CARE HOME ADULTS 18-65
Derwent Cottage 27 Eastgate Seamer Scarborough North Yorkshire YO12 4RB Lead Inspector
Brian Hallgate Unannounced Inspection 11th October 2005 08:20 Derwent Cottage DS0000061996.V254774.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 Derwent Cottage DS0000061996.V254774.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. Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Derwent Cottage Address 27 Eastgate Seamer Scarborough North Yorkshire YO12 4RB 01723 866146 01723 866147 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) Milbury Care Services Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Registered for 4 service users in category LD or LD(E), some or all of whom may also have physical disabilities 7th June 2005 Date of last inspection Brief Description of the Service: Derwent Cottage is a detached house in a small village, approximately five miles from the centre of Scarborough. The home is close to the village centre and amenities. Accommodation and care are provided for up to four people with learning disabilities. One en-suite bedroom, a lounge, dining room and kitchen are at ground level. There are 3 en-suite bedrooms, a shower room and an activity room on the first floor. There is a passenger lift between floors. Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over three and a half hours, including preparation time, and was an unannounced inspection that commenced at 8.20am. A tour of the home was made with a senior support worker and a number of records were inspected. Staff were observed caring for two service users. One service user was still in bed. Four staff were spoken to during the inspection. The key standards not inspected on this occasion were inspected at the last inspection held on the 7th June 2005. What the service does well: What has improved since the last inspection?
Staff spoken to were aware of the complaints procedure and where the book is kept to record any complaints. Some of the staff on duty and some staff appointed since the last inspection have a number of NVQ’s in care at Levels 2, 3 and 4. Staff had undertaken some training and further training was planned with notices on the staff notice board with relevant dates. An application has been received by the Commission for Social Care Inspection from the manager of the home to become the registered manager. Derwent Cottage DS0000061996.V254774.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. Derwent Cottage DS0000061996.V254774.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 Derwent Cottage DS0000061996.V254774.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): None of the above standards were inspected. EVIDENCE: Derwent Cottage DS0000061996.V254774.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): None of the above standards were inspected. EVIDENCE: Derwent Cottage DS0000061996.V254774.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): 12, 13, 15, 16 and 17 Social activities are provided on a regular basis and provide stimulation for the people living in the house. Meals are planned and offer an appropriate diet for the service users. EVIDENCE: Service users take part in social activities at a social club, swimming, walks in the village, drives in the car, aromatherapy, sensory room activities, craft, baking and visits to pubs. All service users are involved in shopping in their local community and a near-by supermarket. The three service users have contact with their families who all visit the home. Service users are also taken by staff to meet their relatives. Staff were observed to address service users appropriately. Senior staff work alongside the support workers and observe their practice on a daily basis. There is a four weekly menu. Alternatives are available and any deviation from the menu is recorded in a separate book specifically for this purpose. The menu and the book were seen. Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were inspected. EVIDENCE: Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home has a satisfactory complaints policy and the complaints book had been used and was examined. EVIDENCE: Staff spoken to knew there was a complaints policy and they were aware of the procedure if a complaint was received. Cards are placed in individual service users files that can be completed if the service users wish to see someone about a concern or complaint. None of the service users are able to complete the cards. Relatives or advocates would need to complete the cards on their behalf. There was one complaint entered in the complaints book since the last inspection. This has been resolved satisfactorily. Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were inspected. EVIDENCE: Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 35 After an initial period of considerable instability in staffing there is now a more experienced staff team with relevant qualifications offering consistency of care within the home. EVIDENCE: Eight members of the staff team have obtained NVQ qualifications at Levels 2, 3 and 4. There was also evidence within the home and from the staff interviewed that they had received training in food hygiene, first aid, infection control, behaviour awareness, introduction to learning disabilities, person centred planning, autism and mental health training. The staff on duty were observed supporting service users. Three staff files were inspected. The necessary documentation was available on staff files with the exception of the date the CRB disclosure was made. Only part of the CRB disclosure forms were forwarded to the home from the Regional or Head Office. It was not possible to check at the inspection if the CRB disclosure had been received before each member of staff had commenced work. The registered person should make arrangements for the necessary information on the CRB disclosure forms to be available for inspection. Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 There was evidence that proper attention is not given to all health and safety issues that promotes a safe and secure environment. EVIDENCE: There was a wooden wedge under the fire door that leads from the kitchen to the hallway. This is a means of escape in the event of a fire. The same door was wedged open at the previous inspection and an immediate requirement notice was issued. A further immediate requirement notice was issued at the time of this inspection. The wedge was removed by a member of staff. A letter was received by the Commission for Social Care Inspection from the Associate Regional Director of Milbury Care dated 30th September 2005 stating that all staff had been instructed not to insert door wedges under fire doors. An application had recently been received from the manager of the home to become the registered manager. The application is being processed. None of the service users are able to verbally express that their views underpin all selfmonitoring, review and development by the home. From observation of the service users, the written records and discussions with the staff on duty it appears that the needs of the service users are being met. In addition to the manager of the home there are two senior support workers. There is usually a
Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 16 member of the senior staff on duty. The manager of the home was on annual leave on the day of the inspection. A senior support worker attended the home after being contacted by a member of staff on duty. Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Derwent Cottage Score x x x x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 1 x DS0000061996.V254774.R01.S.doc Version 5.0 Page 18 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 42 Regulation 23 Requirement The registered person must take adequate precautions against the risk of fire and provide means of escape. Fire doors must not be kept open by unauthorised means. Timescale for action 11/10/05 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 34 Good Practice Recommendations The registered person should arrange for information on CRB disclosure forms to be available for inspection. Derwent Cottage DS0000061996.V254774.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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