Inspection on 06/11/07 for Draycombe House

This inspection was carried out on 6th November 2007.

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

Draycombe House 11/11/08

Draycombe House 22/01/07

Draycombe House 31/01/06

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 6th November 2007 14:00 Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 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 Mr Michael Raymond Wilson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is registered for a maximum of 6 service users in the category of LD (Learning Disabilities) 22nd January 2007 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. The current fees for the home are £361 to £779 dependant upon the individual’s assessed needs. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced, in that the provider, manager, residents nor staff were aware it was to take place on 6/11/07. The site visit is part of the key inspection of the home. A key inspection takes place over a period of time, and involves gathering and analysing written information, as well as visiting the home. The Commission For Social Care Inspection is trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. One of the ways is by involving in the inspection process people who have experienced social care. They are called ‘Experts by Experience’. Experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people who have been appointed by First Step/North West Training and Development Team, under the direction of the Commission for Social Care Inspection, to take part in the inspection of services for people with a learning disability. The inspection involved; • • • • • Observations of care practices Discussions with the residents Interviews with the staff and the manager. Examination of records that are required to be maintained including plans of care. The expert by experience spent time talking with 4 of the people who live at Draycombe House Before the visit took place, the service provider was asked to complete an AQAA (Annual Quality Assurance Assessment) this document is required to be completed annually and reflects how the services are provided. In the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small group of residents during the site visit. All records relating to these individuals are examined. Residents are invited to discuss their experiences of the home with the inspector. A response to surveys was requested from residents, relatives, staff and visiting professionals. The comments contained in the completed surveys included: Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 6 “ It is a nice home” “ I go see my sister on a weekend and I go by myself in a taxi” “ I like my home and my friends and the staff” In relation to complaints people said they would tell Steve (care manager) In relation to making decisions about what to do each day some people stated “Usually” What the service does well: What has improved since the last inspection? The service has taken on board the advice offered during the last inspection in January 2007. Bedrooms did not have windows left open and the rooms were warmer. The care manager has continued to look at increasing the activities available for people. He has consulted with the residents and staff, to ensure people have a fulfilling lifestyle. The expert by experience spoke with 4 of the residents and noted the following: Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 7 “people went : To the local pub Walking around locally Out for meals Some people: Kept in contact with family and friends Had been to a firework display on Monday 5th November Like going to Blackpool for holidays Two people had been to the Isle of Man for their holiday and looked at holiday brochure for their holidays next year” There has been a new shower provided and the shower room has been re tiled. This has improved this facility. What they could do better: There is an intention and determination by the care manager to provide a good service. -The manager acts upon the wishes of the residents, which is a positive approach to caring for people. However there are times when this must be with guidance. Risk assessments must be carried out in relation to the home. For example one lady likes the lounge door to be held open so that she can see who is coming in and out of her home. However this would be a hazard if a fire were to break out. The door should be held open by a device that would release the door should the fire alarm be sounded. This would give the resident her choice and protect people from the possible spread of fire. -There’s a need to ensure medication is securely stored and signed for at the time of administration. Ideally medication should be stored in a locked metal cabinet. -The sports equipment cluttering one of the resident’s toilets should be removed and returned to its owner. It is important to maintain the home in a good standard of decor. When speaking with the expert by experience the residents made the following comments: Some people were not sure who decided on how the house was decorated. They thought the staff decided about decoration but staff listened to their opinions about decorations Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 8 One person said that staff listened to their views about how the house should be decorated and then they organised it There was mixed message about how the house was decorated. The expert by experience felt ‘the decoration could be improved, but was not sure if the people living there felt it should have been improved.’ The staff spoken with had a positive approach to caring for people. They had received induction training and the home has achieved having over 50 of the staff with a National Vocational Qualification. However the recruitment practices need to be improved to ensure 2 written references are obtained for all staff and a POVA First obtained prior to them commencing employment. It is desirable that Criminal Record Bureau clearance is also obtained prior to commencing work. However, in exceptional circumstances the person may commence employment providing they do not work unsupervised. All documentation relating to the recruitment should be stored on the individuals file. All parts of the home should be maintained at a temperature so that the residents are comfortable. The dining room was not warm and the radiator was cold. The management keep a record, when someone requires their finances to be looked after; we advised on a better way of maintaining the record including 2 signatures for all transactions. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 9 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 10 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.V350587.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No-one moves into the home before having their needs assessed and being assured that these will be met. EVIDENCE: There is detailed information available about the home for all residents, or possible residents, which has been developed over time into a very clear and easy to read description of the services provided, and who provides them. It is available in written and on an audio cassette to help the residents understand the content. Individual records are kept for each resident, and the management team discussed the way anyone new would be initially invited to visit the home and meet the residents. A social work assessment would be used to help the owner decide whether the home was the right place for the new person, that the staff were able to give the right care, and that the present residents were compatible with them. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 12 We (Commission for Social Care Inspection) looked at an assessment for the last person admitted to the home and this was based on the individuals diverse needs, to make sure the right care and support is given. The three people involved in the case tracking process had lived at the home a large number of years and asessments of their needs prior to living at the home were not available however their current needs are well known and recorded. There was information on the residents strengths, needs, personal goals, and choices. The residents were included in deciding what the best care for them was. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 13 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents would further benefit from living in a home where they choose their visitors. EVIDENCE: The care files for the three people who were part of the care tracking process had care plans. One person had been visited by a social worker that had carried out an annual review, along with the staff and management. This covered all aspects of care including health care needs. The care plan for this person reflected she likes baking cakes. When asked she confirmed she likes baking and gets the opportunity to do so. The plan also identifies she “can not differentiate between coins.” When looking at the Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 14 ‘record of monies held on behalf of a resident’ we noticed that a round sum of money always went to the individual with no change recorded in the record. We were told the individual kept the change. There is a need to record how much the change was and that it was given to the individual. When a person lacks the capacity to manage their own finances this information should be recorded and the management have a duty of care to ensure the people are safeguarded from possible financial abuse. Risk assessments were seen on files in relation to various aspects of life, for instance one person had a risk assessment in respect of showering. The management of the home ensure that the residents rights to equality are met in a way that best meets their individual needs, for example one resident has been enabled to have a part time job which gives her great pleasure. The employer has accepted her disability whilst recognising her ability to carry out the job. The residents right to choose who comes in their home should be respected and not have visitors imposed upon them. 2 people receiving support through a ‘Supported Living Sceme’ were observed in the home and were not invited in by the residents. One man had come to collect his meal, which wasn’t ready and he was asked by a member of staff, to wait in the dining room, which he declined as he could see we were ‘in a meeting’ When speaking with the expert by experience the manager explained that people’s choice of college courses had been restricted as many courses incur a fee, which is very expensive for people on a low income. In order to address this the care manager has arranged a meeting with ‘Welfare Rights’. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents can choose from a variety of activities to help develop their skills. Their decisions are respected, and daily routines promote independence. The meals in this home are good, offering both choice and variety. EVIDENCE: The expert by experience spent some time talking with 4 of the residents. He noted: “People Go shopping in Morecambe Go to the Arndale centre in Morecambe Go shopping in Preston; one person said that this was boring Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 16 Can go out when they feel like it Watch football with their family (one person with their brother) Go to the cinema - one person said they did not like to go because it cost too much. One person has a mobile phone Other people dont use the phone No one requested a mobile phone One person interviewed went out most days, to the local area including the university to meet friends. Everyone said they were happy and got on together.” The other 2 residents were not available. The information supplied by the care manager states: “The residents are very happy and look forward to their daily life pattern” The residents said we go out in the mini bus with Steve (care manager) or Michael (manager) driving the bus. They spoke of a holiday in Blackpool. 2 people had been to the Isle of Man for a holiday but had decided Blackpool was better. The care manager said that they are continually looking at ways to expand upon activities available to ensure people have a fulfilling lifestyle. Completed staff surveys included the following comments: “Clients are given choices to fulfil their potential” “Need for more one to one outings with the service users” “Need to look at more ideas and involve family and service users” “The home could take people further afield on trips out and out for meals more often.” This comment is indicative of the activities and outings that the residents spoke to the expert by experience about which were nearly all local. Some of the residents have historically had no family contact, in that they have no known family. One person visits her sister each week. Another goes to watch the local football team with their brother on a regular basis. One person has a sister who lives a long way from the home. It might be good if she could speak to her sister on the phone occasionally. She told the expert by experience that she doesn’t use the phone in the home and she does not possess a mobile phone. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 17 The meals provided in the home offer a balanced diet. Special diets are provided as necessary. For instance one resident has meals liquidised due to problems chewing. It is important that each part of the meal is liquidised separately to ensure the meal looks appetising and keeps the individual taste of the meal components, for example vegetables separate to the meat etc. The residents help to choose the week’s menu and to shop for some of the produce. A staff survey included the following comment: “ Clients are well nourished and have a well balanced diet.” Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents would benefit from living in a home where their health and safety was fully promoted. EVIDENCE: Upon viewing the medication storage, we noticed that the lock on the door was broken and that only an Allen key lock was being used, which left medication available to anyone with an Allen key. Upon being given advice about this the care manager arranged for the handyman to replace the lock as quickly as possible. We phoned the day following the inspection to ensure the repair had taken place. We noticed that medication was inside a store cupboard where the care files were and as such all care staff would need access. The medication should only be accessed by the person in charge of each shift. Medication could be securely stored inside a locked metal cabinet. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 19 We viewed the Medication Administration Record and noticed that the lunchtime medication had not been signed for, but we were told it had been given. Medication must be signed for at the time of administration. A tour of the home revealed that one of the toilets was full of sports equipment that did not belong to the residents. The equipment made it hazardous to use the facility. It should be removed from the area and returned to its owner. People have their health care needs addressed as part of their care plan. These were seen for the three people who were part of the care tracking process. The residents spoke of trips to see their doctor when necessary and of staff going with them. Each resident has a ‘Health Record’ book, which includes individual details about their health care needs and medical appointments. There is a health action plan as part of this process. For one resident this included how staff should care for her if she is upset. The staff said that the home meets the needs of the residents. Completed staff surveys included the following comment: “ The service does well at supporting people” One resident has had some emotional problems and spoke of the support she has been given by an appropriate professional. . Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents benefit from living in a home where their opinions matter and their concerns are listened to and acted upon. EVIDENCE: There is a complaints procedure in place, with a complaints book in which to record any complaints that may come to the manager’s attention. All the residents and/or their family receive a copy of the home’s complaints procedure which is also available on audiotape. Neither the home nor the Commission for Social Care Inspection have received any complaints since the last inspection. Each resident is given a post card with their name on stating; ‘I have concerns that I would like to discuss’ this is stamped and addressed to the Commission for Social Care Inspection. This practice ensures people are enabled to raise concerns external of the home if they so wish. Staff spoken to knew about the Adult Protection procedure, and what to do if they had any concerns. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 21 The home’s policies in relation to the protection from abuse are robust and in line with the Department of Health guidance ‘No Secrets’. The residents when asked said, they were happy at Draycombe House and that they didn’t have any complaints. One said, “ I’d tell Steve (Care manager) If I was unhappy about something.” Staff spoken to knew about the Adult Protection procedure, and what to do if they had any concerns. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents would further benefit from living in a home that is safely maintained. EVIDENCE: The manager acts upon the wishes of the residents, which is a positive approach to caring for people. However there are times when this must be with guidance. Risk assessments should be carried out in relation to the home. For example one lady likes the lounge door to be held open so that she can see who is coming in and out of her home. However this would be a hazard if a fire were to break out. The door should be held open by a device that would release the door should the fire alarm be sounded. This would give the resident her choice and protect people from the possible spread of fire. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 23 The sports equipment cluttering one of the resident’s toilets should be removed and returned to its owner. The radiator in the dining room was cold and the room was not adequately warm. All rooms used by the residents must be kept at a temperature that ensures their comfort. The refurbishment of the shower room has made the room look more inviting and provided a safer environment to shower in. The lounge is homely, comfortable and clean, with a television in one corner. One resident sat relaxed on the settee resting her legs on her fiancé’s lap. Another resident was busy knitting in her favourite chair. The residents said that they enjoyed living at Draycombe House and saw it as their home. They appeared relaxed and content in their environment. Resident’s rooms reflected their interests and personalities. There’s a need to ensure a rolling programme of decoration to ensure the home doesn’t become tired looking. Residents should be consulted when a room they use is to be decorated allowing them to choose the décor. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents would benefit from living in a home where the staff recruitment process is robust. EVIDENCE: The staff spoken with had a professional attitude to their work and spoke respectfully about the residents. The staff said there are enough of them to provide a good quality of care to the residents. The residents confirmed that the staff meet their needs and gave examples such as: ‘They take us out in the mini bus’ and ‘we go to the pub’ A completed survey received from staff included the following comments: Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 25 “Good staff morale which lifts the mood within the home and ensures a low staff turnover” Resident’s surveys highlighted the following: “I like my home and my friends and the staff” “The staff are kind to us” And “This is a good home where we are well looked after.” We looked at 4 staff files and found that 1 had no written references and no Criminal Record Bureau clearance had been received. The manager said he’d had a POVA First for this member of staff, but could not find it. Another staff file had no written reference but a note was on the file indicating the manager had received a verbal reference. It did not give the details of the reference and this had not been followed up in writing. The other two staff files had the necessary information. However references were generally limited. The development of a questionnaire to send to referees would ensure all the necessary information required to decide about whether the person is fit for employment, is obtained. The management recognises the importance of staff training. All staff employed at Draycombe House undergo induction training when starting work at the home, using the Learning Disabilities Award Framework. Staff also attend the Learning Disability Award Framework Foundation course. Other training that is undertaken includes: Abuse Awareness Medicine Management Infection Control Fire Safety Health and Safety Food Hygiene. In addition to this 66 of the staff have achieved a National Vocational Qualification in care at level 2 or above. This is indicative of the management’s recognition of the importance of having staff that are trained and competent to carry out their role. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents would benefit from living in a home that is competently managed and where their health, safety and welfare is of paramount importance EVIDENCE: There is an intention to offer a good service at Draycombe House. The staff have a good relationship with the residents. The comments included in the surveys from staff and residents included: “ I like my home and my friends and the staff” “ It’s a nice home” and “The staff are kind to us” Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 27 We viewed 4 staff files as part of the case tracking process and we found, the staff recruitment process lacks a professional approach to ensuring only the right calibre of person is appointed. For instance: -2 written references are not always taken up. -Criminal Record Bureau clearance is not obtained prior to an applicant commencing employment. There is a need to develop a questionnaire for referees to ensure the necessary information is obtained. Notes should be made during interviews and stored on the staff file. Management need to ensure the resident’s home is not used as a base for another service. The home must be maintained in a manner that promotes health and safety. The current practice of fire doors being held opened by devices other than ones where the door would be released should the fire alarm be sounded leaves the home vulnerable to fire spreading. Equally rooms that are for the residents use should not be cluttered with property that isn’t theirs, such as the sports equipment in one of the resident’s toilet area. In addition to a registered manager, the continued employment of a care manager who has experience of caring for people with a learning disability has ensured good practices such as the residents care plans being kept up to date and that people are enabled to have a fulfilling lifestyle. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 28 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 3 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 3 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 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 29 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 YA9 Regulation 17(2) Requirement When an individual is assessed as lacking capacity to manage their own finances, a record as outlined in Schedule 4 of the Care Homes Regulations must be maintained in detail as specified. This would ensure resident’s finances are safe guarded. When inviting other people into the home the wishes and feelings of the residents must be taken into account. Medication must be securely stored at all times, to ensure no one could take medication that isn’t his or hers. The medication Administration Record must be signed at the time of administration, reflecting person has had medication as prescribed. The sports equipment that is making entry to one of the resident’s toilets hazardous must be removed. To promote the health and safety of the residents. Fire doors should only be held open by devices that would release them when the alarm is DS0000042609.V350587.R01.S.doc Timescale for action 30/11/07 2 YA7 12(3) 30/11/07 3 YA20 13(2) 07/11/07 4 YA20 17(1) 06/11/07 5 YA24 12(1)(a) 30/11/07 6 YA24 23(4)(a) 14/12/07 Draycombe House Version 5.2 Page 30 sounded. This would help prevent the spread of fire. 7 YA34 17(3) Staff files must contain all the necessary information reflecting the homes recruitment procedure is effective and safeguards the residents. The home must be managed in a way that promotes the health and safety of the residents. 30/11/07 8 YA37 12(1)(a) 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA24 YA24 Good Practice Recommendations Rooms used by the residents should be maintained at a temperature that ensures their comfort. There is a need for a rolling programme of decoration to prevent the home from becoming tired looking. The residents should be asked as to their choice of décor. Draycombe House DS0000042609.V350587.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@Commission For Social Care Inspection.gsi.gov.uk Web: www.Commission For Social Care Inspection.org.uk © This report is copyright Commission for Social Care Inspection (COMMISSION FOR SOCIAL CARE INSPECTION) and may only be used in its entirety. 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