Inspection on 15/11/06 for Donec

This inspection was carried out on 15th November 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Donec 03/07/08

Donec 04/07/07

Donec 20/12/05

Donec 06/09/05

Donec 17/01/05

Donec 02/06/04

Donec 29/01/04

Donec 14/11/03

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Donec Headley Road Grayshott Hindhead Surrey GU26 6DP Lead Inspector John Vaughan Unannounced Inspection 15th November 2006 09:30 Donec DS0000011876.V319102.R01.S.doc Version 5.2 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 Donec DS0000011876.V319102.R01.S.doc Version 5.2 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. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Donec Address Headley Road Grayshott Hindhead Surrey GU26 6DP 01428 605525 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) www.efitzroy.org.uk Elizabeth Fitzroy Support Care Home 14 Category(ies) of Learning disability (14), Physical disability (3) registration, with number of places Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Donec, managed by Elizabeth Fitzroy Support, is registered to provide a service for fourteen adults with a learning disability or physical disability. The home has links with local General Practitioners, the Community Nursing Team and local community. Donec is a large three-storey house on the outskirts of Grayshott, a small village on the Surrey and Hampshire border. There is no lift available and would therefore be inappropriate for service users with mobility problems and who could not manage stairs. Service users are able to access local facilities and are encouraged to maintain their independence. Rules are kept to a minimum. Visitors are welcome and service users families are encouraged to play an active part in their relatives life. Information provided by the manager confirms the fees are currently £590.62 to £1199.78 per month to live in this service. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector met with service users, staff members and one of the deputy managers of the home during the visit to the service, which took place over one day. During the visit the inspector spoke to service users about their experiences of the home, observed service users and staff, sampled records, interviewed staff and toured the home assisted by the manager and service users. What the service does well: What has improved since the last inspection? Staff members have received training in adult protection to recognise and respond to concerns of service users. A new pictorial menu plan has been introduced to help service users with choosing meals. Records of visits made to the home by the provider’s representative are in place at this visit. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lack of information in a new service user’s file meant that at the time of visiting the service the home could not fully demonstrate that service users have their needs assessed before moving into the home. The practices of the service means that service users who want to move into the home can visit and spend time in the home before they move in. EVIDENCE: There has been one new admission to the home since the last inspection of the service. The inspector looked at the documentation held for the service user who has moved in recently. The inspector also met with this person during the visit. Although a care plan was in place with information on the service user’s needs the person in charge of the home was unable to find the supporting assessment of the service user and the files did not contain an assessment from the care manager. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 9 The inspector advised that this information must be available for inspection to demonstrate that the person’s needs were fully assessed before moving into the home to ensure the home is able to meet these needs. This evidence was available for other service users in the home and the manager telephone and confirmed that this information was in place and will be available in future. During the inspector’s visit a new service user was observed visiting the home supported by a staff member from their current home and an advocate who is assisting with the service user with making choices about were to live. The inspector saw evidence on the three service user’s files sampled during the visit that service user’s are issued with a contract and terms and conditions of residency when they move into the service. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have a care plan and risk assessments to support them with their needs however this would benefit from reorganisation reviewing and updating to fully demonstrate that it is meeting needs. The practice of the home demonstrates that service users are supported to make choices about their lives within an open a friendly environment. EVIDENCE: The inspector sampled three plans one for a new service user who has recently moved in and two for service users who have lived in the home for some time. The new service user’s plan is developing and contains information on the support needs of the individual. The plan contained guidelines for monitoring health concerns, morning and nighttime routines. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 11 Plans seen by the inspector contained good information on service users covering their likes and dislikes, healthcare needs and support strategies. At the last inspection of the service a repeated requirement was made to improve the reviewing of service user’s care plans. One plan examined at this inspection did not have any evidence of a review and update since 2003 and most of the record is dated 2002. The plans use a number of different formats and have a lot of information however the inspector found them hard to go through, as they need to be reorganised to make it easier to read. Some forms in the plans were blank or had not been filled in some time and it was hard to know if they were still in use, for example a risk assessment index was blank and an activity monitoring sheet had not been completed since the beginning of the year. The member of staff in charge told the inspector that a new format is being introduced to address the organisation and flow of information in the care plan. Service users have individual risk assessments and there are general environmental risk assessments also in place. The current practice of leaving dish washer tablets in an unlocked cupboard is covered by a very general cleaning products assessment and does not clarify the procedures to follow, it does not assess individual vulnerability and the home has been advised to put clearer and more focused assessments in place for each person. The home values service user independence and service users are supported to carry out tasks such as using the dishwasher as part of every day life however this support must be supported with a sound risk management strategy to safeguard all people living in the home. Staff members were observed offering choices to services about what to eat and what activities they take part in. Plans contain information on likes and dislikes and regular meetings take place in the home to enable service users to share their views. Service users moved freely around their home accessing communal areas and their private rooms. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a service that provides a wide range of activities based on their assessed needs, interests and hobbies together with a balanced and varied menu offering choices and healthy options. EVIDENCE: The home was very busy on the day of the inspection visit. Service users were going out to activities and day service groups. One service user was preparing to go on a one to one activity with a staff member. A service user told the inspector that they have a job in a local shop, which they enjoy. Two service users told the inspector about their trip out and they enjoyed their meal in a pub. Service users have regular holidays including trips abroad. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 13 Records are maintained for the activities that service users enjoy and participate in. One file examined by the inspector had details of activities and places that have been explored by the service user and are disliked by the individual. Files contained information on contact from families and friends and important relationships are noted. The inspector saw correspondence from family members and some service users visit and stay with family members. The menu plan in the home has a broad range of meals and staff told the inspector that they encourage healthy eating and make sure fresh fruit and vegetables are offered. A number of service users are actively encouraged to prepare and participate in making snacks and drinks. A new pictorial menu chart has recently been introduced to assist service users to make choices about meals and understand what’s on the menu for that day. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides support for service users to access health Care professionals to meet their needs. Personal support is given in a way that respects the privacy and dignity of the individual. The homes practices in the administration and recording of medication meet service users need however revised risk assessments will enhance this practice. EVIDENCE: Each person is registered with a general practitioner and records are kept of all appointments. Evidence was seen to confirm that service users are supported to attend medical appointments and maintain their health needs. Files examined by the inspector contained updated health assessments. Medication records were examined and found to be generally well completed Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 15 however some gaps in the medication record need to be followed up and signed. Medication is stored securely and a medication fridge is also in place to store items, which require lower temperatures. The fridge is monitored and the temperatures are recorded. One service user self-administers some of their medication and this practice has a risk assessment in place. The rest of their medication is taken to the service user and left with them to take unsupervised. The staff member was advised to expand the risk assessment to include this practice and provide guidelines for monitoring safe practice. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home can demonstrate that the views and concerns of service users, their families and representatives would be documented and acted upon however the recording process requires more work to demonstrate the actions taken to investigate complaints. The practices within the home mean that service users are protected from abuse. EVIDENCE: A policy and procedure is in place for responding to complaints within the home. A complaints log is in place and the inspector examined the record to find out how complaints have been responded to since the last inspection. The home ha a complaint tracking from in place and this is used and the inspector saw evidence that the manager had responded promptly in writing to a letter of concern. The information held in the file did not explain what actions the manager took in investigating the concern and what the outcome of the complaint was. This had been raised at previous inspections of the service. A letter expressing concerns about staff training to meet a service users needs was in the file however this was not recorded in the file and there was no evidence that this has been responded to. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 17 The manager must demonstrate that they have a clear record of complaints that can show how the complaint was investigated, what was found and what the outcome of the complaint was. Service users commented that they have good relationships with staff members who help them with any concerns. The inspector spoke to staff about the actions they would take to raise concerns and they were all generally aware of how to make the manager and senior staff aware of concerns, complaints and allegations. Staff have attended training in adult protection. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a comfortable home enhanced by individually personalised private rooms. The overall service would benefit from a refurbishment and repair of the kitchen. EVIDENCE: The inspector toured the home assisted by the staff and deputy manager. The home is clean, tidy and free from any unpleasant smells. Two service users let the inspector view their private rooms. These rooms were decorated to their personal tastes with pictures, posters and personal items. Both rooms had good levels of equipment televisions, DVD, CD players Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 19 and radios. Service users have keys to their rooms and some choose to keep their rooms locked when out of the home. A service user said that they were very pleased with their room and had everything that they need including a personal telephone line to keep in contact with their family. The home is generally well maintained and had good furniture in the communal areas. The kitchen is showing signs of age and staff agreed that it is worn out. A number of doors are off cupboards and the area needs to have prompt attention to improve the area. The home has a large garden with seating for service users and a BBQ area. The home has had updated fire equipment to ensure exists used in the event of a fire are automatically opened and this has improved the safety in the home. An additional stair rail was fitted to assist a new service user to reach their bedroom on the first floor. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment practices demonstrate that a thorough recruitment procedure is followed in the home to maintain the safety of service users. Well-trained staff members support service users however more work is needed to improve the supervision programme in the home. EVIDENCE: The inspector examined the staff recruitment and training records. The inspector also looked at the day-to-day staffing in the home and the supervision and support staff members receive to carry out their roles. The inspector examined six records for staff who have started since the last inspection. All information was found in each file including an application form, two written references and proof of identity. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 21 Details of the individuals Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks are on file and staff who started work with a POVA check remain supervised until the CRB has been returned. Staff training records were examined this provided evidence to confirm that staff are undertaking training and development relevant to their work. Staff undertake an induction and foundation course in line with the Learning Disability Awards Framework (LDAF). Information provided by the manager in a pre-inspection questionnaire indicated that 68 of staff have obtained a National Vocational Award (NVQ) and new staff are beginning their induction and foundation training. Training records confirmed that staff undertake training in moving and handling, fire safety, food hygiene, health and safety, management of violence and first aid. Staff members have also attended training in dementia to support a service user whose needs are changing. The last inspection of the home required the manager to implement a supervision programme for staff, this was an outstanding requirement from the previous two inspections. The record of supervision was examined at this visit and this record had large gaps in dates for staff supervision. The deputy manager checked the actual supervision notes and this confirmed that staff are not consistently supervised. The deputy manager stated that it is the policy of the organisation to supervise staff every four to six weeks however the most any one person has been supervised this year has been three times and in most cases only once. The manager was again required to review and implement a consistent supervision programme within the service to ensure staff members receive support to understand and develop in their roles. The inspector spoke to two staff members who stated that they feel supported by their colleagues. Staff felt encouraged to develop their skills and were able to discuss the current training programme they are undertaking. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are generally well supported by the home’s management practices but the areas for improvement such as complaints and care planning must be addressed. It is essential that a registered manager is in post to take full accountability for the management of this home. The service can demonstrate that a system is in place to develop the service with views from service users and their families included in this process and the home’s equipment is maintained and serviced to keep people safe. EVIDENCE: Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 23 The manager confirmed that they have applied to the commission for registration. The inspector has identified a number of outstanding requirements within this report including reviewing of care plans, recording of complaints and the supervision of staff that are directly related to the management of this service and will need to be addressed to demonstrate that the home is well managed. Regulation 26 visits are completed each month and a report is held in the home. Service user and staff meetings take place on a regular basis in the home. The organisation has introduced an audit tool in the service and the manager and staff are working through a set of assessments in order to implement a development programme for the home. The deputy manager was attending a quality meeting on the day of the inspection to update progress on this work. The inspector confirmed by examining the homes servicing records that the alarm system has been serviced regularly. Weekly alarms tests are completed and fire drills are undertaken. Staff training in fire safety took place in August and November of this year. Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 14 Requirement The registered person must ensure that service users’ care plans are reviewed and updated. Repeated requirement previous timescale of 20/03/06 partly met. 2. YA9 13 The registered person must ensure that service users are supported by clear risk assessments when handling hazardous substances. 3. YA22 22 The registered person must ensure that the complaint recording system clearly identifies the process undertaken when investigating complaints and documents the outcome. Repeated requirement previous timescale of 20/01/06 not met. 4. YA24 23 The registered person must ensure that the kitchen is repaired or replaced. 07/02/07 13/12/06 13/12/06 Timescale for action 07/02/07 Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 26 5. YA36 18 The registered person must ensure that all staff members receive regular supervision and a frequency no less than six times a year. Repeated requirement previous timescale of 20/02/06 not met. 07/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Donec DS0000011876.V319102.R01.S.doc Version 5.2 Page 28 - 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. 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