Inspection on 03/11/05 for Don View

This inspection was carried out on 3rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Don View 12/11/08

Don View 30/11/07

Don View 19/01/07

Don View 01/11/05

Don View 24/08/05

Don View 07/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

Care Home For Adults (Mixed Category) Don View 22 Thellusson Avenue Scawsby Doncaster South Yorkshire DN5 8QN Unannounced Inspection 3rd November 2004 Commission for Social Care Inspection Launched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role. Inspection Methods & Findings SECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Don View Address 22 Thellusson Avenue, Scawsby, Doncaster, South Yorkshire, DN5 8QN Email address bron.sanders@doncaster.gov.uk Name of registered provider(s)/company (if applicable) Doncaster Metropolitan Borough Council Name of registered manager (if applicable) Gareth Anthony Bishop Type of registration Care Home No. of places registered (if applicable) 25 Tel No: 01302 785257 Fax No: 01302 789457 Category(ies) of registration, with (number of places) Learning disability (25) Registration number J070000077 Date first registered 1st April 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection Date of latest registration certificate 8th September 2004 YES NO 07/07/04 If Yes refer to Part C Don View Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 3 3rd November 2004 09:00 am Ian Hall ID Code 074214 Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspection Mr G Bishop Mr T Naylor Don View Page 2 CONTENTS Introduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Adults (18 - 65) & Older People 1. Choice of Home Adults (18 - 65) & Section 1.Older People 2. Individual Needs and Choices Adults (18 - 65) & Section2. 7.1 – 7.6 Health and Personal Care Older People 3. Lifestyle Adults (18 - 65) & Section 3. Daily Life and Social Activities Older People 4. Personal and Healthcare support Adults (18 - 65) & Section 2. 8.1 – 11.12 Older People 5. Concerns, Complaints and Protection Adults (18 - 65) & Section 4. Older People 6. Environment Adults (18 - 65) * Section 5. Older People 7. Staffing Adults (18 - 65) & Section 6. Older People 8. Conduct Management of the Home Adults (18 - 65) & Section 7. Older People Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s Agreement Don View Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care inspection (CSCI), is subject to inspection, to establish if the establishment/agency is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Don View. The inspection findings relate to the National Minimum Standards (NMS) for Adults (18 – 65) and Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • • • • • • • • Inspection methods used Key findings and evidence Overall ratings in relation to the standards Compliance with the Regulations Required actions on the part of the provider Recommended good practice Summary of the findings Provider’s response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates. Don View Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Don View is a Care home providing personal care and accommodation for up to 25 persons who are aged over 50 with a learning disability. The home is owned by Doncaster Metropolitan District Council and is located in the small community of Scawsby located approximately four miles from Doncaster. It is easily accessed from the M18, and there is a frequent bus service stopping near to the home. The home was purpose built in the late sixties and consists of a two-storey building. There is a passenger lift. All residents are accommodated in single bedrooms that are located on the ground and first floor levels. The home is situated in a residential area and well integrated within the local community. There is a day care facility sited within the home on the ground floor. The home is set within its own grounds with large gardens. There are limited car parking spaces however unrestricted on street parking is available. Don View Page 5 PART A SUMMARY OF INSPECTION FINDINGS INSPECTOR’S SUMMARY (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Minimum Standards. Some standards that have been inspected were covered twice during the inspection year 2004/2005, which is considered good practice, and consistent with a professional approach to regulation. Choice of Home The 5 standards assessed were met The home’s statements of purpose and service user guide meet the required standard. The home’s manager or his deputy are involved in all admissions and conduct a pre-admission assessment to ensure that their care needs can be met. Whenever possible the prospective service user visits and spends time at the home before making a decision to live there. Individual Needs and choices The 5 standards assessed were met. The care staff have worked hard to ensure provision of a good standard of record keeping is both provided and maintained as required by the Care Standards Act 2000 Lifestyle The 7 standards assessed were met Service users spoken to confirmed that staff were very supportive and helped them to exercise their own choice. The only limiting factor being availability of staff. The needs of the service user group continue to change due to the ageing process and the limits it has imposed upon individuals. This unannounced inspection for the year 2004/2005 has looked at a range of the National Complaints Concerns and Protection The 2 standards assessed were met No concerns or complaints have been notified to the CSCI. The home operates the DMBC policy for receiving and dealing with complaints and Adult Protection. Personal and Healthcare Support The 4 standards assessed were met SERVICE USERS CONFIRMED THAT STAFF SUPPORT AND HELP THEM TO MAINTAIN THEIR INDIVIDUAL HEALTH AND LIFE CHOICES. Don View Page 6 Environment The 8 standards assessed were met There has been a substantial investment in the fabric of the home throughout this inspection year. A schedule of works has been submitted and various items remain for attention within this financial year. The windows and porch at the home have been replaced. Many service user bedrooms have been re carpeted and decorated. Additional works radiator guards and additional electric sockets centre light fittings and soft furnishings have been renewed/replaced. Dining room light fittings and décor has been renewed. Communal day areas are being refurbished with new armchairs, carpeting, soft furnishings and décor. Staff have purchased a “set top box” for service users to enjoy an increased range of TV programmes. Service users were enthusiastic and confirmed the pleasure they had received from this. The patio and barbeque area were being re-laid with new paving stones on the day of inspection; a new handrail and paths are also being provided. Additional car parking has been provided with work surfacing paths, fence repair and general gardening making an immediate an obvious improvement to the home. The laundry/sluice area has been upgraded. Service users and staff spoken to were very pleased that their environment had been improved. Staffing (Standards 31-30) 6 of the 7 standards assessed were met. The required staffing levels were maintained by the home .NVQ training was in progress. Staff files were unavailable for inspection as they were kept at DMBC offices. Supervision took place at the required intervals. Conduct and Management (Standards 37-44) 7 of the 8 standards assessed were met Staff said the manager was approachable and the home had an open environment. Audit systems were in place. Regulation 26 visits took place. The manager is currently in the process of completing his NVQ 4 additional modules to achieve his Manager’s Award. This unannounced inspection took place on 4th November 2004. It found that many of the National Minimum Standards had been met, with active steps being taken to address the areas identified for improvement as agreed within the action plan. The service users expressed satisfaction with the care they were receiving however the common concern that they raised was that staff time was limited. They were therefore unable to fully exercise their choice to visit places or take part in activities outside the home. The overall quality of care was good. Staff clearly demonstrated their interest and motivation in both maintaining and further improving the standard and service provided at Don View. Don View Page 7 Requirements from last Inspection visit fully actioned? If No please list below YES Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Met (Yes / No) YES Don View Page 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office. STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard * 1 1 OP28 OP31 A minimum of 50 of staff achieve NVQ level 2 by 2005 The registered manager to complete his NVQ 4 modules to achieve the registered managers award. * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. MX10 refers to Standard 10. Don View Page 9 PART B INSPECTION METHODS & FINDINGS The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other (Specify) ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Relatives/significant others survey/feedback Service user survey Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES YES YES NA YES NA YES YES YES YES YES NA YES YES NA YES 15 2 X YES YES YES YES 9 X 03/11/04 08.30 7.75 Don View Page 10 As this establishment accommodates residents who are both over and under 65 years, the report format reflects the likely differing needs by drawing together the National Minimum Standards for Care Homes for Older People and for Adults (18 –65). Both sets of Standards are broadly similar, but where there are differences these have been highlighted in italics. The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls) 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable. Don View Page 11 Choice of Home The intended outcomes for the following set of standards are: • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations • Prospective service users have an opportunity to visit and to ‘test drive’ the home. This process will also involve the service user’s relatives and friends. Each service user has an individual written Contract or statement of terms and conditions with the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. • • Standard 1 (1.1 – 1.4) Y.A & Standard 1 (1.1 – 1.3) O.P The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides prospective and current service users with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2 (Y.A), 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10 (O.P): a summary of this information appears in the home’s service user’s guide. Range of fees charged From (£) 490.00 To (£) 490.00 Any charges for extras YES CHIROPODY, PAPERS TOILETRIES If yes please state what the extras are: 3 Key findings/Evidence Standard met? The home has compiled a detailed user-friendly statement of purpose and service user guide. Both documents are freely available and accessible for service users and their advocates. Don View Page 12 Standard 2 (2.1 – 2.8) Y.A. & Standard 3 (3.1 – 3.5) O.P. New service users are admitted only on the basis of a full assessment undertaken by people competent/trained to do so, involving the prospective service user, his/her representatives (if any) and relevant professionals using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? Records examined demonstrated that the manager and his staff are involved fully in assessment of the individual before admission to the home. Visits to the prospective service user are undertaken whenever practicable. Assessment documents produced by other professionals such as social workers are obtained on individual case files. Standard 3 (3.1 - 3.10) Y.A. & Standard 4 (4.1 – 4.4) O.P. The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The manager and his team are proactive and ensure that the individual’s physical, social and psychological care needs. Specialist health care workers assessment/involvement is sought as required prior to admission. Standard 4 (4.1 – 4.5) Y.A. & Standard 5 (5.1 – 5.3) O.P. The registered manager invites prospective service users to visit the home and to move in on a trial basis, before they and/or their representatives make a decision to move there, and unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? All service users residence is subject to a trial period. Individual service users visit the home often for a number of occasions to enable them to form an opinion whether they wish to live there unless he/she is unable to do so. Standard 5 (5.1 – 5.5) Y.A. & Standard 2 (2.1 – 2.2) O.P. The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Contracts stating terms and condition are provided for each service user and /or their advocate. Don View Page 13 Standard 6 (6.1 – 6.5) O.P. Where service users are admitted only for intermediate care, dedicated accommodation is provided, together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This service is not provided. Don View Page 14 Individual Needs and Choices • • • • • 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. Standard 6 (6.1 – 6.10) Y.A. The registered manager develops and agrees with each service user an individual Plan generated from a comprehensive assessment, which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Overall the standard of individual care assessment of care and planning was of a high standard. It reflected both the service users aspirations and needs. A variety of assessment tools are used to gather and record information. Service users are involved whenever possible and their input obtained and recorded. Standard 7 (7.1 – 7.7) Y.A. & O.P. general good practice Staff respect service user’s right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The documentation and practice were observed to work for the service users. Service users rights and choice are the central focus of the care plans. Risk assessments are in place to enable and facilitate service users to exercise choice and self-determination. Standard 8 (8.1 – 8.5) Y.A. specific & O.P general good practice The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard Met? Service users are encouraged participate in their meetings and express their individual views and make suggestions about the home. A number of service users made their thoughts and wishes clearly understood throughout the day of inspection. Don View Page 15 Standard 9 (9.1 – 9.4) Y.A. Specific & O.P general good practice Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Service users rights and choice are the central focus of the care plans, this was observed clearly in practice on the day of inspection. Risk assessments are in place to enable and facilitate service users to exercise their right to “take risks” Standard 10 (10.1 – 10.6) Y.A. & Standards 36 & 37 O.P. Staff respect information given by service users in confidence, and handle information about service users, in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? The DMBC policies and procedures for maintaining confidentiality and data protection are available and utilised by the home’s staff. Staff spoken to clearly appreciated the need and value of confidentiality. Don View Page 16 Lifestyle • • • • • • • 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. Standard 11 (11.1 – 11.4) Y.A. specific & O.P. general good practice Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? The service users are encouraged to access day centres and work placements as they are able. A number of service users visit local public houses or the shops, this is limited by staff numbers on occasion. Service users rights and choice are the central focus of the care plans. Risk assessments are in place to enable and facilitate service users to exercise choice and self-determination. Standard 12 (12.1 – 12.6) Y.A. specific & O.P. general good practice Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Structured opportunities are provided for all service users who wish and are able to attend placements that meet their individual needs. Some activities are provided within the building with service users attending the day centre located on site. Standard 13 (13.1 – 13.5) Y.A. & Standard 13 (13.1 – 13.6) O.P. Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans and service users’ preferences. 3 Key findings/Evidence Standard met? Testimony from both staff and service users demonstrated that there are wide range of social opportunities are encouraged by care staff. Only the numbers of staff on duty limits staff level of support for the group. Don View Page 17 Standard 14 (14.1 – 14.6) Y.A. & Standard 12 (12.1 – 14.6) O.P. Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Service users visit a range of leisure facilities of their choice. This may be to a local public house or for a meal. Opportunities exist for service users to interact with service users from other homes/placements. These may be in single or group visits. Standard 15 (15.1 – 15.5) Y.A. & Standard 13 (13.1 – 13.6) O.P. Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary) service users are able to have visitors at any reasonable time. 3 Key findings/Evidence Standard met? A limited number of service users have family visitors. Some service users visit relatives homes and they visit the home. Should anyone not have next of kin advocacy services are available. Visitors are welcomed at any reasonable hour Standard 16 (16.1 – 16.11) Y.A. & Standard 14 (14.1 – 14.5) O.P. The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? There are few restrictions at the home. Care plans demonstrate plans and efforts by staff to foster independence for the service user group. Don View Page 18 Standard 17 (17.1 – 17.9) Y.A. & Standard 15 (15.1 – 15.9) O.P. The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The meal served was nutritious and attractively presented. Staff asked service users about the size of portion they would like. Records of food provided for each service user were maintained, with each person being encouraged to make their choice from the menu each day. There was a list of birthdays and residents personal preferences available. The menu demonstrated both choice and variety. Fresh meat, fruit, vegetables and adequate stocks of foodstuffs were available. The cook was aware of and provided for special diets. The mealtime observed was unhurried and service users were given sufficient time to eat. Staff were observed to be assisting residents with their dietary intake. All staff working in the kitchen had relevant food handling qualifications and experience. Service users said they could have a drink or snack whenever they wanted. Visitors to the day centre had their midday meal at Don View. Service users at the home appeared to be happy with this arrangement and had made many friends amongst the visitors. Don View Page 19 Personal and Healthcare support • • • • 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. Standard 18 (18.1 – 18.11) Y.A. & Standard 10 (10.1 – 10.7) O.P. Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives with particular regard to personal care giving social contact and consultation. 3 Key findings/Evidence Standard met? Individual care plans reflect service users preferences. They have been compiled with the service user whenever possible and reflect their choices of rising and retirement times, meals, sense of dress, bathing and individual activities. Standard 19 (19.1 – 19.5) Y.A. & Standard 8 (8.1 – 8.13) O.P. The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 2 X 3 Key findings/Evidence Standard met? Care staff assists service users to access medical care and treatment. Some service users require support when receiving treatment or at consultation, staff accompany and provide advocacy whenever needed. Staff was able to describe and illustrate their advocacy role in conversation with the inspector. Don View Page 20 Standard 20 (20.1 – 20.14) Y.A. & Standard 9 (9.1 – 9.11) O.P. The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines 3 Key findings/Evidence Standard met? Locked facilities exist for service users to store their personal medicines. There is a policy for self -administration for persons able to manage their own medicines. The ordering, storage administration and return of medicines was in accordance with the home’s policies and procedures. Records were maintained satisfactorily. Service users visit the medicines administration area to receive their prescribed medicines. Standard 21 (21.1 –21.8) Y.A. & Standard 11 (11.1 – 11.12) O.P. The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Staff have received additional training and preparation to assist with last offices. They demonstrated their knowledge of their role. They were able to recall previous experiences and how they had supported service users and their next of kin Don View Page 21 Concerns, Complaints and Protection The intended outcomes for the following set of standards are: • • • Service users and their relatives and friends feel their views and their complaints are listened to and acted on. Service users are protected from abuse, neglect and self-harm. Service users’ legal rights are protected. Standard 22 (22.1 – 22.7) Y.A. & Standard 16 (16.1 – 16.4) O.P. The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and times-scales, for the process, and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The home has adopted the Local Authority policies and procedures for responding to and managing complaints. The policy and information for service users and others is displayed. There is a book to record any concerns expressed however minor they may appear. Don View Page 22 Standard 23 (23.1 – 23. 6) Y.A. & Standard 18 (18.1 – 18.6) O.P. The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. Standard 17 (17.1 – 17.3) O.P. specific Y.A. general good practice Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POCA/ POVA lists YES X 3 Key findings/Evidence Standard met? The home has adopted the Local Authority policies and procedures for adult protection. Staff had received training in recognition, prevention and actions to be taken should abuse be witnessed or suspected. Staff were clearly aware of the special needs and vulnerability of their service user group. Don View Page 23 Environment The intended outcomes for the following set of standards are: Service users live in a homely, comfortable and safe environment with indoor and outdoor communal facilities. • Service users’ bedrooms suit their needs and lifestyles are safe, comfortable with their own possessions around them. • 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 pleasant and hygienic. Standard 24 (24.1 – 24.13) Y.P. & Standard 22 (22.1 – 22.8) O.P. The home’s premises are suitable for its stated purpose; accessible, safe and wellmaintained; meets service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The ground and first floor areas are easily accessible. A passenger lift provides access to the first floor. A wing containing private bedrooms is only accessible via a small flight of stairs; physically able service users only are resident in that area. The services of occupational therapists and physiotherapists are utilised to advise if additional aids or adaptations are required. The homes owner has submitted an action plan for works and improvements to the home. Extensive works and improvements have been undertaken throughout the last year. Additional car parking, new patio area have been completed. New double glazed windows have been provided throughout the home. Redecoration and re-carpeting of single rooms and communal areas have been and continue to be ongoing. • Don View Page 24 Standard 25 (25.1 – 25.8) Y.A. & Standard 23 (23.1 – 23.10) O.P. The registered person provides each service user with a bedroom which has useable floor space sufficient to meet individual needs and lifestyles which meets minimum space as follows: Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of rooms accommodating wheelchair users with at least 12sq.m of space Total number of rooms accommodating wheelchair users with less than 12sq.m of space Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 25 X X X 25 X X X X X 3 Key findings/Evidence Standard met? The survey of the home during 2002 for the NCSC identified that adequate facilities and dayspace were provided at the home. Don View Page 25 Standard 26 (26.1 – 26.4) Y.A. & Standard 24 (24.1 – 24.8) O.P. The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? A number of service users had personalised their rooms with memorabilia and special keepsakes. Service users were happy with the range of furnishings provided, additional items would be provided as they wish. Some service users had bought items of furniture and had electrical items for their personal use, radio, TV and video players etc. Service users choose colour schemes as rooms are decorated. Standard 27 (27.1 – 27.6) Y.A. & Standard 21 (21.1 – 21.9) O.P. The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? Toilet facilities are lockable and contained all the basic facilities and aids, they would however benefit from a “softening” of the room with curtaining, pictures etc. These areas are planned for upgrading as part of the homes ongoing maintenance programme. Standard 28 (28.1 – 28.3) Y.A. & Standard 20 (20.1 – 20.7) O.P. A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? There is a range of day and dining room facilities. Service users, who wish to enjoy a cigarette, the other areas being smoke free, use one lounge. One lounge has been provided with additional TV channels facility following staff fund raising actions. The main dining room was being redecorated with domestic lighting being provided on the day of inspection. Standard 29 (29.1 – 29.8) Y.A. & Standard 22 (22.1 – 22.8) O.P. The registered person ensures the provision of the environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? Adequate and suitable environmental adaptations for specific service user needs have been made. The manager keeps this provision under review. Don View Page 26 Standard 30 (30.1 – 30.9) Y.A. & Standard 26 (26.1 – 26.9) O.P. The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home was well presented being both clean and fresh smelling. The homes owner has redecorated and re carpeted a number of bedrooms and areas of the home. There is an ongoing plan to continue this process. The laundry and sluice area although combined has been redecorated and a risk assessment undertaken. The home has a policy for prevention and control of infection. Staff were observed to wear the provided protection appropriately. Standard 25 (25.1 – 25.8) O.P. specific & Y.A. general good practice The heating, lighting, water supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? The home’s owner is reviewing and amending lighting provision in individual rooms as part of the ongoing refurbishment programme. Individual bedroom heating control review and change was in progress. Don View Page 27 Staffing The intended outcomes for the following set of standards are: • • • • • • Service users benefit from clarity of staff roles and responsibilities. Y.A. specific & O.P. advice Competent and qualified staff supports Service users. An effective staff team supports Service users with appropriate numbers and skill mix. Service users are supported and protected by the home’s recruitment policy and practices. Appropriately trained staff meets Service users’ individual and joint needs. Service users benefit from well-supported and supervised staff. Y.A. specific & O.P. advice. Standard 31 (31.1 – 31.7) Y.A. specific & O.P. general good practice The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 3 Key findings/Evidence Standard met? All staff are issued with local authority job descriptions, they have access to information / other workers job descriptions. Standard 32 (32.1 – 32.6) Y.A. & Standard 27 (27.1 – 27.7) O.P. Staff have the competencies and qualities required to meet service user’s needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The manager stated that all staff received induction training within six weeks, and that the induction programme had been revised to include N.T.O. workforce training targets. Staff have individual training needs plans. Supervision took place at the required frequency and is recorded. Staff meetings took place on a regular basis (monthly or more frequently). Three staff have achieved LDAF competence with a further 4 working through this valuable and specific training programme. Don View Page 28 Standard 28 (28.1 – 28.3) O.P. specific A minimum ratio of 50 trained members of staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 4 25 2 Key findings/Evidence Standard met? Staff at the home continues to work positively to achieve their NVQ’s in care. The manager is confident that 7 additional staff will undertake and complete their training and assessment for NVQ. Don View Page 29 Standard 33 (33.1 – 33.11) Y.A. specific & O.P. general good practice The home has an effective staff team, with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs Total No. of staff hours required No. of staff with NVQ level 2 or above X X X 7 X No. staff hours allocated No. staff hours allocated Total No. of staff hours provided X X X X X No. of trainees registered on Sector Skills Council training programme No. of staff with nursing qualifications (where applicable) X 3 Key findings/Evidence Standard met? The required levels of staff were on duty at the home on the day of the inspection. The staff duty rota corresponded to the members of staff on duty. The carer in charge of the home had telephone access for advice and support from senior management at all times. The Inspector observed staff/resident interactions that were conducted appropriately and with empathy. Domestic staff was employed by the home.. Staff also said that the home had been short staffed but the situation had improved. The manager confirmed this and said the staff team was stable; a number of staff had worked at the home for several years. The home had a key worker system that worked well. Staff were at least 18 years of age and those in charge at least 21 years. Standard 34 (34.1 – 34. 8) Y.A. & Standard 29 (29.1 – 29.6) O.P. The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The home utilises the local authority (DMBC) recruitment process and human resources department. The process is reported to be slow and unwieldy with long periods elapsing before references and statutory checks being completed. Don View Page 30 Standard 35 (35.1 - 35.8) Y.A. & Standard 30 (30.1 – 30.4) O.P. The registered person ensures that there is a staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Staff were able to access the DMBC training programme which provides a wide range of training opportunities with the additional benefit of meeting staff from other homes and sharing experiences. Standard 36 (36.1 – 36.8) Y.A specific & O.P. general good practice Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? The manager stated that individual plans to identify staff training needs were undertaken. Supervision took place at the required frequency and was recorded; staff meetings took place on a regular basis (monthly or more frequently). Don View Page 31 Conduct and Management of the Home The intended outcomes for the following set of standards are: • 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. Standard 37 (37.1 – 37.4) Y.A. & Standard 31 (31.1 – 31.8) O.P. The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent? NO 2 Key findings/Evidence Standard met? The manager has completed his registration as manager. He has the HNC in Management Studies and considerable experience in a variety of management roles and the client group. He is currently undertaking NVQ assessment to achieve the registered manager’s award. Standard 38 (38.1 – 38.6) Y.A. & Standard 32 (32.1 – 32.7) O.P. The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The staff spoken to said that the manager was approachable and that the home had an open and friendly atmosphere. They felt confident in expressing their views and were clear on the lines of accountability and management structure within the home. Standard 39 (39.1 – 39. 10) Y.A. & Standard 33 (33.1 – 33.10) O.P. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The home undertook in-house audits of documentation and the home’s environment including the kitchen. The views of service users were ascertained through advocates. The manager confirmed that regulation 26 visits took place and that copies of reports were sent to the CSCI. Don View Page 32 Standards 40 (40.1 – 40. 6) Y.A. specific The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The manager reported no change in the file Standard 41 (41.1 – 41. 3) Y.A. & Standard 37 (37.1 – 37.3 ) O.P. Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? The inspector checked a sample of the records that the home was required to keep. These were appropriately completed and kept securely. Standard 42 (42.1 – 42 . 9) Y.A. & Standard 38 (38.1 – 38.9) O.P. The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The home had a health and safety policy. Risk assessments are in place. Staff interviewed confirmed they had had mandatory training in fire prevention, food hygiene, moving and handling, first aid and health and safety. No fire exits were blocked and fire doors closed on their rebates. Risk assessments were in place and notifiable incidents had been reported. Standard 43 (43.1 – 43. 7) Y.A. & Standard 34 (34.1 – 34.5) O.P. The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met? The manager stated that DMBC had a general financial plan for Don View, and that he kept accounts of expenditure within the home. Don View Page 33 Standard 35 (35.1 – 35.6) O.P. Specific The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X 3 Key findings/Evidence Standard met? Service users have their individual bank accounts with small amounts of personal monies being kept for service users at the home. Families and appointees manage financial affairs for service users requiring support. Don View Page 34 PART C (where applicable) COMPLIANCE WITH CONDITIONS Condition Comments Compliance Condition Comments Compliance Condition Comments Compliance Condition Comments Compliance Regulatory Inspector Second Inspector Regulation Manager Date Ian Hall Signature Signature Ann Micklethwaite Signature Don View Page 35 Public reports It should be noted that all CSCI inspection reports are public documents. Don View Page 36 PART D D.1 PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTS Registered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection. We would welcome comments on the content of this report relating to the Inspection conducted on 3rd November 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses are available on request. Don View Page 37 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NO Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate NO NO NO Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YES Action plan was received at the point of publication YES Action plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan YES Other: enter details here Don View Page 38 D.3 PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies. D.3.1 I Joan Beck of Don View confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on 3rd November 2004 and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Joan Beck of Don View am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on 3rd November 2004 for the following reasons: Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable. Don View Page 39 Don View / 3rd November 2004 Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.uk S0000031838.V148955.R01 © This report may only be used in its entirety. 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