Inspection on 08/02/06 for Devon Way, 13

This inspection was carried out on 8th February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Devon Way, 13 21/06/05

Devon Way, 13 25/02/05

Devon Way, 13 24/09/04

Devon Way, 13 01/10/03

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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 Ged Durkin Unannounced Inspection 5:20 8 February 2006 th Devon Way, 13 DS0000027088.V270636.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 Devon Way, 13 DS0000027088.V270636.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. Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Devon Way, 13 Address Hillingdon Middlesex UB10 0JS 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) 01895 235432 devon1@lifeopportunitiestrust.co.uk Life Opportunities Trust Mr John Denman Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate LD service users with a Physical Disability. Date of last inspection 21st June 2005 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 DS0000027088.V270636.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 5:20 and 7:35 pm. The Inspector had tried to inspect the home the previous evening but no body had been in. As a result the Inspector telephoned the home the following afternoon to ascertain whether staff and service users were there. On confirmation there were people in the home the Inspector confirmed he would be visiting and arrived at the home 45 minutes later. The Inspector saw and spoke with all three service users, met with the staff member on duty, had a tour of the premises and examined a number of policies and procedures. 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 DS0000027088.V270636.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 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 the following standard(s): The key standard had been inspected at the previous inspection and was not inspected on this occasion. EVIDENCE: Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 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 the following standard(s): 6 and 9. Service users have their needs assessed in a detailed and comprehensive care plan format, which is subject to regular review. Appropriate risk assessments are undertaken on a number of activities that form part of an independent life style. EVIDENCE: The Inspector examined all three service user’s care plans. Each was a comprehensive document that detailed all of the service users needs and identified priority action plans to meet specific areas of need. Each action plan showed evidence of recent review. The home has a key worker system and staff on duty write a daily record on each service user. The placing authority on an annual basis reviews all the service user’s placements. All the service users have risk assessments, all of which had been reviewed in the past year. One service user was observed to make himself a cup of tea in the kitchen with staff supervision, but there was evidence of any risk assessment having been undertaken for such an activity. Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 Page 9 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): 16 and 17 Service user’s rights are respected on an ongoing basis as well as through formal reviewing processes. Service users are also encouraged to participate in domestic activities as part of the responsibilities of communal living. Service users have meals that they enjoy in a homely and domestic setting. EVIDENCE: The home have regular meetings that are opportunities for staff to inform service users about forthcoming events, changes to the staff team and to check with service users their wishes about items such as menus or planned holidays. Staff are also aware of service user’s likes and dislikes and ensure that these are recognised on an ongoing basis. Service users are also encouraged to undertake simple domestic tasks as part of communal living. Staff cook all the meals in the home for the service users. Service users were witnessed having their supper, which they appeared to enjoy. Menus are organised on a four weekly basis. There was plenty of food in the home that included fresh fruit and vegetables. Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 Page 10 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 and 20 Service users receive personal support and have any health care needs met in a manner sensitive to their well being. Medication is administered in a safe and appropriate manner. EVIDENCE: The staff member on duty spoken to by the Inspector was able to detail the individual arrangements that service users received their personal care. Some needed more direct input than others but all need supervision. All efforts are made to enable service users have as much choice and control in the manner in which personal care is given. All the service users were appropriately dressed and well groomed. All the service users are registered with the same GP practice. Apart from one long standing condition, under control by medication for one service user, none of the service users have any other health concerns that need particular attention. The home uses a Nomad medication system, which is securely stored in a purpose built cupboard. The Inspector examined all the medication administration sheets, which were complete, but the Inspector noted that correction fluid had been used, which is not good practice. Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home makes real efforts to ensure that service user’s views are listened to and acted upon. The home has systems in place to ensure that service users are protected and kept safe. EVIDENCE: The home has regular meetings with service users that service users have the opportunity to make their views known. The staff member on duty told the Inspector that although two of the service users are not particularly verbally communicative they were able to make their opinions known about topics that interested them e.g. food choices and planned outings. There have been no complaints about the home since the last inspection. The homes complaints procedure was displayed prominently. The staff member on duty indicated a good awareness of adult protection and was able to demonstrate to the Inspector what he would do in the event of him witnessing any form of abuse. Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 Page 12 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, 25, 27, 29 and 30. The service users live in a comfortable, clean, well decorated home with an appropriate bathroom and toilet and personalised bedrooms. EVIDENCE: The home is comfortable and well decorated. The furnishings and furniture are all to a satisfactory standard. All the service users have bedrooms that have a good level of personalisation. The bathroom and toilet in the home was functional and afforded all necessary privacy. The home has all the necessary specialist equipment needed for the service users that include a ramp and railings at the entrance and grab rails around the toilet. On the day of the inspection the home was clean and tidy. The home has no dedicated cleaning staff, instead care staff undertake all the necessary cleaning duties. Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 Page 13 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 and 35 Service users benefit from the home having an effective and appropriately trained staff team. EVIDENCE: The home has four full time staff with access to the company resource of bank staff to cover for sickness and annual leave. The rota is organised so as to try and ensure that two staff work together for at least part of most days of the week. There is one sleep in staff at night. The morning period can be busy when all the service users are having to be got ready to go to day centres. The Registered Manager is currently also involved with over seeing another care home, which does not currently have a manager. The member of staff on duty was able to inform the Inspector about the amount of training that he had received so far, which included non violent intervention and epilepsy training. Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 Page 14 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 and 42 Service users benefit from a well run home with a good regard for health and safety. EVIDENCE: It was evident from the inspection process there was a good emphasis on communication and documentation which indicated that the home was well run and organised. The home has undertaken a recent health and safety audit and has work based risk assessments in place. A check of records indicated that there were no on going health and safety issues. Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 Page 15 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 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 x 3 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Devon Way, 13 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x DS0000027088.V270636.R01.S.doc Version 5.0 Page 16 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4)(c) Requirement There must be risk assessments for any activities that service users undertake as part of an independent life style. Timescale for action 28/03/06 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. Refer to Standard YA20 Good Practice Recommendations Correction fluid should not be used on medication administration sheets. Devon Way, 13 DS0000027088.V270636.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection West London Area Office 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 DS0000027088.V270636.R01.S.doc Version 5.0 Page 18 - 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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