Inspection on 27/06/06 for Drummond Court

This inspection was carried out on 27th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Drummond Court 16/06/08

Drummond Court 23/07/07

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 08/07/2008.

CARE HOME ADULTS 18-65 Drummond Court Mill Road South Bury St Edmunds Suffolk IP33 3NN Lead Inspector Jan Davies Key Unannounced Inspection 27th June 2006 11:45 Drummond Court DS0000063432.V301941.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.V301941.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.V301941.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 01325 351 100 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) 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.V301941.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. 6th September 2006 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. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key unannounced inspection, carried out on a weekday between the hours of 12.50am and 6.00pm. The Registered Manager was present during the inspection and residents and staff of the home fully contributed to the inspection process. The inspection involved a tour of the premises, discussions with staff and residents and the examination of a sample number of residents care plans and four staff files. A variety of other documents including policies, procedures and medication records were looked at during the inspection. This report assesses key standards relating to younger adults and reassesses those that were not entirely met at the time of the last inspection in September 2005. What the service does well: What has improved since the last inspection? The Quality Assurance Review has been developed further to ensure that residents are involved in planning annual objectives for the home. The home’s training programme has been developed to include dementia training for staff to better care for the resident for whom this applies. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5, Quality in this outcome area is good. Prospective service users can expect that they will be provided with the information they need to make an informed choice about where to live, that they will have their needs assessed and met and that they will be provided with the opportunity to visit the home before they decide to move in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection six residents care plans were examined. Each of them contained a copy of the home’s Service User Guide. The guides were appropriate to the residents’ needs and provided clear information about the home and its services using plain language and pictures to aid understanding. Residents’ records contained comprehensive pre admission assessments and personal information. The home’s care manager had undertaken assessments of need and further information had been sought by the home via questionnaires. The questionnaires demonstrated that the home had consulted other relevant professionals, the individuals concerned and their relatives. The home had used the assessments to develop personal support plans and individual risk assessments. The manager confirmed that prospective residents are welcome to visit and experience short stays before admission. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 9 Contracts were seen to be in place and set out the terms and conditions of the home. However for one resident the contract had not yet been completed and it was explained that their recent admission had been in response to an emergency situation and a contract was to be completed at the earliest opportunity. There was no reference on the resident’s file to clarify this. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 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): 6,7,8,9, Quality in this outcome area is good. Residents can expect to make informed decisions about their lives and matters in the home. They can also expect to be consulted about their plan of care. They can expect that they will be supported to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection four residents care plans were examined. Each plan contained detailed information about the resident’s needs, wishes and aspirations. The home then used the information to formulate a list of priority goals, action plans and risk assessments. The four care plans examined were of a good standard and demonstrated the fact that residents had been involved in the development of their plans. However the inspector found that on two occasions care plans had not been recorded as updated. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 11 Individual risk assessments were in place in each of the care plans seen. These were detailed and contained sufficient information to enable staff to approach and respond to that resident safely and effectively. There was evidence that the home gives assistance to enable residents to make informed decisions about their lives. Residents had been consulted about their care plans and there were also records of residents meetings that had been used as a process to consult residents about matters in the home. Where residents’ decisions had been limited for their own safety and protection documentation was held within their care plans and supported by risk assessments. On the day of inspection staff were encouraging residents to participate in the domestic routines of the home and enabling them to make decisions about their daily lives, for example meal times and preparation, shopping and leisure activities. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 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): 11,12,13,14,15, 16,17 Quality in this outcome area is good. Residents can expect to have opportunities for personal development and be encouraged to participate in appropriate social and leisure activities. Furthermore, residents can expect to be fully involved in the planning and preparation of their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans evidenced that residents have access to a wide range of opportunities to maintain and develop social and independent life skills. Staff confirmed that residents are given opportunities within the house and wider community to fulfil their needs and goals. On the day of inspection residents were observed being actively encouraged to practice their skills with appropriate support. Residents were seen participating in the day to day activities within the home but were also seen coming and going throughout the day to work experience / college and the local shops. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 13 The staff confirmed that they were supporting residents in the development of structured weekly programmes and gave examples of some of the activities being considered including college and further education courses. Care plans evidenced that residents are supported to ‘get out and about’ on a daily basis. As well as local facilities such as the shops, cinema and clubs and social centres, the residents have enjoyed travelling further a field in the home’s own ‘people carrier’ and on holidays abroad. One resident told the inspector about the play they were acting in and another resident talked about a favourite holiday that they had enjoyed arranged for them by the home’s manager. Conversations with staff and residents indicated that the home provided good support to maintain family relationships and offer opportunities to create and maintain social networks. There was evidence that the home is respectful of individual’s personal and sexual relationships and provides appropriate support and guidance. Risk assessments are in place and reviewed. On the day of inspection staff were observed respecting service users rights to privacy. Bedrooms were not entered without resident’s permission and all communication observed between staff and residents demonstrated that staff were respectful and polite. Each unit had a communal kitchen, which were all seen to be clean and hygienic with sufficient facilities. Staff reported that the residents are encouraged to participate in preparing and cooking their own meals and this was observed on the day of inspection. Staff and residents confirmed that residents are involved in shopping for groceries and able to chose their own meals with encouragement and advice about healthy and balanced diets. Records of meals taken and choices offered were seen and satisfactory. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 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): 18,19,20 Quality in this outcome area is good. People who use this service can expect to have their care needs documented and met most of the time, but more consistent recording of medication will ensure quality of care for every resident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans, daily records and conversations with staff and residents indicated that staff provide personal support appropriately to individuals. Support was being provided flexibly and in consultation with residents. Staff reported that there were no fixed times for meals, getting up, going to bed or any other activities. Observations on the day of inspection were that residents were supported according to their needs and wishes. Individual care plans identified health care needs and included formats for monitoring health and weight and records of medical visits such as GP’s, community nurses and outpatient appointments. Whilst auditing medication on one unit it was observed that there were gaps in the medicine administration record for two residents and no explanation written or offered for why this was the case. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 15 The manager spoke with the senior staff member with responsibility for the administration of medicine in the unit and no further clarification could be offered. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 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): 22,23 Quality in this outcome area is good. The home has appropriate complaints procedures in place and residents can be assured that there are sufficient strategies in place to protect them from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure in place and this is summarised in the Statement of Purpose and Service User Guide. It includes information on how to make a complaint and the stages and timescales of the complaints process. The complaints procedure was available in different formats to ensure that residents could understand it. Staff spoken to confirmed that they had training on the protection of vulnerable adults as part of their induction and the manager confirmed that the home works within the guidelines of the Suffolk Inter Agency Policy and Procedures for the protection of vulnerable adults. Records of incidents were seen during the inspection and discussed with the manager. These were appropriate and were addressed by risk assessments and related strategies for intervention within residents’ care plans so that care staff were aware of the action to be taken to be consistent in addressing specific behaviours. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 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): 24,25,26,27,28,29,30 Quality in this outcome area is good. Residents can expect to live in a clean, comfortable and safe environment with a good standard of facilities to meet their individual needs but can not expect that carpets will be promptly replaced to provide appropriate and pleasant looking flooring. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During a tour of the units most areas were seen to be clean and well appointed with the exception of the carpets in Honeysuckle and The Lodge units where the carpets were old, grubby and worn and had no pile left. In The Lodge communal area there were flies and the carpet there also had crumbs and needed hovering. Generally the home was well maintained and the remaining areas of those units and the other units were clean and tidy. Furniture and fittings were in keeping with the style and décor of the home and created a comfortable and homely environment. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 18 Five bedrooms were seen during the inspection at the invitation of residents. Each had an en-suite bathroom or shower with washbasin and WC. All were spacious and individually decorated and reflected the resident’s likes, dislikes and interests. Residents had been supported to personalise their rooms with their own belongings, for example photographs, computers and televisions. Residents were able to have a key to their own room unless identified as a risk and agreed in their care plan. Residents spoken with on the day of inspection indicated that they were happy with their rooms, and seemed to enjoy the privacy and independence they offered. All bathrooms and WC’s were well decorated with suitable working locks. Some adaptations had been made to the home, including access ramps for wheelchair users. Staff confirmed that residents are encouraged to participate in the laundering of their own clothes and bedding. The laundry facilities were sufficient and provided domestic and commercial washing machines that could be set up to 90 degrees centigrade, and a tumble dryer. Clothes and other laundry were drying outside on washing lines as it was a hot day and they were fresh smelling. The laundry room was clean, hygienic and free from any obvious hazards. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. Residents can expect to be safeguarded by the home’s recruitment procedures and be supported by an effective and committed team of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken with on the day of inspection were clearly committed to training and development and reported that they had received comprehensive induction programmes to ensure that they were equipped to ‘do the job’. Training records reflected that training had taken place and included Moving and Handling, Health and Safety, Fire Safety, Protection from Abuse Training, Medication training, Understanding Epilepsy, Foundation Certificate in Food Hygiene, First Aid, Boots medication, infection the staff have had training in promoting respect for others. There were two staff with level 3 NVQ; nine with level 2 and undergoing level 3 training. Eight other staff are undergoing level 3 training. The home has reached its target of 50 level 2 NVQ completion for care staff. Staff spoken with all had previous relevant experience before joining the team and were very positive about the mix of knowledge and skills amongst the team. Their comments included ‘it’s a good team, very cohesive…’ Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 20 Staff reported that staff meetings take place and include agenda items such as admissions, transitions, staff issues, resident’s holidays, health and safety issues and staff training. Four staff files were examined during the inspection. They all contained evidence of thorough recruitment procedures including two written references, Criminal Record Bureau (CRB) Disclosure Checks and personal identity documentation. Staff records also included copies of supervision contracts and individual supervision’s. Staff spoken with confirmed that they had regular supervision and felt supported by the management team. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 21 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): 37,38,39,40,41,43 Quality in this outcome area is good. Residents can expect to be consulted about life in the home. Care practices reflect that the health, welfare and safety of residents are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents care plans, daily records and minutes of residents meetings demonstrated the homes’ commitment to actively seeking the views of residents. The home had also completed an annual quality assurance review which had included some consultation with residents, relatives / advocates, other professionals and staff. An action plan was available based on the results of the findings. The home’s policies and procedures were available for inspection and included health and safety codes of practice. Staff spoken with and training records examined also evidenced that the home ensured staff had essential health and safety training during their induction programme including Manual Handling, Fire Safety, Food Hygiene and First Aid. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 22 A recent report from the fire department identified a potential fire hazard in one unit where several videos were being stored in a shelving unit near to the rear fire door. The recommendations of this report were being addressed by removal of the videos and safe storage elsewhere. The homes’ manager has several years experience in care and management of this type of home and has completed the Registered Manager’s Award and has level 4 NVQ, as has her deputy also. The manager has a calm and professional style of management and is approachable. Residents were observed throughout the visit to come to find her to tell her about their plans for the day and achievements of the week. One resident who was appearing in a production of the Tempest had to have an appropriate dress code for the next day. Although this did not allow much time to arrange, the manager calmly organised for an immediate shopping trip with a carer and the resident was very pleased with the outcome and told the inspector this on their return. Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 23 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 3 5 2 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 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 4 14 3 15 X 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 x 3 3 3 3 3 x 4 Drummond Court DS0000063432.V301941.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 Requirement All staff who administer medication must adhere to the procedures for the recording of medicines. Carpets in Honeysuckle and The Lodge must be replaced to provide a comfortable and clean environment. Timescale for action 31/08/06 2. YA28 23 31/10/06 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 YA6 YA5 Good Practice Recommendations Care plans should be dated when reviewed. All residents’ files should contain contracts at the earliest opportunity. 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