Inspection on 06/06/05 for Desboro House

This inspection was carried out on 6th June 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 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

Desboro House 03/10/05

Desboro House 19/02/05

Desboro House 06/05/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Desboro House Main Road Toynton All Saints Lincs PE23 5AE Lead Inspector Sue Hayward Unannounced 6 June 2005 02:00pm 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 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 Stationary 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. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Desboro House Address Main Road Toynton All Saints Lincs PE23 5AE 01790 753049 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Linkage Community Trust Mr Simon Brown Care Home PC 8 Category(ies) of LD Learning disability (8) registration, with number of places Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19th February 2005 Brief Description of the Service: Desboro House is a care home operated by a voluntary organisation, Linkage Community Trust Care Services. The house is a two storey detached property situated in the small village of Toynton-all-Saints, which is approximately a mile and a half from the market town of Spilsby. The home stands in its own spacious grounds and gardens. Access to work, shopping and recreational facilities is via public transport or the homes minibus which is also shared with another home in the group located nearby. The home is registered to provide personal care for up to eight residents with a learning disability. All bedrooms are for single occupancy. The home is part of Linkage Trusts long stay project. The trust also operates a day centre facility at Scremby Grange approximately five and a half miles from Toynton. The residents are able to attend this facility and as part of their personal development, are also involved in community work experience projects. A number of residents are employed part-time and receive therapeutic earnings. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first of two inspections, which are required by law each year. It was unannounced and took place from 14:00 – 17:30. The main method of inspection used was “case tracking”. This involved selecting two residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and the manager of the home (who was present throughout most of the inspection) and observation of care practices. One other resident was spoken to on this occasion. A sample of regulatory records and policies and procedures were seen and a partial tour of the premises took place. This included viewing a sample of three resident’s bedrooms as well as the kitchen, dining area, lounge and activities room. What the service does well: What has improved since the last inspection? There were no requirements or recommendations made at the time of the last inspection. However, since the last inspection the programme to provide guards to radiators is now complete and thermostatic mixer valves have been provided to all wash hand basins to reduce the risk of scalds and burns that could potentially be posed. The maintenance of the home and redecoration is ongoing and residents continue to be consulted about the running of the home. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 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. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 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 standard(s) 2 There are satisfactory procedures in place for residents to be admitted to the home, which ensure that their needs are met. EVIDENCE: No residents have been admitted to the home since the last inspection however there are satisfactory policies and procedures in place in relation to this and discussion with a staff member confirmed that residents and their relatives are able to visit the home prior to deciding to stay. Residents records confirmed that each resident is given a “service user guide” informing them about the home. The previous inspection report of 19th February 2005 made reference to this information being available in various forms including DVD, widget, makaton and audio form should residents need it in these forms. Both residents records seen contained an individual plan of care containing information about their assessed needs and how they were to be met. Care plans are reviewed on a monthly basis. Residents records were noted to contain information from other professionals who had or were assisting to assess on an on-going basis. Risk assessments were also in place. Residents spoken to confirmed that they were aware of and had seen their care plans. All residents spoken to made comments which indicated that they liked living at the home and had the support they needed. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 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 standard(s) 6, 7 and 9 The care planning and risk assessment system in place enables resident’s individual needs and aspirations to be met. This home promotes the independence of residents and they have choices as to their lifestyles. EVIDENCE: Comments from residents indicated that they were involved in the development of their care plans and reviews that are held. Records demonstrated that care plans are evaluated on a monthly basis however there is a more formal review held annually or as needed. A key worker system is in operation giving staff specific responsibilities for specific residents. Residents commented they “liked the staff”. Residents records showed that individual risk assessments are done in relation to any activity that may pose a risk such as using an oven, self-medicating or using public transport. Risk assessments are regularly reviewed. There was discussion with the manager about including additional information in one instance to give a clearer picture of any risks identified. A staff member demonstrated that he had a good knowledge of the needs of residents and of the help and support they required. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 10 Residents made comments, which indicated that they are able to make their own decisions and choices about their preferred lifestyles in this home, such as whether they attend medical appointments on their own or with staff and what activities they choose to do. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12, 13, 14 and 15 The home enables residents to participate in a wide range of activities and leisure interests both within the home and community, which are based on individual preferences. Residents are supported to maintain links with family and friends. EVIDENCE: From discussions with staff and residents and observations made there is a wide range of activities that residents can participate in both within the home and the community. For example a resident was working in the garden on the day of the inspection, another said that they liked to listen to music in the activities room. Residents said that swimming, martial arts and bowling were some of the activities that they could do if they wished. Another resident mentioned that there are work opportunities at Scremby Grange. Staff comments also confirmed that residents have opportunities to gain work experience in the community and that there is a range of opportunities for residents to pursue. A holiday has been arranged to Wales. This had been decided at a resident’s meeting. Residents are also consulted individually as to Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 12 their preferences. Records also confirmed that residents are consulted about trips out and activities. The home shares the use of a minibus with another home in the group that is within the area. Some residents also use public transport. Discussions with staff and residents indicated that visitors are welcome at this home. The staff member spoken to gave a good account of the homes visiting policy, which included checking whether residents wished to see visitors and the identity of any visitor not known to the home. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19 Residents physical, emotional and health care needs are being well met in this home. EVIDENCE: Comments from residents indicated that they felt comfortable to raise any health problems with staff and appointments would be made on their behalf with the relevant health professional such as doctors or dentists. Residents are able to attend appointments in private or staff will accompany them if they prefer. A health action plan was in place on a residents record and information indicated that health is regularly checked and other health professionals involved as needed. A good rapport was noticed between staff and residents on the day and residents made positive comments about the support they received from staff. For example one resident described staff as being “brilliant”. A staff member had a good knowledge of the needs of residents including their healthcare needs and the support they required to keep healthy such as having a healthy diet and taking exercise. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 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 standard(s) 22 Residents are protected by the systems in place, which enable them to make their views known and raise concerns in the knowledge that they will be listened to and action taken to resolve issues. EVIDENCE: There is a complaints policy in place and a record is kept of any complaints or compliments about the service. All residents spoken to knew who to raise concerns with and said they would feel comfortable to do so. One resident gave an example of a matter he had raised and said that it had been dealt with to his satisfaction. A staff member spoken to had a good knowledge of the complaints procedure and how to advise and support residents to raise their concerns. Residents have various means of raising concerns including individually with staff or during weekly house meetings. Records kept of house meetings demonstrated that residents had opportunities to raise any issues. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 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 standard(s) 24 The home is well maintained and provides comfortable and clean and safe accommodation for residents who are involved in the choice of décor and furnishings of the home. EVIDENCE: The home is a domestic type property. Those areas of the home seen included three residents bedrooms, the lounge, kitchen, dining area and games room. The home was clean, tidy and comfortably furnished. Bedrooms reflected resident’s particular tastes and interests. Residents spoken to said that they had choices as to how they were decorated and furnished for example one resident said he had chosen the carpet, another the colour of the paint. All radiators have now been guarded to ensure low surface temperatures and wash hand basins have been fitted with thermostatic mixer valves to regulate water temperatures. There is an ongoing programme of maintenance and redecoration and residents can also be involved in some tasks if they wish to be, for example a resident makes staff aware when light bulbs need changing and residents can Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 16 assist with gardening. Records are kept to demonstrate that maintenance issues are addressed. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35 There is an established team of committed staff who receive regular training to ensure that they have the necessary knowledge and skills to care for service users safely. EVIDENCE: There have been no new staff appointed since the last inspection therefore no records of recruitment were checked on this occasion. A staff member seen however described the recruitment process that he had experienced within the organisation. This included completing an application form, attending an interview, which was conducted by two people, providing two referees and completing a health declaration. He said that the organisation had undertaken a criminals record bureau check. Information provided on the pre-inspection questionnaire also confirmed this. The organisation has an induction and foundation training programme. Discussion with staff and records confirmed that there is a variety of training and one staff member said that since his employment in September 2004 he had attended a lot of training including adult abuse, health and safety, epilepsy, basic food hygiene, manual handling, first aid and fire training. He also confirmed that he had commenced the National Vocational Qualification (NVQ) Level II award. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 18 The manager confirmed that in addition to himself there are two staff members who have achieved NVQ levels II and III. One staff member has achieved level II and two have commenced level II awards. The home has policies and procedures relating to recruitment and an employee handbook. The General Social Care Councils code of conduct was also on display in the home. It was noticed that the policy in relation to staff recruitment needs to be reviewed to incorporate the changes in relation to POVAFirst/CRB checks. Residents spoke positively about their relationships with staff and a good rapport was noticed during the inspection with staff treating residents with respect and in a kind and courteous manner. There is flexibility with staffing arrangements to ensure that residents needs are met, for example additional staff had been rostered on duty to meet the needs of a specific resident. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 42 The home is being well managed. Staff are further supported in their roles from the training that is provided by the organisation, the policies, procedures and record keeping systems in place which all help to ensure the health, safety and welfare of service users living in this home. EVIDENCE: The manager attended for the majority of the inspection. He also manages another home within the same group, which is approximately a mile away. His time is flexibly managed between the two homes. The manager has achieved a National Vocational Qualification award at Level IV and a registered managers award. He has significant experience working in the care profession. Resident’s comments indicated that they were aware of who was in charge and could raise concerns if they had any. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 20 Staff are provided with a range of training which includes training in relation to health and safety matters such as manual handling, First Aid and fire training. All staff follow an induction training programme. Information provided on the pre-inspection questionnaire demonstrated that regular checks on the home environment are done such as servicing of the central heating boiler for example. The organisation has a range of policies and procedures in place relating to health and safety issues. Risk assessments have been recorded in relation to the environment as well as in relation to individuals. Record keeping systems are being well kept. Residents comments indicated that they were satisfied with the care and accommodation that the home provides. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 21 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 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 4 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x x x x x x Standard No 11 12 13 14 15 16 17 x 4 3 3 3 x x Standard No 31 32 33 34 35 36 Score x x x 3 4 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Desboro House Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 22 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 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. 1. Refer to Standard 34 Good Practice Recommendations It is recommended that the procedure in relation to staff recruitment is reviewed to reflect the changes in relation to CRB/Pova First checks that was issued in July 2004. Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unity House, The Point Weaver Road, off Whisby Road Lincs LN8 3YA 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 Desboro House C53 C04 2351 Desboro House V234802 060605 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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