Inspection on 21/06/05 for Devon Way, 13

This inspection was carried out on 21st 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

Devon Way, 13 08/02/06

Devon Way, 13 25/02/05

Devon Way, 13 24/09/04

Devon Way, 13 01/10/03

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Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Devon Way, 13 Hillingdon Middlesex UB10 0JS Lead Inspector Paula Eaton Unannounced 21 June 2005, 10:00 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. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 13 Devon Way Address Hillingdon, Middlesex UB10 0JS 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) 01895 235432 Life Opportunities Trust Mr John Denman Care Home 3 Category(ies) of Learning Disability (3) registration, with number of places Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25/02/05 Brief Description of the Service: Thirteen Devon Way is a registered care home for three people with learning disabilities. The current service users are all male. The home is operated by the Life Opportunities Trust and was originally registered in 1993. The home gives board and personal care on a twenty four hour basis. The service users accommodation is provided on the ground floor and all the bedrooms are single. There is an office/sleeping in room for staff on the first floor and a garden to the rear of the building with a seating area and lawn. The home is set in a quiet cul-de-sac near to local shops in Hillingdon and Uxbridge town centre. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two and a half hours as part of the annual inspection process. The Registered Manager was not on duty at the time of the inspection so the member of care staff on duty assisted with the inspection process. Two service users were spoken to and records, policies and procedures were examined. What the service does well: What has improved since the last inspection? 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. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 6 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 Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 7 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 appropriate systems in place for the assessment of prospective service users to ensure that their needs can be met by the home. EVIDENCE: The home has appropriate assessment procedures in place for prospective service users. The current service user group have been at the home for several years and the assessment documentation for these service users has been examined at previous inspections. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 8 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 Service users changing needs are not always reflected in their individual plan which could lead to service users needs not being met. Systems are in place to ensure service users are encouraged to make choices and any risks to service users are assessed and monitored. EVIDENCE: All three service users had an individual plan of care in place. These were generally comprehensive documents outlining the service users needs and action to be taken by staff to meet them. The care plans were very detailed, for example in one care plan viewed there was a record that the service user did not like salt and pepper and that he may eat too fast and also that he may use his electric shaver too harshly. However, one service user had broken their ankle and as a result their care needs had changed. The individual care plan for this service user had not been updated to reflect the change in their needs. Daily records are maintained for each service user. There was clear evidence in the service user plans of service users being given choices regarding their day to day lives. Service users were also observed choosing their own breakfast at the time of the inspection. None of the service users in the home are able to manage their own finances. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 9 Individual risk assessments were viewed in the service users records. These included risk assessments relating to travelling and activities such as swimming. These risk assessments had been regularly reviewed. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15, 16 and 17 Service users are offered a wide range of social and leisure activities to meet their individual needs. Systems are in place to encourage and maintain links with family and friends. The meal provision in the home is good and meets the needs of service users. EVIDENCE: None of the service users currently living at the home are able to work. All three service users attend a local day centre four days of the week where they participate in various activities. One service user has been unable to attend the day centre for a couple of months due to his broken ankle so he has been supported in the home during this time. All three service users attend various evening clubs during the week specifically for adults with learning disabilities. The member of staff on duty at the time of the inspection said that service users regularly go out into the community and use local facilities such as shopping centres, local pubs and restaurants and cinemas. The records seen and one of the service users spoken to confirmed this. Two service users had recently been on holiday to Milford-on-Sea for a week, some photographs taken during the holiday were Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 11 seen. The member of staff on duty said that one of the service users enjoys cooking so he is assisted to take part in cooking activities. Service users are encouraged to maintain links with family and friends. The member of staff on duty said that one service user spends every other weekend with his family and one service user has a sister who visits occasionally and telephones regularly. The other service user does not have any family that visit although the staff member said that the home had tried to establish links with family such as nieces and nephews but that this had been unsuccessful. The staff member on duty was observed treating service users respectfully, knocking on doors before entering and encouraging service users to be as independent as possible. Service users are not limited from going anywhere in the home. They are encouraged to assist with small household tasks such as laying the table and clearing away and helping to tidy their bedrooms etc. The home has an appropriate menu in place, this may change depending on what activities the service users are involved in and service users are offered alternatives if they want to have something different from what’s on the menu. Service users assist staff with the food shopping for the home and are encouraged to help at mealtimes. The member of staff on duty said that one service user is encouraged to assist with making his lunch to take to the day centre. There were snacks and drinks available in the home for service users. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 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 standard(s) 18, 19 and 20 Systems are in place to ensure service users health needs are met and service users are provided with appropriate support. Procedures for the administration and storage of medication ensure the safety of service users. EVIDENCE: At the time of the inspection the member of staff on duty was assisting a service user with personal care. This was being carried out in a way that respected the privacy and dignity of the service user whilst ensuring that the service user maintained a level of independence. Service users health care needs are assessed and recorded in their individual plans. Health care appointments are recorded and health checks take place as required. One service user as discussed earlier had broken his ankle and he was due to have his cast removed the following day. Although it was evident that this service users health care needs were being met records relating to this need to be updated. None of the service users at the home are able to self medicate. Since the last inspection the medication cabinet had been changed to ensure that medication is stored at the correct temperature. All medication was stored correctly and the medication administration record sheets were up to date and had been fully completed. The receipt and disposal of medication was appropriately Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 13 recorded and a local pharmacist visits regularly to audit the medication systems in the home. It was noted that an incident form had been completed regarding a medication error where a service user was not given his morning medication. This incident had been dealt with appropriately however it had not been reported to the CSCI as required under regulation 37 of the Care Homes Regulations. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 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 and 23 Satisfactory systems are in place to ensure that concerns about the service are listened to and responded to and to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The home has an appropriate complaints procedure in place that clearly states how someone can make a complaint about the service. This is also produced in a suitable format for service users who have a learning disability. The complaints record was viewed and there had been no complaints since the last inspection. The home has satisfactory policies and procedures in place for the protection of vulnerable adults. There have been no allegations of abuse at the home. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 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 and 30 Service users live in a homely, comfortable and safe environment and the home is clean and hygienic. EVIDENCE: The service is provided in a very clean and comfortable environment. The furnishings are very domestic in character and the environment is very homely. The home has been maintained to a high standard. There were no maintenance issues in the home at the time of the inspection. All areas of the home are accessible to service users. There were no outstanding LFEPA or Environmental Health requirements. The home records any maintenance issues and when action to remedy these is taken. The home has appropriate laundry facilities in place and infection control polices and procedures are in place. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the outcomes for the above standards were assessed during this inspection so a judgement about them could not be reached. Staffing will be addressed at the next statutory inspection. EVIDENCE: Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 17 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) 41 and 42 The homes recording systems are generally satisfactory. The home protects the health and safety and welfare of service users. EVIDENCE: Records in the home are generally kept up to date and in order. However, as mentioned earlier in this report service user plans must be updated as required as well as information regarding health care needs. Also regulation 37 reports must be forwarded to the CSCI following any notifiable incident. Health and safety maintenance and servicing records were viewed. All gas and electrical equipment was being tested as required. Fire safety equipment was being regularly tested and regular fire drills were taking place. There was also an up to date fire risk assessment in place. A health and safety audit of the home had taken place in April 2005. Work practice risk assessments were in place for risks such as the management of challenging behaviour and lone working and appropriate procedures were in place for accident reporting. Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 18 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Devon Way, 13 Score 3 2 3 x Standard No 37 38 39 40 41 42 43 Score x x x x 2 3 x G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 19 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. 2. 3. Standard 6 19 41 Regulation 15(2)(b) 17(3)(a) Schedule 3(3)(m) 37(1)(e) Requirement Service user plans must be updated and reviewed as service users needs change. Service user records must contain up to date infromation regarding any health care needs. The CSCI must be notified of any event in the care home which adversely affects the well-being or safety of any service user. Timescale for action 1/08/05 1/08/05 21/06/05 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 Good Practice Recommendations Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST 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 Devon Way, 13 G61-G10 s27088 Devon Way v214902 210605 Stage 4.doc Version 1.30 Page 21 - 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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