Inspection on 20/12/05 for Donec

This inspection was carried out on 20th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 15/11/06

Donec 06/09/05

Donec 17/01/05

Donec 02/06/04

Donec 29/01/04

Donec 14/11/03

Similar services:

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 Drew Gurney Unannounced Inspection 20th December 2005 09:30 Donec DS0000011876.V272814.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 Donec DS0000011876.V272814.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. Donec DS0000011876.V272814.R01.S.doc Version 5.0 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) Elizabeth Fitzroy Support Care Home 14 Category(ies) of Learning disability (14), Physical disability (3) registration, with number of places Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in LD & PD categories not to be admitted under the age of 18 years 6th September 2005 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 Practioners, 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. 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. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a period of three and a half hours. The inspector had the opportunity to speak with three of the service users, a visiting relative and friend and to speak briefly with staff on duty. The registered manager has recently returned from a leave of absence but continues to manage another of the group’s homes for an agreed period of time. In her absence, the assistant manager has been promoted to undertake the role of Acting Manager and assisted the inspector ably throughout the course of the current inspection. Five requirements were placed at the current inspection. This total includes three requirements from the previous inspection that were not addressed by the provider and two additional requirements. Two of the outstanding requirements are now seen as in need of an urgent response. What the service does well: What has improved since the last inspection? Preparatory work for person centred planning is progressing well with the support of advocacy; new flooring has been installed in various areas within the establishment; a new freezer has been purchased and is sited in the kitchen; care management contractual information is now available for service users; agreement of residency information has now been updated and is currently being issued to all service users; Donec DS0000011876.V272814.R01.S.doc Version 5.0 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. Donec DS0000011876.V272814.R01.S.doc Version 5.0 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.V272814.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 The registered person is now able to demonstrate that service users have been provided with a contractual agreement. EVIDENCE: Care files now contain copies of formal contractual agreements between funding authorities and service users. These have been signed and dated by service users or a supporting representative. Further work has been undertaken to develop the Agreement of Residence documentation. This information now reflects the advised contents of the National Minimum Standards and the information is signed and dated accordingly. The assistant manager advised the inspector that staff had explained this paperwork to service users and supporting relatives. Signatures were observed within the documentation to support this statement. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 8 Appropriate care plans were included within personal files but there was no indication that these are regularly reviewed. Service users are involved and participate in reaching decisions within the home. EVIDENCE: Care plans viewed by the inspector at the previous inspection contained full and appropriate information however, no information was available on file that indicated that care plans are regularly reviewed on a six monthly basis. This procedure must be introduced to comply with the National Minimum Care Standards. Since the previous inspection, a great deal of work has been undertaken to provide person centred planning for all service users. This work has been undertaken on a group work basis at Day Services with service users. The participation and gathering of individual service user information continues to progress with the support and involvement of the East Hampshire Advocacy Service who have conducted and developed the information individually with service users. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 10 The person centred planning process is also being undertaken in conjunction with a staff development programme to ensure that staff become familiar and competent with the approach towards service users’ essential lifestyle plans. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 15 Service users are encouraged to participate in community events; positive contact is encouraged and welcomed by staff and is supported by appropriate available information regarding sexual relationships. EVIDENCE: The inspector was shown membership cards for all service users indicating membership of the local Grayshott Social Club. Membership of the Club involves being able to attend snooker sessions and monthly discos. There is no close direct contact with neighbours, but the assistant manager stated that service users are invited to community events, including parties. During the course of the inspection, it was observed that members of staff were involved in preparing to visit local shops to participate in the purchase of Christmas presents. Another service user was delighted at the prospect of visiting the local shops to purchase a new skirt for the festive season. According to the assistant manager, visits are made to local pubs, the village shops, accounts are held in the local bank and all service users are encouraged to participate in any elections, either local or national. Family and friends visit service users frequently and these visits are recorded in both the visitors’ book and on individual service user records. During the Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 12 inspection visit, a relative and friend arrived to take one of the service users out for Christmas lunch and the prospect of this outing very obviously pleased the service user. The visiting relative was happy to share views with the inspector that he has always found that the service user is well looked after by staff and considered that the level of care provided was of a high standard. There had been no reason for complaint and the service user always looked well cared for and always appeared happy. The family were well satisfied by the care provided. There is a full and comprehensive policy statement with regard to sexual relationships and this documentation is part of staff training procedures. The assistant manager discussed the rights of service users and that service user wishes would be treated with respect and an informative outlook. Information and guidance on this topic is undertaken for both staff and service users at workshops designed to explore relationships and feelings. Courses have been provided and liaison is undertaken with day services where an input has been provided during drama sessions based on the importance and understanding of relationships. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Various methods have been introduced to ensure that service users’ physical and emotional health needs are met in a positive manner. EVIDENCE: Service user health files were viewed and found to contain full information regarding health needs. During the course of the inspection, one service user was escorted to attend an outpatient hospital visit to investigate a specific health need. The inspector had a chat with the service user involved who identified the specific problem and on return to the home, was able to discuss the progress being made in this concern. With this in mind, the service user has been given the opportunity to consider moving to a ground floor bedroom that was empty, to lessen the pressures experienced in climbing stairs, in the absence of a lift within the home. The service user was delighted to have the opportunity to move to this room and to discuss with the inspector, plans for the décor and to show the wallpaper that had been chosen and discuss the colour scheme. Other emotional needs being addressed by staff are to encourage service users to visit family and home for Christmas or where this is not possible, to ensure that plans are in hand to provide a happy Christmas Day under the wing of a senior member of staff in a family home setting. Service users are also Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 14 accompanied by staff, to visit family and friends to assist with communication difficulties. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 15 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 complaint recording procedure must indicate that issues have been finalised. Adult protection training is outstanding and places service users at risk. EVIDENCE: The complaint recording procedure was discussed at the previous inspection, and a requirement placed to improve the procedure, but this remains to be put into practice. There is no clear tracking process to identify how complaints have been tracked or addressed. The log does not identify comprehensively, all information to enable tracking of a complaint. The requirement is renewed that the complaints tracking procedure is reviewed and must be observed with a sense of urgency. Records indicate that there have been no complaints received since the previous inspection. The Commission for Social Care Inspection (CSCI) has received no complaints since the previous inspection in September 2005. As reported following the previous inspection, there is an adult protection procedure and copies of recognised documentation are available. There is no evidence that adult protection training has been provided for all care staff. A requirement is again made under standard 35 that all staff must receive this training, to ensure that staff have adequate understanding of procedures. Such training should include instruction regarding the whistle blowing process. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 16 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 and 30 Service users live in a homely, comfortable and safe environment. Floor covering has been renewed in several areas. The home is clean and odour free. EVIDENCE: New wooden style vinyl has been laid in the dining room, the activity room and three corridors in the ground floor of the establishment. The same style flooring has been introduced in a service user bedroom where an unpleasant odour was reported in previous inspections. The effect is both attractive, pleasing and easier for staff to maintain in a clean and hygienic state and no evidence of odour was noted on the date of inspection. The light colour chosen for the flooring, also provides a lighter effect in the room and presents well. The dining room has been decorated since the previous inspection and now looks bright, cheerful and attractive. New curtains have also been purchased for this room. The assistant manager informed the inspector that the home has been provided with capital budget money to provide new furniture for the sitting room and activity room and this will include tables and chairs. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 17 A new freezer has been installed in the kitchen as it was observed at the previous inspection that the seals had perished on the previous model. Bathrooms, toilets and communal areas were clean on the day of the inspection process. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 18 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): 35 and 36 Most mandatory training has been completed satisfactorily, however adult protection training is outstanding and places service users at risk. Mental health training is not provided for staff. Supervision must be maintained regularly. EVIDENCE: Staff have undertaken core topics in training and certificates were available to support this statement. All staff undertake one-day manual handling training. Medication administration is in line with Donec general training and includes all care staff undertaking a one-day medication course. It was highlighted at the previous inspection and under standard 23 that adult protection training must be provided for all staff and a requirement was placed to this effect. This training remains to be arranged and provided. It is now a matter of urgency that adult protection training be provided for all care staff who have not received this training, to ensure that staff have adequate understanding of procedures. Such training should include instructions regarding the whistle blowing process. It is also necessary that staff attend suitable training to meet specific mental health needs of service users to equip them in response to particular needs and situations. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 19 At the previous inspection, no evidence was available that recorded supervision is taking place at regular intervals. From discussion with the acting manager, little, if any, progress has been made to address this concern. Only two recorded formal supervision sessions have taken place since the previous inspection undertaken in September 2005. A requirement is made that the provider must take urgent steps to ensure that supervision is undertaken for all staff on a regular basis at least six times per year as outlined in the National Minimum Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 20 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): 41 Copies of Regulation 26 visits undertaken by the responsible individual were not available for the three-month period prior to the inspection visit. EVIDENCE: The provider does not submit regular monthly reports of Regulation 26 visits to CSCI. It is an expectation therefore that copies of monthly visits undertaken by a responsible person within the organisation are available for viewing upon request by an inspector. The most recent copy of a Regulation 26 visit being made to the premises available for viewing on this occasion, was for the visit undertaken during August 2005. There was little evidence of other copies being available and no positive source to check receipt of such information. Two copies have been received formally at CSCI for the year 2005. Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X x 3 Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X x 1 1 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Donec Score x 3 x x Standard No 37 38 39 40 41 42 43 Score X X X X 1 X x DS0000011876.V272814.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA66 Regulation Requirement Timescale for action 20/03/06 2. YA2222 3. YA2323 and 35 YA3636 4. 5 YA4141 14{2}d{a}{b} The assessment of service users’ needs must be kept under review at regular intervals 22 The complaint recording system must clearly identify the process undertaken when investigating complaints. 18{1}{c} Staff training must include adult protection. This is a repeat requirement last made on 6.9.2005 18 {2} Recorded supervision must be provided for all staff before March 2006. This is a repeat requirement last made on 6.9.2005 17 {2} Reports made under Sched.4.17 Regulation 26{4}{c} must be available for CSCI.. 20/01/06 20/01/06 20/02/06 20/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Donec Refer to Good Practice Recommendations DS0000011876.V272814.R01.S.doc Version 5.0 Page 23 Standard Donec DS0000011876.V272814.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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