Inspection on 30/07/05 for Draycombe House

This inspection was carried out on 30th July 2005.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Draycombe House 11/11/08

Draycombe House 06/11/07

Draycombe House 22/01/07

Draycombe House 31/01/06

Draycombe House 28/10/04

Draycombe House 22/05/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Draycombe House 1 Draycombe Drive Heysham Lancashire LA3 1LN Lead Inspector Jenny Dunkeld Unannounced 30 July 2005 10:00am th 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. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Draycombe House Address 1 Draycombe Drive, Heysham, Lancashire. LA3 1LN 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) 01254 858316 Draycombe House Care Ltd Mrs Gwynne Burgess CRH Care Home 6 Category(ies) of LD Learning Disability 6 registration, with number of places Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider should at all times employ a suitably qualified and experienced manager who is registered with the CSCI. 2. The home must not accommodate more than 6 people with a Learning Disability. 3. The home must be staffed in acordance with the Residential Staffing Forum Guidance. Date of last inspection 15th December 2005 Brief Description of the Service: Draycombe House is registered with the Commission for Social care Inspection to care for six adults with a learning disability. It is a large detached property. It is relatively close to shops and local amenities. The residents accommodation is situated on the ground floor. Each resident has a single bedroom and there is a large lounge, which has teamaking facilities within it, there is a separate dining room. Two of the bedrooms have en-suite facilities and there is a communal bathroom and a separate toilet. The management actively promote the integration of the residents into the community. The residents are enabled to take calculated risks in order to increase independence. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has been inspected against the National Minimum Standards for Adults introduced in April 2002. This year, all registered Care Homes are to be inspected at least twice and both visits can be unannounced. This inspection was unannounced and lasted over a 4hr period during the afternoon of Saturday 30th July and during the morning of 2nd August and looked at various aspects of care. In the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small group of residents. All records relating to these individuals are examined, along with the rooms they occupy in the home. Residents are invited to discuss their experiences of the home with the inspector; this is not to the exclusion of the other residents who contributed in many ways. This inspection included discussion with residents, staff and the manager in addition to viewing the home’s required written information such as the resident’s plans of care. Each resident has a written plan of care which is a document outlining the needs of the individual resident and how these are to be met. They cover all aspects of the individual’s life including health, personal care and social activities. Thereby ensuring people are content in the care they receive. The residents the inspector spoke with were generally happy with life at Draycombe House. The staff enjoyed their work at Draycombe House and spoke to the inspector in a professional manner about the residents. The service at Draycombe House needs to look at ways of ensuring that the residents have their right to a quality life that gives fulfilment is met in the most appropriate ways. Comment cards were received from a number of Residents and the inspector spoke with all of them during this inspection revealing that the residents are generally happy with the care they receive. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.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 Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.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 There is a good system for assessing the needs and abilities of all prospective residents. This means services are tailor made to suit the individual. EVIDENCE: The pre- admission assessments for people admitted to the home in the future will ensure their needs are addressed and enabled to put into practice by appropriate funding to meet their staffing needs. The written assessment includes all aspects of care social, health, and communication. The manager explained that once admitted the assessment is on-going leading to the development the plan of care. The inspector viewed the pre-admission assessment form for the last person admitted to the home, as part of the ‘Care tracking process’. This person has one-one care support in order that his needs are fully met. However the majority of the residents have lived at the home for a large number of years and to a certain extent have become set in their ways. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.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 The people who live at Draycombe House have a Plan of care about them addressing their individual needs and choices. The residents know that their wishes will be listened to in order that they make the decisions about their life. EVIDENCE: They stated that they make the basic decisions about their life such as when to rise/retire to bed. The times of meals are flexible around what the residents are doing that day. The residents said they were aware that the home had a plan of care about each one of them, but some people had never asked to see their plan. The residents participate in the review of their plan of care to ensure their changing needs are addressed but again they need some guidance as to what they have a right to expect from life. One man takes himself out on a regular basis and is able to inform staff of what he wishes from life and how he wishes to be cared for, but not all the residents have this capability. Some relatives are included in the review of the individual’s plan of care. One resident said she would like her sister to be at her next review. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 10 The inspector also viewed the minutes of the residents’ meetings, which demonstrated that the residents made decisions about their lives which are acted upon for instance they discussed where individuals wanted to go on holiday to and the holidays were arranged accordingly. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.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) 13 15 & 17. The residents need to have more activities to enable them to have fulfilling lifestyles and benefit from being part of the local community. The residents benefit from being enabled to see their friends and family when they wish. The residents enjoy their meals but their diet lacks variety. EVIDENCE: The residents in discussions with the inspector told her that if they suggested an activity the manager would act upon the suggestion and endeavour to arrange for them to partake in such an event. However, as stated previously some of the residents have become set in their ways and have had limited opportunities in life. As such they are not always aware of what could be available for them and look to the management and staff to offer them age appropriate activities not only in the home but also in the community. It might be useful to look at the lifestyle of someone living in the community of a similar age to the resident when reviewing their plan of care, this may identify new experiences and opportunities that people could try. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 12 The residents appear content living at Draycombe House indeed they said they like living there and made comments such as ‘the staff are nice and we like Anne (home owner) and Gwynne (manager)’ With greater stimulation in life people would not be telling the inspector they are ‘bored’. The residents told the inspector of the holidays that they have been on this year. Some people have been to Blackpool as that is where they chose to go. Two people went to the Isle of man and had enjoyed being there. These 2 residents have become ‘engaged’ and whilst there are no plans to get married as yet, it is good that the management of the home recognise people’s rights to have relationships. One man spoke of how his brother visits him and takes him out. One woman had her sister visiting at the time of this inspection; indeed she was staying for tea. She told the inspector that she is always made welcome and is regularly invited to stay for a meal. One resident would like to trace the where abouts of her brother and the manager has agreed to help her to do this. People’s food likes and dislikes are recorded as part of their plan of care and meals are frequently discussed at the residents meetings. The inspector viewed the record of meals that people had received over the past month. The repetition of similar meals was noted e.g. one day the menu was ‘Fish cakes and spaghetti’ the next day it was ‘Fish chips and spaghetti’. The manger said this was due to different staff preparing the meals. As discussed the manager should in consultation with the residents, write a menu for the month ensuring it is not repetitive and offers a balanced diet. The weekly shopping list can then be drawn up around the weeks menu. The inspector is sending the home some advice regarding menus that has been provided by the community dietician. This does not take away people’s right to choose but guides people into the necessary contents in order to live healthily. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.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 & 19 The people who live at Draycombe House are supported to ensure their physical and emotional health needs are met. The staff provide personal support to people in a way that suits the residents needs and preferences meaning that, residents remain satisfied and generally contented in their care. EVIDENCE: The files viewed as part of the ‘tracking process’ reflected a list of health care professionals involved with the individuals, including, for example; Doctor, Community Nurse, Dentist and psychiatrist as necessary. One resident had recently been in hospital for a major operation and the management and staff have supported her in her recovery, helping her to feel reassured. As stated in the previous section of this report the provision of a menu would ensure people benefit from eating less repetitive meals. The residents spoke of how good the staff are. They also stated that the staff offer support in the way their individual needs and wishes require. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 14 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 The residents are able to talk freely about any concerns they may have. The management and staff at the home act on all expressions and views made by the residents ensuring that residents are confident that their concerns are important in the home. EVIDENCE: The home has a well written policy on complaints. The procedures are that people should in the first instance speak to a member of staff or the manager if they have any complaints. Contacting the Commission for Social Care Inspection if there is still a problem can follow this up. All the residents receive a copy of the complaints procedure. In addition to this the home provides each resident with a postcard pre stamped and addressed to the Commission for Social Care Inspection, alerting them that the resident would like to talk to the inspector. This is a good practice that enables the residents to be able to contact the Commission for Social Care Inspection whenever they have any concerns. The home’s complaints record book reflected that there have been no complaints in the last 12 months. The residents said that if they weren’t happy they would tell Gwynne or Anne and they would put it right. One resident said that she would tell her key worker. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 15 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 The home is safe and generally in an acceptable condition of décor. The residents benefit from living in a home that is safe. EVIDENCE: Whilst the home is in an acceptable condition of décor there are some parts that need a face lift e.g. one of the ground floor toilets/shower room. Some of the external areas also need attention, for instance the rear garden and the side of the house that the residents bedrooms look onto. Staff need to check the toilet areas at frequent intervals throughout the day ensuring that they are kept in a clean condition. A paper towel dispenser and a soap dispenser would be of benefit in the communal toilet areas. Many of the windows in the home have been replaced with double glazed units and have enhanced the appearance of those rooms. The lounge settee is in need of recovering/replacing as the covers are torn. The residents proudly showed the inspector their bedrooms, which contained personal possessions reflecting the residents’ personality. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 16 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) 35 The level and calibre of staff is good. The residents are cared for by a staff team that are receiving appropriate training. EVIDENCE: The inspector viewed 2 staff files. These contained all the relevant information such as Criminal Records Bureau clearance, 2 references, an application form with a full employment history. A record of training in the individuals file revealed appropriate training including; Learning Disability Award Framework induction and foundation First Aid; Food Hygiene Health and Safety One member of staff has completed National Vocational Qualification level 2 in Care and another member staff is currently undertaking the training. Other courses that might be of benefit to the staff include; Introduction to Learning Disability Understanding Abuse The residents said that they like the staff with comments such as ‘The staff are nice’ ‘I like my Keyworker’. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 17 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 The residents know and benefit from living in an environment where, their opinion matters. EVIDENCE: The residentsare verbally consulted on a regular basis as to the quality of the care they receive . Meetings are held with the residents and these are minuted, the inspector viewed the record of the last meeting. The home via the plans of care is able to assess it`s effectiveness in providing the care the individual requires. Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 18 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 x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x x 2 x 3 x 2 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Draycombe House Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x x x F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 19 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 YA13 Regulation 16(2)(m) Requirement The registered person must ensure people are given the opportunity to engage in local,social and community activities. The registered person must ensure people receive suitable, wholesome and nutricious food which is varied. The registered person must ensure the residents have a meaningful lifestyle. Timescale for action 30/9/05 2. YA17 16(2)(i) 31/8/05 3. YA13 16(2)(n) 30/9/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA 24 Good Practice Recommendations The service provider should produce an audio tape/talking CD Rom of the Service users Guide, thereby enabling service users to be aware of it’s content The registered person should ensure the home and grounds are well maintained Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 2nd Floor, Unit 1 Tustin Court, Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Draycombe House F57 F09 S42609 Draycombe House V216667 300705 Stage 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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