’. The statement of purpose also says that Delrose House are committed to: ‘actively promoting each person’s participation in an ordinary lifestyle’ ‘support people to access the community facilities’, Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 11 ‘have positive expectations by stressing each person’s achievements and strengths without losing sight of their disability and individual needs’, ‘support service users in attending religious services and cultural events that are important to them’. When the home is next inspected these values can be measured. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19. Delrose House has the potential to provide service users with the personal support in the way they prefer and meet service users physical and emotional health needs. EVIDENCE: The care plan format seen on the day of inspection had a section for medication and a separate medication policy. The care plan had sections for the emotional and physical needs of the service user as well as personal care needs and social needs. The deputy manager said that when service users are admitted, there are a number of GP services available in the local area and the home would check which GP surgery would be prepared to take on new patients. Likewise, a service user would be supported to register with an optician of their choice, a dentist etc. Service users would have access to all health care services, for example hospital care. Service users will be supported to attend appointments and escorted where needed. Alternative therapists will be included if the service users prefer. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 13 The policies and procedures did not include a formalised method of the process of registering service users with local services. The statement of purpose aims to ‘provide quality personal care that respects their dignity’. The assessment seen by the inspector for the prospective service user had clear detailed information about the service users health and personal care needs and how they could be met. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home were able to demonstrate their intention to protect service users and that service user views will be listened to and acted on. EVIDENCE: The home had a clear and effective complaints procedure in place at the time of inspection. The complaints procedure was discussed in the statement of purpose and how service users would be protected. Details of the Commission were included in the complaints procedure and timescales for dealing with complaints were given in the policy. The complaint procedure can be presented to a service user in appropriate format and language depending on the need. This is something that can be developed in the future by the home and checked at inspections. All complaints would be responded to within 28 days. Service users can make a complaint one-to-one with a member of staff or use an independent advocate where requested. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Delrose House was able to provide a clean, hygienic, comfortable and safe environment. EVIDENCE: The home had been recently registered. All required environment standards had been met. The home was clean and hygienic. There was COSHH facilities in a separate utility room, the equipment and furnishings were all new, the flooring and coverings were all new. The entire building was newly maintained, decorated and furnished. The décor was homely and modern. There was sufficient heating, lighting and ventilation throughout. The home was situated near to Ilford town centre, rail station and local bus routes. The premises was checked by the fire safety department in January 2004 and the recommendations made were in place at the time of inspection. The deputy manager said that the environmental health department had been notified and informed of their opening. Some areas of the home required safety signs to prevent potential accidents, such a ‘mind the step’ signs. This was discussed at the inspection. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34. Service users will be protected by the home’s recruitment policies and procedures, however, stringent checks will need to be improved. The confusion of more than one policy will also need to be addressed as recommended in this report. EVIDENCE: The home operate with the Croner consulting guide to management. This document has the recruitment policy that the home follow. This policy did not echo the national minimum standard and Regulations for two written references to be obtained. There was a support worker employed at the home at the time of the inspection as well as the deputy manager. Her file was checked and there was only one written reference obtained and only one referee given on the application form. However, in another recruitment policy also used by the home a requirement to obtain two references was detailed, but it did not specify if the references had to be written or verbal. The deputy manager had all the required documentation in the file held at the home but the copy of the passport picture of the deputy manager was indecipherable. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 17 Requirements have been made in this report for the home to operate a thorough recruitment procedure, this will include two written references and a clear recent photograph of the individual. All staff employed had a returned enhanced CRB check, which were held on file at the home. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 . The registered manager of Delrose House was not present for the inspection. There was a manager job description and the manager has been newly registered by the Commission and therefore had the required experience and qualification to run the home. The home were able to demonstrate that they operated safe working practices. EVIDENCE: The registered manager had her file held at the home, which was checked during inspection and contained the required information. The manager was due to enrol for the Registered Managers Award. The deputy manager who was available throughout the inspection, had been working at the home and was in the process of sorting out the policies and procedures. It was unclear when the manager would be taking over at the home as there were no permanent service users living at the home. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 19 The inspector checked the health and safety manual held at the home. This manual contained information regarding risk assessment, manual handling, protective equipment, drug handling and fire safety. Certificates for gas safety, electrical installation, portable electrical appliance testing were readily available for inspection. The premises had a keypad entry system, an alarm system and CCTV installed outside the building. Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 X 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Delrose House Ltd Score 3 2 X x Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 x DS0000063030.V253137.R01.S.doc Version 5.0 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 16 Requirement Some areas of the home are required to have safety signs to prevent potential accidents, such a ‘mind the step’ signs over the patio doors and at the top of the cellar door. The home must operate a thorough recruitment procedure, which must include two written references for potential employees and proof of identity, including a clear recent photograph of the individual. Timescale for action 23/12/05 2 YA34 7,9,18,19 10/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA19 Good Practice Recommendations The policies and procedures should include a formalised method of the process of registering service users with local services Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Delrose House Ltd DS0000063030.V253137.R01.S.doc Version 5.0 Page 23 - 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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