Inspection on 31/01/06 for Draycombe House

This inspection was carried out on 31st January 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 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 30/07/05

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 Draycombe House 1 Draycombe Drive Heysham LA3 1LN Lead Inspector Mrs Jennifer Dunkeld Unannounced Inspection 31st January 2006 17:00 Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 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 Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 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. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Draycombe House Address Draycombe House 1 Draycombe Drive Heysham LA3 1LN 01254 858316 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) Draycombe House Care Ltd Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The registered provider should at all times employ a suitably qualified and experienced manager who is registered with the NCSC The home must not accommodate more than 6 people with a Learning Disability The home must be staffed in accordance with the Residential Staffing Forum Guidance 30th July 2005 Date of last inspection 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, which 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 tea-making 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. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 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 was the second unannounced inspection this year and lasted over a 2.5hr period during the evening of 31/1/06 looking 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 service provider 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 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. What the service does well: Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 6 A company called Draycombe House Care Ltd owns Draycombe House. One of the Directors of this company is Mrs Anne Withers who has a wealth of experience in caring for people. Mrs Withers strongly believes in the benefits of training staff to be competent in their work. The company usually employs a manager to oversee the care on a day-to-day basis. The manager recently left the post and Mrs Withers has applied to register another manager whose application is currently being processed by the Commission for Social Care Inspection. Mrs Withers upholds people’s rights to have friendships and relationships; indeed two of the residents have become engaged to one another since living at Draycombe House. What has improved since the last inspection? What they could do better: The residents outlined their activities for the week and for some people their life is repetitive and does not offer the opportunity for new experiences. As stated in the report following the previous inspection there is a need to compare the social life of a resident to that of someone of similar age living in the community this would give an insight to how limited life and experiences are for the people living at Draycombe House. It is difficult for people who have lived in various institutions for a number of years to know what is available to them. They need input, guidance and support from the people caring for them. The tourist information office for instance, would have details of what the area has to offer. People could then choose the activities they would like to experience. It is recognised that funding has an impact upon the staffing levels of the home. But there is a requirement upon the service provider to ensure the needs of the residents can be fully met by the care home. Advice was offered in relation to funding. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 7 People should not have to go out in a group all the time; there should be opportunity for specific activities to meet the individual’s needs. 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 DS0000042609.V270575.R01.S.doc Version 5.1 Page 8 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 Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 9 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): None of these standards were assessed during this visit as the key standard was fully met during the previous inspection. EVIDENCE: Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Risk assessments are carried out in relation to life within the home but there is limited recognition of the value of risk assessments enabling experiences within the community. This results in people having a repetitive lifestyle. EVIDENCE: Risk assessment were seen on individual care files in relation to life within the home and the assistance people require in relation to personal physical care needs. However some of the residents have become set in their ways and need greater motivation and encouragement to take calculated risks as part of developing their social life. As part of the ‘case tracking’ process one resident, when asked about her week’s activities stated ‘I go to club on Wednesdays’ (local Mencap club) ‘We all go to the pub on Thursdays’ ‘I go to College once a week’ ‘And one day I go shopping or for a walk.’ The same resident visits her sister once a week in another care home, or she comes to visit her and stays for tea. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 11 There is a need to talk with the individuals about other experiences they may wish to have and risk assess those activities in order that people have a more fulfilling life style appropriate to their age. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16 & 17 There is limited opportunity for people to take part in age appropriate activities. This results in people being bored. There is recognition of the resident’s rights but limited understanding of their need for fulfilment. The residents’ benefit from being offered a healthy balanced diet EVIDENCE: The residents spoke with the inspector about their weeks activities. When asked if they had ever been to the local Bowling Alley one said yes a long time ago and another said ‘No’. When asked if they would like to go bowling they stated ‘yes’ . The conversation came around to television and it was apparent that some of the residents enjoyed ‘Emmerdale Farm’ but had never been to see where it came from. When asked if they would like to go, one resident asked me ‘Yes Jennifer when are you taking us?’ This is not the first time when the residents have expressed their enjoyment at the visit from the Commission for Social Care Inspection a see it as a social occasion. The inspector has known the majority of the residents for a number of years and whilst it is good that they enjoy talking with the inspector, it is also indicative of their limited social life. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 13 The limited activities and experiences for the residents is further exasperated by the demands on staff time and attention that one resident requires. His current funding is inadequate to provide the level of staff support that he needs which has an adverse affect upon the staff time available for the other residents. During this inspection the resident spent half an hour in the lounge when the behaviour displayed was detrimental to the other residents. There is a need for the service provider to seek a reassessment of this residents needs in order that his needs are fully met with appropriate staff support. Another resident is totally reliable on staff support to meet his personal needs as well as social and emotional needs. He currently has limited one-one funding and as such his full needs are not met. The service provider should seek a reassessment of this mans needs in order that he receives the care and support that he needs. When asked about the meals they receive the residents were more positive than during the previous inspection and stated that they enjoy the meals they receive. They explained how they plan the meals together for the forthcoming week. The inspector viewed a copy of the menus, which reflected a varied, and healthy balanced diet is now being offered. As part of the ‘Tracking process’ the inspector viewed individual care plans which reflected that people are not weighed on a regular basis and therefore weight loss/gain may only be noted when clothes become loose/tight. There was a record sheet to record weight but for some people this had not been completed since August 2005. Regular checking of peoples weight is an essential part of monitoring health needs. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Medication is appropriately administered. The residents benefit from the homes policies and procedures for dealing with medication. EVIDENCE: The homes policies and procedures in relation to the administration and storage of medication are robust and adequately protect people. The records seen reflected that medication is signed for at the of administration, the service provider confirmed that the staff are trained to administer medication appropriately. At the current time the home does not use a monitored dose system and is looking to do this in the near future. There is also a need for the residents and /or their representative to sign a ‘Medication consent form’ outlining that they wish the staff at the home to administer their medication or that they wish to administer their own. Risk assessments are carried out in relation to peoples ability to administer their own medication. All medication is securely stored. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 15 Any homely remedies used in the home are signed for by the GP agreeing the appropriateness for the individual. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The policies and practices within the home ensure that the residents are protected from abuse, neglect and self harm. EVIDENCE: The homes policies in relation to the protection from abuse are robust and in line with the Department of Health guidance ‘No Secrets’. The external doors to the home are locked to prevent intruders. The type of lock is such that people can leave the building without the use of a key. Each resident has a key to enter the front door and to their own bedroom. The residents stated that they feel secure living at Draycombe House. All staff have to receive Criminal Records Bureau clearance prior to commencing employment in the home thereby ensuring they do not have a criminal record that may leave the residents open to abuse. The homes ‘Complaints Procedure’ needs to be available on a video or audio tape to ensure all the residents understand it. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 17 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 & 30 The residents enjoy living in a clean and hygienic home but would benefit from a warmer environment. EVIDENCE: The lounge was not warm as the inspector entered the room. Indeed one resident was stood against the radiator and another went to join her. They said they often stand there to watch TV. When asked if they were warm enough they said ‘No’. The radiators were on but the room still felt cool. The fire was turned off. The lounge door was wedged open. When asked about this practice the Mrs Withers said they can put the fire on whenever they wish. The residents later confirmed this was true. Mrs Withers also stated that they keep wedging the door open. This practice is one which would not prevent the spread of fire should one occur. There is a need to remove the wedges from the home in order that people cannot wedge fire doors open. The heat provided in the room would then stay in the room. The provision of a wall thermometer would enable staff to ensure that the room temperature is adequate. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 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 The current staffing level is inadequate to meet the needs of the residents which affects the activities and social experiences. EVIDENCE: The residents informed the inspector that some of the staff have left. Mrs Withers explained that the home has recruited replacements for the current vacancies but are awaiting Criminal Records Bureau clearance prior to commencing work. However the lack appropriate funding to meet the needs of two residents has an adverse affect upon the staffing level within the home. Mrs Withers recognises the importance of staff training and to this end the following training was evident in the staff records. 1 member of staff has completed National Vocational Qualification level 2 in care Another member of staff has almost completed the course 1 member of staff is commencing National Vocational Qualification level 3 Care. 1 member of staff has completed level 3 in care. The person applying to be the registered manager is currently completing level 4 in care. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 19 In addition to this 2 staff have completed the Learning Disabilitry Award Framework induction training. 1 member of staff the service provider and manager have completed Medicine Management training Staff have also completed in-house training in the following; Fire Safety Food hygiene Moving and handling. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 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): 42 There is an intention to provide the correct level of protection to the residents in relation to health, safety and welfare but this is not always achieved. EVIDENCE: The wedging open of fire doors leaves people at risk from the spread of fire should one occur. There is a need for the home to carry out a risk assessment of the home in relation to fire safety. Ensuring action is taken to eliminate/ reduce the identified hazards. The inspector viewed the fire safety record and noted that the last fire drill was 4/11/05. The home has a practice of sounding the alarm on a weekly basis to ensure it is effectively working. As previously stated in this report the provision of wall thermometers would enable room temperatures to effectively monitored and thereby ensure the residents did not feel cold. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 21 The management regularly tour the home to ensure any possible causes of slips/trips/falls are erradicated. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 x 14 x 15 x 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 3 x x x x x 2 x Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 23 yes 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 the residents have a meaningful lifestyle. The service provider must ensure that fire doors are not wedged open. The service provider must ensure that the home has adequate temperatures for the comfort of the residents. The service provider must employ a manager who is registered with the CSCI The service provider must ensure that the staffing levels are appropriate to the needs of the residents. The service provider should carry out risk assessments in relation to developing the social lives of the residents. The service provider must ensure re assessments of the residents are carried out when necessary. DS0000042609.V270575.R01.S.doc Timescale for action 30/03/06 2. 3. 4 YA13 YA42 YA24 16(2)(n) 13(4)(a) 12(3) 30/03/06 28/02/06 28/02/06 5 6 YA37 YA33 8(1)(a) 18(1)(a) 30/03/06 30/03/06 7 YA14 13(4)(b) 30/03/06 8 YA3 14(2)(a) 30/03/06 Draycombe House Version 5.1 Page 24 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 YA24 Good Practice Recommendations The service provider should produce an audio tape/video of the Service users Guide, thereby enabling service users to be aware of its content The service provider should install wall thermometers to monitor room temperatures. Draycombe House DS0000042609.V270575.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection North Lancashire Area Office 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 DS0000042609.V270575.R01.S.doc Version 5.1 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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