Inspection on 06/09/05 for Donec

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Donec 03/07/08

Donec 04/07/07

Donec 15/11/06

Donec 20/12/05

Donec 17/01/05

Donec 02/06/04

Donec 29/01/04

Donec 14/11/03

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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 06/09/05 9.30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Donec Address Headley Road, Grayshott, Hindhead, Surrey, GU26 6DP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01428 605525 Elizabeth Fitzroy Support Karen Bond CRH 14 Category(ies) of LD, PD registration, with number of places Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in Ld and PD categories not to be admitted under the age of 18 years. Date of last inspection 17/01/05 Brief Description of the Service: Donec is registered to provide a service for fourteen adults with a learning disability or physical disability. The home has well established links with local General Practioners and the Community Nursing Team. The home is managed by Elizabeth Fitzroy support and is well established in the 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 H54 S11876 Donec v236681 060905.doc Version 1.40 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 six hours. The inspector had the opportunity to speak with two of the service users and to have introductory meetings with several staff. The registered manager has recently returned from a leave of absence but is currently managing 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 inspection. What the service does well: What has improved since the last inspection? The sitting room and activity room have been decorated. One bedroom has been completely re-decorated and provided with new furniture, bedding and carpeting. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 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 H54 S11876 Donec v236681 060905.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Donec H54 S11876 Donec v236681 060905.doc Version 1.40 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 standard(s) 2, 5 The needs of prospective residents who are able to visit the home prior to admission are assessed in a favourable manner, according to their needs and those of the existing residents. The registered persons are not able to demonstrate that residents have been provided with a contractual agreement. EVIDENCE: Documentation was available that has been developed to incorporate required assessment standards. Assessment information for new admissions presents a holistic approach. The documentation incorporates risk assessment, level of support required, aspirations of service users, interests, continuing education, history of education, night support required, household participation ability, finance and budgeting skills, social interaction skills, communication skills, behaviour, dietary requirements, medical and personal care information, moving and handling and general mobility. In response to a requirement placed at the previous inspection, no evidence was found on service user files that work had taken place to provide contracts for service users who have lived in the service for many years and who have never been provided with contracts. It is understood that this issue was being addressed at an organisational level. A contract must be provided for each service user in the home. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 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 standard(s) 6, 7, 9 Appropriate care plans were included within personal files. Service users are involved and participate in reaching decisions within the home Service users are supported to take risks as part of an independent lifestyle and this is very clearly documented. EVIDENCE: In response to the previous inspection, the home has provided care plans for two service users where these were not available. Files viewed during the current inspection were found to include appropriate care plans. The minutes of service user meetings were viewed by the inspector and these indicate that regular meetings are held and amongst topics discussed, service users draw up a rota of household tasks and jobs that are designated to individuals. A service user confirmed this arrangement during a conversation with the inspector. Service users were observed as being encouraged by staff to express their views and this was also reflected in comment cards returned by service users. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 10 Risk assessments were available on those files viewed and indicated the level of risk involved with activities undertaken by service users, including leisure activities. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 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 standard(s) 12, 16, 17 Service users participate in educational and leisure activities. The home and staff respect service users’ choice. Service users are provided with a nutritious diet EVIDENCE: In response to a requirement placed at the previous inspection, the home and community nurse have provided a timetable showing the day time activities for a particular service user who has chosen not to attend a day centre and for whom the home receives funding for him to receive 10 hours of one-to-one support per week. This timetable has only just been introduced and therefore, insufficient information was available to provide conclusive detail. This will therefore, be viewed at the next inspection. The team respects service users’ rights. Service users are provided with keys for their bedrooms and front door keys. This was evidenced during a tour of the building, as the majority of bedroom doors were observed as being locked. It was also confirmed by a service user that mail is given directly to service users, with assistance provided by a member of staff where this is required. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 12 Service user responsibilities are observed by encouraging them to be independent in undertaking personal household skills. One service user was observed to be happily ironing clothing during the inspection visit. Other observations included the general household duty list, available in the activities’ room. The current week’s menu was also on display and presented a well-balanced, nutritious approach to diets. Whilst meals were not directly observed, the chef who is employed on a three day basis by the home, was observed preparing the evening meal and the content looked both attractive, appetising and of nutritious content. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 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 standard(s) 18, 20 Service users do receive personal support in the way they prefer with personal care. The administration of medication is being met EVIDENCE: All service users have a key worker to support them as part of the structure of Donec. Personal hygiene is encouraged and there is a choice of bathing or showering. All service users observed by the inspector, looked well cared for both in their general appearance and their clothing. Service users confirmed that they enjoy shopping for clothing with staff and enjoy having their hair done by the attending hairdresser. There is a mixed gender amongst staff giving choice for service users who need personal care. Currently, apart from hand-rails on baths, no service users require special equipment towards undertaking personal care. The inspector observed that one shower area is fitted with a seat should this be required. During the previous inspection, it was observed that no record had been made in one instance where a service user had refused medication. This procedure was checked during the current inspection and an accurate record had been kept of a recent refusal to accept medication. The information was recorded, dated and coded as required. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 14 Administration and control of medication were clearly recorded and corresponded accurately with the documentation and stock where this was checked. All staff undertake training in the administration of medication and are required to complete a competency test. The inspector recommended to each assistant manager that a specimen of all staff signatures involved in the administration of medication is introduced. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 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 standard(s) 22, 23 The complaint recording procedure must indicate that issues hae been finalised. Service users are at risk due to insufficient staff training for adult protection. EVIDENCE: 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. A requirement is made that the complaints tracking procedure is reviewed. Records indicate that there have been two complaints received since the previous inspection. One complaint concerns direct assistance regarding the support provided to a service user prior to a home visit and the other regarding head lice. In both instances, information was available indicating that these issues have been addressed through the provision of staff supervision and secondly, by installing procedures to ensure sound hygiene procedures for head care. There is an adult protection procedure available 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 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 H54 S11876 Donec v236681 060905.doc Version 1.40 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 standard(s) 24, 26, 27, 30 Service users live in a homely, comfortable and safe environment. Most furniture and fittings were satisfactory and bedrooms decorated attractively. The home is clean but an odour remains in one service user’s bedroom. EVIDENCE: In those bedrooms viewed by the inspector, these are comfortable and have been provided with the required furnishings and have been personalised to reflect the interests of the residents. It is a homely environment. In most circumstances, the level of decoration, including furnishings and fittings, was in attractive and bright colours, although worn in some instances. Carpeting was of a reasonable quality in most rooms but very stained in places. The home is currently subject to a deep clean and this will include carpet cleaning. The table and chairs in the activity room are shortly being renewed to finish the uplift recently undertaken in this area. Lounge chairs are also included within the budget for replacement as these are worn. The last inspection referred to odour in one service user’s bedroom and during the current inspection, it was again detected. A requirement is made that this Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 17 is adequately addressed. One option discussed was that alternative flooring is placed in this particular bedroom to counteract the odour. Bathrooms, toilets and communal areas were clean on the day of the inspection process. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35, 36 Staffing was appropriate on the day of the inspection. Most mandatory training has been completed satisfactorily, however adult protection training is outstanding and places service users at risk. Service users will also benefit from formal care training once this is complete. Supervision must be maintained regularly. EVIDENCE: Sufficient staff were available on the date of the inspection and rotas indicated that shifts are covered adequately. The home has for a considerable period of time had three staff vacancies. Additional staffing support continues to be provided on a regular basis and rotas reflect the regularity by agency staff, which provides consistency for service users. Files were viewed for two recently appointed members of staff and were found to contain all recruitment information in compliance with requirements, including criminal record checks and references. 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, all care staff undertaking a one day medication course. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 19 Currently, there are 15 members of staff employed at Donec, two of whom have long term sickness absence. At the time of the inspection, three members of staff have completed NVQ level 2 training. One assistant manager is about to commence NVQ level 3 and the other assistant manager is about to commence NVQ level 4 training. It was discussed with the provider that there is an expectation that 50 of staff are trained to NVQ level 2 or above. Adult protection training must 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. No evidence was available that recorded supervision is taking place at regular intervals. From discussion with the acting manager, no supervisionis being undertaken.A requirement is made that this is undertaken to comply with the statement to provide six supervision meetings at least within the period of one year. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, There are activities that involve seeking views and monitoring of the service, however a service user survey to include their views is still an outstanding requirement from a previous inspection. EVIDENCE: The inspector viewed minutes from both service user and staff meetings that are held on a regular basis. A service user confirmed participating at meetings. The home has developed a survey to gain the views of relatives and friends of service users. A previous requirement was made to develop a tool to gain the views of service users. This had not been achieved at the time of inspection, hwoever the organisation as a whole has a plan of how to address this, which can be reviewed at the next inspection. Information was available supporting fortnightly visits made by an advocate from the East Hampshire Advocacy Service. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 21 Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 1 Standard No 22 23 ENVIRONMENT Score 2 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 x x 2 Standard No 11 12 13 14 15 16 17 x 3 x x x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Donec Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x x x H54 S11876 Donec v236681 060905.doc Version 1.40 Page 23 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 5 Regulation 6{c} Requirement A contract for the provision of services by the registered provider must be provided to all service users. A requirement placed on 17.1.05 has not been met. The complaint recording system must clearly identify the process undertaken when investigating complaints. Premises must be free from offensive odours throughout. A requirement placed on 17.1.05 has not been met. Staff training and development must meet the needs of all existing service users, including adult protection. Recorded supervision must be provided at regular intervals Timescale for action 6.12.05 2. 22 22 6.12.05 3. 30 16{2}{k} 6.11.05 4. 35 18{1}{c} 6.1.06 5. 6. 36 18 {2} 6.10.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 24 1. 20 That a specimen signature list be provided for the administration of medication. Donec H54 S11876 Donec v236681 060905.doc Version 1.40 Page 25 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton, Hants 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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