Inspection on 17/02/06 for Derwent House

This inspection was carried out on 17th February 2006.

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 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Derwent House 01/06/07

Derwent House 13/12/06

Derwent House 29/03/05

Derwent House 03/08/04

Derwent House 14/01/04

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

CARE HOME ADULTS 18-65 Derwent House 206/8 Lightwood Road Longton Stoke-on-Trent Staffordshire ST3 4JZ Lead Inspector Dawn Dillion Unannounced Inspection 17th February 2006 09:00 Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 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 House DS0000008222.V284988.R01.S.doc Version 5.1 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 House DS0000008222.V284988.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Derwent House Address 206/8 Lightwood Road Longton Stoke-on-Trent Staffordshire ST3 4JZ 01782 599844 01782 318281 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) Mr Alan John Bradshaw Mrs J Bradshaw Mrs Joy Bradshaw Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2005 Brief Description of the Service: Derwent House is a registered Care Home that provides a service for fourteen adults of both genders who have a learning disability. The home is located in Stoke On Trent, Staffordshire and is accessible via public transport and is in close proximity to local amenities. The property consists of two large mature semi-detached houses. The exterior of the properties remain as two houses, in keeping with the local community. The interior structure had been designed to allow access through both buildings. The home provides ten single occupancy and two shared bedrooms, of which were located on the ground and first floor. There are no passenger lift or specialist aids or adaptations available. Three bedrooms are equipped with an en suite, with the remaining bedrooms having a washbasin. Two toilets are located on the ground floor, one bathroom and a shower room is situated on the first floor. The property also provides a dinning area, a separate lounge, two kitchens and a small laundry. Service users have access to two gardens located at the rear of the property. Limited parking is available at the front of the building. Staffing is provided on a twenty-four basis. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Derwent House was undertaken in five hours. The methodology used to establish the quality of the care and service delivery, involved the examination of records and systems to ascertain the effectiveness of the management of the home. Four service users were interviewed, to develop an overview of their experiences living at Derwent House. What the service does well: What has improved since the last inspection? Discussions with service users confirmed that they have freedom of movement throughout the home and were able to access the kitchen and use the appliances with the supervision of staff. It was pleasing to hear that training with regards to care planning had been arranged for the staff. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 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 House DS0000008222.V284988.R01.S.doc Version 5.1 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 House DS0000008222.V284988.R01.S.doc Version 5.1 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, 3, 4, and 5 The homes admission procedure do not ensure that prospective service users are provided with sufficient information, to enable the individual to establish whether the service and facilities provided, would be suitable to meet their needs. Contracts in relation to the term and condition of residency were not consistently issued to service users. EVIDENCE: The examination of the homes admission process, identified that there were no formal procedure in operation, to ensure that prospective service users or their representative are provided with information relating to the service and facilities provided within the home. A pre admission assessment was not undertaken to establish the homes suitability of meeting the health and physical needs of the prospective service user. Discussions with the Deputy Manager confirmed that the home relied on information obtained from the Social Workers assessment. Prior to admission prospective service users were able to visit the home, having the opportunity of view the premises and to meet the existing service users and the staff team. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 9 Three files pertaining to service users were randomly selected for examination, information contained, provided brief detail in relation to the intervention of specialist health services. Discussions with the service users and the Deputy Manager confirmed that self-advocacy services were not made available. There were no service users in residence from the ethnic minority group or individuals with specific religious needs. There was no evidence that the homes care planning focused on cultural or religious needs. One out of three files examined contained a contract with regards to the terms and condition of residency. It has been identified within the contents of this report, that service users should have the opportunity to access a selfadvocate, when drawing up the contract, to ensure that the individual have a full understanding of information contained, prior to signing the document. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 10 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): 6, 7, 8, 9 and 10 The homes practices and procedures did not incorporate the views or participation of the service users. There was very little emphasis focused on care planning or identifying the support and assistance, the individual required to enable service users to reach their full potential in society. Risk assessments were in place and other information pertaining to service users were located in the office on the third floor and were accessible to the individual. EVIDENCE: As previously identified within the contents of this report, three files pertaining to service users were randomly selected for examination. Two contained a care plan, discussions with the Deputy Manager, raised concerns relating to the lack of knowledge of developing and implementing a care plan. The Deputy Manager informed the Inspector that a number of staff would be undertaking training in care planning. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 11 Information contained within the care plans were very brief, discussions with one service user confirmed that she did not have any involvement in the development of her care plan, she informed the Inspector that “staff write what they like in the care plan”. There was also an inconsistency in ensuring that plans were reviewed every six months, to reflect the changing needs of the individual service user. The format and the layout of care plans did not promote the understanding of the service user group. The Deputy Manager informed the Inspector that the home does not operate a key worker system, although this information was identified within the care plan. Service user meetings were undertaken and records evidenced that the last meeting took place on 10 December 2005. The examination of these minutes raised concerns, relating to confidential items discussed within this meeting, with reference to the individual service users goals and aspirations, of which should be discussed when developing and reviewing service users care plans and risk assessments. There was no evidence that service users were involved in the running of the home or provided with information relating to changes. Risk assessments were in place identifying potential risks/hazards and provided information with regards to control measures. Service users files were maintained within the office located on the third floor, service users informed the Inspector, that they had access to records relating to them. The Deputy Manager informed the Inspector that the office was locked when not in use. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 12 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, 12, 13, 14, 15, 16 and 17 Service users had access to a variety of social activities within the community. There was very limited information to evidence, that service users were provided with the support and assistance to develop and learn new skills within the home. The majority of service users had the capacity to access local colleges independently. Service users were able to continue to maintain contact with her family and friends and to develop new relationships. EVIDENCE: Most of the service users at Derwent House were fairly independence and were able to access leisure services within the community independently. Discussions with four service users identified that they had access to the local college to develop and learn skills. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 13 A number of service users were employed on a voluntary basis, working at Kwick Save, Deaf Club and Brookers Whole Sale. On the day of the inspection one service user who was more dependent, was observed colouring a child’s colouring book. It has been identified within the contents of this report, as a recommendation that the home should encourage and provide activities and pastimes that are more age appropriate, stimulating and are of the choice of the individual service user. Service users informed the Inspector that they had access to services within the community such as swimming, gym, art club, shopping and visiting the local pub. Discussions with the service users confirmed that a number of them were going on an activity holiday in the Lake District, organised by Leek College. The service users also informed the Inspector that they went to France last year, which was organised by the home. With reference to the homes routine, service users informed the Inspector that they were able to retire to bed and awake when they so wished. Discussions with service users relating to politics identified that they were not particularly interested within this subject. All four service users that were interviewed, confirmed that they were registered on the electoral roll and were able to vote at the elections if they wished. General observations identified that service users had freedom of movement throughout the home, of which was confirmed by the service users. Service users informed the Inspector that the staff were respectful and would knock on their bedroom doors before entering. Service users confirmed that their letters were distributed to them unopened, and that staff would assist them with reading if necessary. Interviews with the service users and general observations identified that the service users had developed a positive and friendly relationship between one another. On the day of the inspection one service user had a hospital appointment and another service user went along with her to offer her some support. Service users informed the Inspector that they were able to maintain contact with their family and friends. One service user informed the Inspector he was going to Yorkshire to spend some time with his parents. During the course of the inspection, discussions with another service user identified that she was going out to see her boyfriend. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 14 With reference to meals and mealtimes, the Inspector asked all four service users what was available for lunch that day, non of the service users were aware of what meals were available that day. A hand written menu was located on the notice board of which did not identify an alternative. There was no emphasis focused on ensuring that service users nutritional needs were met or to reflect the individual’s likes or dislikes. Service users informed the Inspector that they were not involved in the purchasing of food provisions and that they eat what was available in the cupboard. Service users informed the Inspector that the staff prepared and cooked the meals and that they were able to help sometimes. One service user informed the Inspector, that she had made a cheese and potato pie and a marmalade tart last week. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 The homes practices, systems and procedures were not proactive in promoting the health and welfare of service users. There was no recorded evidence that service users were provided with the necessary support and assistance, to meet their healthcare needs in relation to routine annual health checks. Medication systems were not robust to ensure the safety of service users. There was no emphasis focused on the future needs of the individual service user in relation to age, illness or disability. EVIDENCE: Discussions with service users and general observations throughout the course of the inspection identified that they were fairly independent requiring minimal support. Care plans were very brief in providing information relating to the support and assistance, the individual required in ensuring and promoting their wellbeing. All service users within residence were mobile and there were no requirements with regards to moving and handling. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 16 Service users were able to choose their own clothing, on the day of the inspection; one service user showed the Inspector some new items of clothing she had brought that day. There were no aids or adaptations within the home; the property would not be suitable for individuals who have a physical disability. Records were maintained of healthcare visits and there was also evidence, that one service user who suffered from epilepsy, had access to a specialist nurse within this area, in view of monitoring the pattern of seizures and to review their medication. The Deputy Manager informed the Inspector that service users, had access to an annual health check; service users records did not substantiate this. With reference to the homes medication system, the Nomad monitored dosage system was used. Records relating to the administration, storage and recording of medicines were examined. The Deputy Manager informed the Inspector that homely remedies were not used, on examination of the medicine cupboard, a number of homely remedies were in storage, paracetmols, and lemsip, cough mixtures and Imodium. The Deputy Manager informed the Inspector that some service users had purchased these items themselves. It was of concerns that homely remedies were being administered, with staff having no knowledge to whether they would have an adverse affect with regards to the individuals prescribed medicines. There were no formal procedures or consistency with regards to the medication system. A number of medicines were not incorporated within the Nomad system. There were no records to evidence that the respective General Practitioner had authorised the use of homely remedies. Medicines and prescribed creams were not all securely maintained, medicines were left on top of a bookshelf and also on top of the medicine cabinet. An immediate requirement was issued on the day of the inspection, with regards to ensuring that all medicines were securely maintained and that authorisation should be obtained from the General Practitioner for the use of homely remedies. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 17 To promote the safety of service users, it has been identified as a requirement within the contents of this report that the registered person should obtain professional advice and support from the dispensing pharmacist, to improved the homes medication system. With reference to aging and death, discussions with the Deputy Manager and the examination of records evidenced, that there was no emphasis focused on the future needs of the individual service user. The Deputy Manager informed the Inspector that Derwent House was a home for life. It is of concern that there were no contingency plans in place with regards to age, frailty, illness or disability. It was evident that the home would not be able to meet the needs of any individuals within this category. No consideration had been given in obtaining service users wishes in the event of their death. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 18 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 homes complaint procedure was not designed in a format to promote the understanding of the service user group or to enable the individual to raise concerns formally. There was a lack of knowledge in relation to the protection of vulnerable adults. EVIDENCE: The homes complaints procedure was located within the lobby; there was also a copy within the policy folder. The design and format of the complaints procedure did not promote the understanding of the service user group. The document identified that the complaint should be put in writing, discussions with a number of service users evidenced, that they would not be able to do this. Service users did not have access to a self-advocate to promote their rights. The complaints policy made reference to the Commission For Social Care Inspection. It has been identified as a recommendation within the contents of this report, that the homes complaints procedure should be reviewed, to ensure that the design and format is more user friendly and promotes the understanding of the service user group. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 19 The Deputy Manager did not have access to files containing evidence of POVA 1st and Criminal Record Bureau checks. Other records pertaining to staff identified that two written references were obtained prior to the offer of appointment. Discussions with the Deputy Manager identified a lack of understanding in relation to the protection of vulnerable adults and No Secrets, the Department of Health Guidance on the protection of vulnerable adults. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 20 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, 27, 28, 29 and 30 The home was reasonably maintained; some areas required decorating to ensure the comfort of service users. There was a lack of emphasis focused on promoting the privacy of service users. There were no systems in operation in relation to infection control. EVIDENCE: Derwent House is located in Stoke On Trent, Staffordshire and is accessible via public transport and is within close proximity to the City Centre. The property consisted of two large mature semi-detached properties, the exterior design had been maintained, to present as two houses in keeping with the local community. In interior structure had been designed to allow access through both buildings. The home provided ten single occupancy and two shared bedrooms located on both the ground and first floor. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 21 Three bedrooms were equipped with an en suite, with the remaining bedrooms having a washbasin. A number of bedrooms and en suite were in need of decorating. Service users bedrooms were equipped with the basis furnishings and efforts had been made to personalise bedrooms to reflect the individual interests. To promote the privacy of service users, the registered person is required to ensure that all bedroom doors are fitted with a locking device, as approved by the Fire Safety Officer, as standard. Privacy screening should also be provided within shared bedrooms. Two toilets were located on the ground floor, one toilet had water damage on the wall and floor and there was no screening provided at the window. One bathroom and a shower room were located on the first floor. The registered person should ensure that appropriate screening is provided at all toilet and bathroom windows to promote the privacy of service users, pattern glazing was not sufficient. To ensure the safety of service users the registered person should ensure that the window located within the bathroom is fitted with restrictors. The property also provided a dinning area, a separate lounge of which was equipped with essential furnishings. Two kitchens and a small laundry were also provided. The corridors were institutional in appearance and the dinning room provided very little home comforts. Service users had access to two gardens located at the rear of the property; both gardens were in need of tidying up and rumble to be removed. The patio area was cracked posing a tripping hazard. Outbuildings contained old equipments and furnishings. The second garden was more pleasant but lacked privacy due to the neighbouring road. There were no aids or adaptations in place; the home would not be suitable for individuals who have a physical disability. With reference to infection control, there were no systems in place, liquid soap and disposal towels were not provided in all communal hand wash areas. Spare toilet tissues were stored on the back of toilet cistern, increasing the spread of germs from splash back from the toilet. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 22 Staff had to transport dirty linen through the kitchen to access the laundry area; there were no evidence of red alginate sacks for the transportation of contaminated linen. There was no protective personal equipment (PPE) within the laundry or any hand wash facility. The cleanliness within the home was of a good standard. There was no evidence of a maintenance programme to ensure that all repairs and decorating are undertaken in a timely manner. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 Staffing was provided on a 24-hour basis to ensure the constant supervision of service users. Staffing levels were sufficient in meeting the needs of the service user group with regards to their dependency level. EVIDENCE: The examination of staff rotas and discussions with the Deputy Manager confirmed that two staff were provided per shift, having one wakeful night staff and one staff member sleeping-in. The Deputy Manager informed the Inspector that there was currently one Care Assistant off sick, hours of which were covered by the existing staff team. There were no catering or domestic staff employed within the home, the Deputy Manager was confident that staffing levels were sufficient to meet the needs of the service user group. As previously identified within the contents of this report service users were fairly independent and the Inspector was satisfied that the current staffing level was appropriate in meeting the needs of the individual service user. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39, and 43 The management approach did not incorporate the National Minimum Standards and there was very little emphasis focused on quality assurance. Policies and procedures were not designed to include the needs of the service user group, in promoting their understanding. There was no evidence of a clear leadership in promoting diversity or a quality service. EVIDENCE: The Registered Manager was not present on the day of inspection, assistance with the facilitation of the inspection was provided by the Deputy Manager in respect of the retrieval of information. The service user group were very independent with some requiring minimal support, service users informed the Inspector that the staff were brilliant and they respected their privacy. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 25 The examination of the service user questionnaire, identified that these were completed on a group, rather than obtaining the views of the individual. It has been identified as a recommendation, that the questionnaire are completed by the individual service user and where necessary service users, should be provided with a self-advocate to provide additional support. Information collated from the questionnaire should be feedback to the service user group. The views from service users families, friends and other outside agencies should also be obtained, to ensure that the service provided is diverse and effective in meeting the needs of the individual service user. With reference to the health, safety and welfare of the service users and the staff group the following were identified. Emergency lighting was last tested on 13/01/06. Fire alarm was last tested on 12/02/06. There was evidence of the undertaking of regular fire drills. There was no fire risk assessment in place, of which has been identified as a requirement within the contents of this report. Water distribution temperatures were identified as 47oC – 48oC. A generic risk assessment was in place dated March 2005. Portable Appliance Testing (PAT) was undertaken 28/08/05. The Inspector raised concerns that the snooker table was obstructing the main fire door. The door closure on one fire door was not operating effectively to provide a seal in the event of a fire. The registered person is required to ensure that all wardrobes are securely secured to walls; on examination of one wardrobe, there was a lot of movement. The old wardrobe located within the lobby should be removed. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 26 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 x 2 1 3 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 3 29 N/A 30 1 STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 1 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 1 1 X 2 2 X X 1 X Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 27 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 YA2 Regulation 14(1)(a) Requirement The registered person should ensure that all prospective service users are subject to a pre admission assessment; to ensure that the home has the capacity to meet the individuals identified care needs. (Outstanding from April 2005) Written confirmation should be given to the prospective service user or their representative, of the homes suitability to meet the individuals identified care needs. The registered person should ensure that all service users are issued with a contract with regards to the terms and condition of residency. The registered person should ensure that a plan of care is in place for all service users. Service users should where possible be involved in their care planning. (Outstanding from 8 August 2005) Timescale for action 01/05/06 2 YA2 14(1)(d) 01/05/06 3 YA5 5(1)(b) 01/05/06 4 YA6 15 & 12(2) 20/05/06 Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 28 5 YA6 12(2)(b) 6 YA17 16(2)(i) 7 YA19 12(1)(a) 8 9 YA20 YA20 13(2) 12(1)(a) 10 YA24 12(4)(a) 11 12 13 14 YA24 YA24 YA27 YA24 YA27YA24 23(2)(b) 12(4)(a) 12(4)(a) 23(2)(b) 15 YA24 13 Care plans should be reviewed on a six monthly basis, to reflect the changing needs of the individual service user. Service users should be provided with a variety of meals to reflect the individuals likes, dislike and to ensure that their nutritional needs are met appropriately in accordance to their plan of care. Service users should be offered an annual health check, information of which should be recorded. All medicines should be securely maintained. Authorisation should be obtained from the respective General Practitioner for the appropriate use of homely remedies. To promote the privacy of the individual, all bedrooms should be fitted with a locking device as approved by the Fire Safety Officer as standard. The identified bedrooms and en suites should be decorated to a suitably standard. Screening should be provided to all bathroom and toilet windows. Dividing screens should be provided in all shared bedrooms. The toilet located on the ground floor identified with water damage, should be decorated to a suitable standard. Window restrictor should be fitted to the identified bathroom window. 20/04/06 01/04/06 01/06/06 17/02/06 17/02/06 01/07/06 01/08/06 20/04/06 20/05/06 20/05/06 28/03/06 Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 29 16 YA24 13 The garden area should be tided 30/05/06 up and rumble should be removed. (Outstanding from 8 August 2005). 17 YA30 18 19 YA30 YA30 20 YA42 21 YA42 22 YA39 Cracked paving stones should be made safe to reduce the risk of tripping. 13 Personal protective equipment (PPE) should be provided in the laundry area. A hand wash facility should also be provided within this area. 13 Red alginate sack should be provided for the transportation of contaminated linen. 13 The practice of storing toilet tissue at the back of the toilet cistern should cease to reduce the risk of germs due to splash back. 13 & A fire risk assessment should be 23(4)(a) development of which should be reviewed on an annual basis or to reflect any structural changes to the building. 13 & The snooker table located by 23(4)(c)(iii) the main fire door should be removed to provide a clear route for escape in the event of a fire. 24 The home quality assurance system should be reviewed to ensure the quality and diversity of the service provided. 13 & 23(4)(a) Repairs to the identified fire door should be undertaken to ensure that the seal is effective in the event of a fire. The old disused wardrobe located within the lobby should be removed. 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 20/05/06 23 YA42 31/03/06 24 YA42 13 31/03/06 Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 30 25 YA20 13(2) 26 YA42 13 With reference to the health and welfare of the service users. Professional advice and support should be obtained from the dispensing pharmacist to improve the homes medication system. In the interest of infection control, the registered person should ensure that liquid soap and disposal towels are provided in all communal hand wash areas. 31/03/06 20/04/06 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 2 3 Refer to Standard YA3 YA11 YA21 Good Practice Recommendations To ensure that service users have access to a selfadvocacy service. With reference to the identified service user, activities provided should be more age appropriate and stimulating. Contingency plans should be put into place in relation to ageing and death, to identify whether Derwent House is a home for life. Service users wishes in the event of their death should be obtained and recorded. Although records identified that staff have received training in relation to the protection of vulnerable adults, the registered person should ensure that all staff are aware of what actions should be taken in the event or suspicion of abuse. The homes complaint policy should be reviewed to ensure that it is designed in a format to promote the understanding of the service user group. A maintenance programme should be developed and implemented to ensure that repairs and decorating is undertaken in a timely manner. 4 YA23 5 6 YA22 YA24 Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 31 7 YA39 The service user questionnaire should be completed by the individual service user and not on collective basis. 8 9 YA17 YA17 Service users should be involved in the choice and purchase of foods. Menus should be available so that service users know what is available and are able to exercise choice. Derwent House DS0000008222.V284988.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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