Inspection on 16/06/08 for Drummond Court

This inspection was carried out on 16th June 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Drummond Court 23/07/07

Drummond Court 27/06/06

Similar services:

Claremont House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Firstlings

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Drummond Court Mill Road South Bury St Edmunds Suffolk IP33 3NN Lead Inspector Claire Hutton Unannounced Inspection 16th June 2008 09:35 Drummond Court DS0000063432.V366546.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 Drummond Court DS0000063432.V366546.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. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drummond Court Address Mill Road South Bury St Edmunds Suffolk IP33 3NN 01284 767445 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) drummondcourt@activecarepartnerships.co.uk Active Care Partnerships (Drummond) Ltd Mrs Christine Ellen Fryer Care Home 36 Category(ies) of Dementia - over 65 years of age (1), Learning registration, with number disability (26), Learning disability over 65 years of places of age (10) Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for one named service user with dementia (DE(E)) as described in variation dated 22/03/05. 23rd July 2007 Date of last inspection Brief Description of the Service: Drummond Court is a residential care home for a maximum of 36 adults with learning disabilities. Drummond Court provides a variety of accommodation with varying levels of support. Accommodation offered includes bungalows, houses and flats. Drummond Court is situated in pleasant surroundings, close to the centre of Bury St. Edmunds. Bury St Edmunds offers a small town and has a range of services, which residents of Drummond Court may use. The home’s manager is Mrs Christine Fryer. At the time of the inspection the manager reported that fees ranged from £422 to £1179 per week, dependant on the levels of care required by each service user. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use the service experience good quality outcomes. This was an unannounced key inspection that focused upon the core standards relating to Adults (18 – 65). It took place on a weekday lasting 9 hours. The inspection process included visiting all areas of the home, discussions with staff and residents, observations of staff and resident interaction, and the examination of a number of documents including residents’ care plans and associated documents, medication records, the staff rota, records relating to health and safety and records relating to staff recruitment. The inspection team was made up of an Inspector, an Expert by Experience and his supporter. Darren Cunningham (Expert by Experience) and his supporter came from ‘Barking and Dagenham centre for Independent Living Consortium’ as a service user Darren Cunningham has an expert opinion on what it is like to receive services for people who have a learning disability. His comments are included throughout this report where he is referred to as an ‘Expert by Experience’. The Expert by Experience found Drummond Court a very warm and friendly place. All the residents he had spoken with were very happy and liked living here. The Expert by Experience spoke with both the CSCI inspector and the manager to inform them some of his findings. The report has been written using accumulated evidence gathered before and during the inspection. The Commission had received an Annual Quality Assurance Assessment (AQAA) completed by the deputy manager before the inspection. This is a self-assessment document. Six completed surveys were received back from the home. These were all positive. Three completed surveys were received back from relatives and friends of the residents. One relative said ‘Our relative is happily settled and the staff are always approachable’. Three completed surveys were received back from the residents. No surveys were received back from staff members so we interviewed 4 staff in private during the visit to Drummond Court; three other staff were met and spoken with in passing. Comments received by people who use this service are used throughout this report. On the first day of this inspection an immediate requirement was left as the hot water temperature from a shower was so hot it presented a possible risk of scalding to the vulnerable resident who used it. We received a letter from the service to tell us that the risk had been addressed. However when we visited again on 2nd July we found excessive hot water temperatures on 2 showers at the home and therefore there was still as risk of scalding to residents. We left a further immediate requirement and subsequently received a letter to say that the matter had been addressed. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 6 When we visited on 21st July we found that the hot water outlets to showers had been addressed. Showers now provided hot water, but this was restricted to a temperature that was less of a risk to scald those vulnerable people who used the showers. What the service does well: What has improved since the last inspection? At our last key inspection of this home in July 2007 we left no requirements. At our initial visit to the home this year on 16th June 2008 we left the immediate requirement around hot water that we came back to check on. We also gave feed back on other matters that were required to be addressed such as the fire extinguishers not being serviced on schedule, several fire doors being wedged open and maintenance required to shower rooms and purchase and fitting of washing machines. We found that on our 2 visits in July to ensure the immediate requirement was met, these outstanding requirements had also been addressed. This shows that although these matters were not in place, when pointed out directly to the manager she ensured quick compliance to the standards. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 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 Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to be provided with the information they need about living at the home, that their needs and aspirations will be assessed and met and that they are provided with the opportunity to visit the home before moving in. EVIDENCE: In the main entrance to the home that also houses the day centre and offices, there were copies of the Statement of Purpose and Service Users Guide available for anyone to take away. The manager was aware of a change in the Responsible Individual that had just occurred and the need to up date the Statement of Purpose with the information. Relative surveyed told us they were happy with the information available. The self-assessment told us: ‘Pre-admission documentation is included into the service users care plans’. Three sets of documentation were examined at random. All three people had evidence of assessment before they moved into the home. Social Workers also provided information to the home on the assessed needs. The manager had visited one individual in hospital and this person had visited the home before they moved in, however from the time of assessment to the time of moving in care needs for this individual had changed. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 10 Therefore staff did not immediately have the correct information to care appropriately for the individuals physical needs. The home acted and has since implemented assessments and agreements drawn up in a multidisciplinary setting that gave assessments, equipment and guidance from external professionals such as occupational therapists and social workers. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they have an individual care plan, that they make decisions regarding their lives and that they are supported to take risks as part of an independent lifestyle. EVIDENCE: The care plans and associated documentation for 3 residents from different units were examined in detail. These had been reviewed on a monthly basis and had accessible information for staff to follow. The care plans included details of support they required in all aspects of their daily living. The documents included information taken from the needs assessments, which had been undertaken prior to admission and were regularly updated with changing needs and preferences. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 12 One care plan showed that there were clear instructions available to staff on how best to support the individual. There was a behavioural support plan and staff had recorded information about behaviour to share with other staff who were supporting that individual. Staff spoken with knew how to complete these forms and were confident about how best to support individuals, which ensured a consistent approach. The same person had daily records duly completed by staff about personal support given, meals and drink offered and eaten, sleep patterns and activities they had participated in. These records were completed well and gave good information. The care planning information in place for one individual was also examined and discussed with the manager. There was a care plan that had yet to be fully developed, but the individual had been there 12 days. The care plan in place was developed further on the day to a satisfactory level and then had developed more at the subsequent visit to the service. There was evidence available at the subsequent visit to the home that a formal review with the funding authority in a multidisciplinary setting had enhanced the care service available to this individual. There was evidence that residents did make decisions about everyday activities. Resident choice was respected when offering activities. Daily records also documented choices offered and made. A resident told the Expert by Experience he was able to make his own cup of tea/coffee if he wanted. The Expert by Experience noticed the residents having their own boxes with their names on for their washing. The resident said “I do my own washing”. Expert by Experience asked the resident did he have house meetings to put his grumbles and ideas across. The resident said “house meetings are once a month, but I can say what I want, I don’t wait for house meeting”. The resident told the Expert by Experience “I like to go out on my own in town”. Relatives surveyed said they felt the home always met the needs of their relative. The risk assessments in care plans identified the risks in daily living and methods of minimising them. These had been reviewed and reflected what people had spoken about during our visit such as going out with support, swimming, using the kitchen, behaviour that may be challenging, falls and food and drink. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with appropriate opportunities for leisure and personal development that met the needs of the resident group. People enjoyed a healthy varied diet. EVIDENCE: There was a good range of activities available for residents to participate in, both in the community and in the home. There was a range of materials for activities available in the home which included arts and craft materials, books, television, music and films. Resident’s bedrooms had their personal belongings which they used for entertainment including music, television and computer games. The Expert by Experience reported very favourably on this section of the report and here are some of the comments and observations made: The Expert by Experience asked a resident if they go out with friends/family. The resident Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 14 said “I go out to eat and I go to Pot black (snooker club) and bowling on Tuesday, I am going to the gym today at 2pm”. The resident also said “I can have friends visit me in my room when I want”. The resident spent their birthday celebrating with their family and girlfriend. The resident showed the Expert by Experience their bedroom with all their personal belongings. The resident had many different certificates hanging on the wall; some were for cooking, swimming. The resident showed the Expert by Experience their play station and their new wii console. The resident said “I like playing the sports games”. The resident said “I want an X-box”. The resident chose the carpet and bedding for their room and they can choose when they wake and go to bed. This demonstrates that individual rights, choices and self-determination were respected. Interaction between staff and residents was observed to be positive and respectful. Staff were observed including residents in their discussions. There was lots of laughter and friendly chat observed. Staff were observed to knock on bedroom doors before entering and they asked permission for the inspector to view their home or bedroom. The self-assessment told us we ‘Ensure the people who use our service are encouraged to make decisions regarding the way they live their lives. This is done by finding out as much as we can about each individual, what their interests and ambitions are as well as any barriers they percieve there are to achieving these. We try to ensure that all activities are meaningful to the individual and we encourage people to take up education training or employment with appropriate levels of support. We encourage all people who use our service to take up their rights as citizens, by applying the companys policy on service user rights and voting by service users and to access and be part of the community to promote a sense of belonging. We also try to ensure that personal and sexual relationships are thought through and appropriate, with guidance for service users personal relationships, which can be provided on request’. One relative told us ‘I’m very happy that my relative is at Drummond Court. Our relative is unable to express himself but we feel they are happily settled. The care staff are always approachable’. Records showed that relatives had regular contact by telephone and relatives can regularly visit if they so wish. Two relative wrote on their survey ‘My relative is looked after very well’. Care staff were seen to be preparing refreshments throughout the day as and when people requested them. A resident told the Expert by Experience a staff member did food shopping on a Wednesday and if they asked him he would go shopping. The resident said he does choose what he wants to eat. The Expert by Experience said ‘Staff were preparing a healthy lunch for the residents and putting the food in the fridge with labels showing dates of the food’. The Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 15 Expert by Experience asked staff if they have a choice with their meals. staff said “residents have a good healthy menu; food is cooked fresh every day and one resident has her food liquidize”. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported in a manner suited to their personal preference. Residents can also expect to have good access to healthcare services. Medication practices were generally effective to protect people. EVIDENCE: Resident’s records viewed included details of the personal support they required and preferred, including their preferred routines. Three staff spoken with were all quite clear about how they would promote privacy and dignity when supporting individuals with personal care. ‘I would always ensure doors were closed and curtains drawn. I would encourage a person to do as much as they could for themselves. It’s also important not to get embarrassed’. The Expert by Experience asked a resident could they choose to have a bath or shower. The resident said “I can have bath and shower I can”. The health records relating to 3 individuals were examined. Records were kept of visits to the general practitioner (GP) and other health professionals. All residents were registered and had access to the doctor’s surgery in Bury St Edmunds. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 17 A record of visits to the GP, wheelchair services and dentist were seen in one residents care plan. Another plan contained specific health related assessments such as continence care, falls assessments and manual handling – this had an on going weight record also. This individual also had an assessment completed for the use of bedrails and this had recently been reviewed. The Expert by Experience asked a member of staff if the residents have the same Doctors/Dentist and do the residents visit them? Staff told the Expert by Experience “residents do have their own Doctors/Dentist and they can see them if they need to”. The home used a MDS (monitored dosage system). Medication records and storage was examined in 2 units. Storage and security was on the whole good, but one medication cabinet in Harmony House had a very worn lock. The manager agreed to look into replacing this. The MAR (medication administration records) charts viewed were completed appropriately, in most cases and staff had signed to evidence that medication had been administered. However there was one gap found. Staff spoken with believed this to be a missed signature and that the resident had received their medication. The MAR charts included a photograph of the resident and what medication they were prescribed. In Harmony House we tried to audit the medication for one resident, but were unable to make the medication add up, however on our second visit to the home this had been examined by a staff member and all medication was able to be accounted for. Where residents self medicated, records were maintained on a weekly basis and residents were provided with a dossette box with their medication on a weekly basis. Their records explained the procedure for the support they required. There were also good written procedures in place for medication needed ‘as and when’. However the records of stock held should be maintained each month, even when nothing has been administered to allow auditing if required. The staff spoken to were quite clear that they were only to administer medication if they had received training to do so. One staff member told us they had received training, but were awaiting their observation before being allowed to administer medication alone. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a clear policy and procedure in place for making complaints and dealing with allegations or suspicions of abuse. People were protected and their views listened to. EVIDENCE: The self-assessment completed by the home tells us ‘We have a robust and clear complaints procedure for the people who use our service and their relatives, and a whistle-blowing procedure. Staff and management are approachable and available to listen to comments and complaints and will always take appropriate action. We manage complaints objectively and effectively and have clear timescales in which we provide a response. A copy of the complaints procedure is clearly displayed in the home’. A copy of the homes complaints procedure was made available to the residents and their relatives in the Service User Guide. This is also found in the main entrance. The self assessment also told us that in the last 12months the service had received 7 complaints and that all of these had been resolved within the 28day timescale. The complaints book was seen; we found evidence that complaints were acknowledged, investigated and appropriate action taken. One relative told us that ‘I have made a complaint in the past and this was dealt with immediately’. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 19 In relation to the protection of vulnerable adults from abuse we know that the home has the appropriate local policies and procedures in place and is aware of how to use them. All 3 staff spoken with were quite clear about their responsibilities in relation to safeguarding and to listening and reporting any concerns that the residents may raise. All these staff said they had received training in this area. The self-assessment told us ‘we have clear policies, available to staff, service users and visitors on prevention of abuse and protection of vulnerable adults. Staff are aware of these procedures and regular training is provided’. In relation to residents finances there were different measures in place for different people that offered protection but also independence. The Expert by Experience asked if residents have their own money. Staff said “some residents do not understand money so we help them, one resident needed shoes so we bought them for him”. The Expert by Experience asked a resident they has their own money and if they can spend it on what they want. The resident said “I get my money on Friday for the week from the office I put it in my tin in my room with a key. I like to spend my money”. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Drummond Court was comfortable, clean and generally well maintained. Ineffective laundering does compromise the hygiene in one area of this complex. EVIDENCE: The self-assessment completed by the manager told us ‘Provide a relaxed, friendly, safe environment that encourages individuality and a sense of belonging to the people who live in our service. We encourage service users to individualise their rooms, and take an active part in choosing furniture for communal areas in their homes. Service users are encouraged to take a pride in their environment by keeping their individual bedrooms clean, tidy and odour free. Staff are always available to assist service users who require assistance’. However we could improve the environment by ‘Continuing with a redecoration programme and continually updating furniture and soft furnishings and well as improving the gardens’. We toured the premises and agree with this statement made in the self-assessment. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 21 We found that this purpose built home offered good-sized accommodation with enough communal and private space for residents to spend time on their own or be involved in a group activity. There was a communal area in the main building of the home, where residents could participate in arts and crafts activities. There were also clusters of seating in the grounds for use by the residents. The home provided vehicles, which residents could use and a short walk from the home could access local bus services. There had been decoration of various parts of the home, new flooring purchased and new equipment such as washing machines and refurbishing shower rooms. A new bath with hoist had been fitted into one of the bungalows to meet the needs of the people who lived there. Residents spoken with said that they liked their home and that they could choose the décor and furnishings. The home had a lot of wear and tear due to the complex behaviours of the residents; generally the houses were clean, airy and comfortable and repairs and maintenance were promptly carried out. The décor was generally bright and cheerful, but there were some areas that needed attention. In the Lodge The Expert by experience commented that the Lounge was not homely. The Expert suggested that it would be nice if this room looked more homely as it looked very bare. The Expert by Experience also found in some areas of the home no plugs, soap or hand towels within the bathrooms. We also found that the trees at the back of Harmony House were so tall that they stopped any natural light from entering those rooms at the back of the building. These points were fed back to the manager and she had begun to action them when we visited the home again. A discussion was held with the manager about ensuring level access to all areas of the home for people with mobility problems. This was in relation to one of the flats where a resident used a wheel chair, but staff struggled to access through the front door and in relation to a stair lift that had been installed in Harmony House. If residents are unable to manage stairs then they should be moved to more appropriate accommodation such as a bungalow. This was of particular relevance to one resident and the manager agreed this would happen as soon a place became available. Resident’s bedrooms viewed during a tour of the complex, each reflected the resident’s individuality. Bedrooms were very different from each other. Furnishings provided met with resident’s needs and included a bed, wardrobe, set of drawers and seating. The Expert by Experience found bedrooms were very personal with resident’s belongings. This pleased the Expert. One resident had lots of pictures with Cliff Richard on the walls. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 22 The laundry rooms in the houses were generally well equipped to launder clothes appropriately. However staff in Harmony House told us that they had up to 5 people who had continence problems, but on inspection the washing machine did not have a sluice facility to launder clothes appropriately to ensure adequate cleaning. The self-assessment also told us the home had not used the Department of Health’s ‘Essential Steps’ to assess their current infection control management. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be assured that staffing levels meet residents health and care needs and that staff are trained to do their job. Residents were protected by the homes recruitment practices. EVIDENCE: The roster in use at the home was examined and this showed sufficient staff were consistently on duty. Relatives told us that they believed the staff group met the needs of people at the home and staff always had the right skills and experience to look after people. Staff spoken with said they had been appropriately recruited, were never asked to do tasks beyond their knowledge or skill. All 3 staff spoken with had NVQ 2 in care and freely listed the training they had attended recently. This included manual handling, 1st aid, food hygiene, fire, health and safety, abuse awareness and medication. The self-assessment completed by the home tells us ‘We operate a robust recruitment procedure to ensure staff have the right experience, qualifications and personal attributes to provide a high standard of care. This is done by adhering to our equal opportunities policy. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 24 Personnel files are complete and are audited on a monthly basis. All appropriate documentation in received prior to any staff commencing duty. The duty rota in the home is managed to ensure that adequate staffing, with the appropriate skill mix are on duty. Every member of staff have an individual training plan which ensures all statutory and obligatory training is facilitated and to ensure their own individual personal development’. Recruitment records for 2 staff were examined and these found that background checks were completed in line with regulation therefore provide the safeguards to offer protection to people living at the home. The 4 staff spoken with confirmed that they received regular formal supervision. One person said ‘It is regular and the deputy and manager are always available to answer questions’. Another staff member said that they also received supervision in the form of observation from time to time whilst administering medication. A resident told the Expert by Experience that they have a key worker ‘she helps me choose my clothes and she helps me with my money’. The Expert by Experience noted to his support worker how happy this resident was. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Drummond Court was well managed. The health, safety and welfare of people was responded to, but closer monitoring would be proactive. EVIDENCE: The Statement of Purpose identified that the home’s manager had achieved an NVQ level 4 registered manager award. The manager was also registered with us at the Commission. The manager spoke of her plans to retire in the coming months and that plans were under way for her replacement. Staff spoken with said that they felt they had adequate support from the managers within the home and that the team meetings were helpful, but 2 staff said that communication from management could be improved and would benefit the service provided. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 26 There was a good quality assurance process within the home and residents were regularly consulted regarding the care they received and the running of the home. This was in the form of surveys to users of the service. On our last visit we looked at these and said they were good as they were accessible to people with a learning disability. There were regular Regulation 26 visits, undertaken by a senior manager. The visits included the monitoring of records and the environment and discussion with staff and residents, points for action were made during the visits if required. The managers spoke of regular audits and checks that they made in the home on a monthly basis, including resident’s records and medication. Their bimonthly home audits were validated by a senior manager who attended the home on the months between the completion of the audits. At our initial visit to the home this year on 16th June 2008 we left the immediate requirement around hot water that we came back to check on. We had to visit the home twice to ensure that residents were safe. Showers now provided hot water, but this was restricted to a temperature that was less of a risk to scald those vulnerable people who used the showers. On our first visit we also gave feed back on other matters relating to health and safety that were required to be addressed such as the fire extinguishers not being serviced on schedule, several fire doors being wedged open and maintenance required to shower rooms and purchase and fitting of a washing machine in the flat. We found that on our 2 visits in July to ensure the immediate requirement was met, these outstanding requirements had also been addressed. We found that all matters around fire safety were up to date, showers were functioning and a washing machine was fitted. This shows that although these matters were not in place, when pointed out directly to the manager she ensured quick compliance to the standards. Still outstanding at the time of writing was Harmony House needed to have appropriate facilities to launder soiled clothing to ensure good hygiene standards for the safety of residents and staff. Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 3 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 3 25 3 26 X 27 X 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 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 3 X 3 3 3 X X 2 X Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 YA30 Regulation 13 (3) Requirement Harmony House needs to have appropriate facilities to launder soiled clothing this will ensure good hygiene standards for the safety of residents and staff. Timescale for action 13/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Flour Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 0845 015 2255 or 0191 233 3588 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 Drummond Court DS0000063432.V366546.R01.S.doc Version 5.2 Page 30 - 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. 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