Inspection on 25/11/05 for Drummonds

This inspection was carried out on 25th November 2005.

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

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

Other inspections for this house

Drummonds 11/07/07

Drummonds 15/08/06

Drummonds 20/05/05

Drummonds 16/11/04

Drummonds 21/04/04

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Claremont House

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Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

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

CARE HOME ADULTS 18-65 Drummonds The Street Feering Colchester Essex CO5 9QJ Lead Inspector Andrea Carter Unannounced Inspection 25th November 2005 09:30 Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 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 Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 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. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Drummonds Address The Street Feering Colchester Essex CO5 9QJ 01376 570711 01376 570580 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) SCOPE Mrs Sheila Oldham Care Home 46 Category(ies) of Learning disability (46), Learning disability over registration, with number 65 years of age (6), Physical disability (46), of places Physical disability over 65 years of age (6) Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a physical disability who may also have a learning disability (not to exceed 46 persons) Six persons of either sex, aged 65 years and over, who require care by reason of a physical disability who may also have a learning disability, whose names have been made known to the Commission The total number of service users accommodated in the home must not exceed 46 persons 20th May 2005 2. 3. Date of last inspection Brief Description of the Service: Drummonds is a purpose built home, which has five units within the main building. Situated in the grounds is a three-person bungalow, one selfcontained flat and two bed-sits within a larger old house used to accommodate overseas student volunteers. Drummonds offers care for service users with physical disabilities and other difficulties associated with cerebral palsy. It provides a wide range of facilities to meet the needs of service users in the home and to support them in the local community. The manager and staff work with the service users to encourage and enable them to lead individual and fulfilling lifestyles through individual service user plans and a commitment to service user input and empowerment. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a two week period. This included a site visit on one day, involving discussion with service users, staff and management, sampling of records and observation of working practice and on site activities. The inspector received survey forms back from four service users, one relative and two health and social care professionals. The inspection focused on ten key standards, of which nine were met with one having a minor shortfall. What the service does well: What has improved since the last inspection? There were no previous requirements or recommendations. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 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. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 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 Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 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): None of these standards were looked at during this inspection. EVIDENCE: Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The service users are supported to take risks as part of an independent lifestyle. EVIDENCE: Three service users files were case tracked and provided sound evidence of the assessment of individual risks in relation to specific areas. One individual had pictorial risk assessments, which would enable them to access the document, and comprehend its content. The complex healthcare needs of another individual were assessed and in depth documentary evidence supported this. The manager had a clearly identified list of all areas to risk assess, to include generic risk assessments, and individualised areas in relation to specific risk. The missing persons procedure would enable the prompt response in the event of a service user going missing. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 10 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): 14 15 16 and 17 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. EVIDENCE: The inspector spoke with the activities coordinator, who outlined the current age range is from 20 years to 80 years of age, therefore the activities are aimed at a diverse group of people. Meetings are arranged every 2 months to enable service user to discuss and their choices. The choices are then symbolised and depict the forthcoming weeks events. There are a wide variety of activities on offer, including it, music and movement, sport and dance. These are formal courses run by the local adult education department. Service users were interviewed on site and the courses set up within the activities section of the main building. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 11 Access to the community was evidenced through a variety of community-based activities, both educational and recreational. These included a trip to the London Eye, ice-skating, trampoline, and bible classes. There is also a range of holidays for which service users have the choice of identifying and participating. Currently some of the service users have the full holiday cost agreed as part of the overall funding, as yet others funding for holidays is still under negotiation with the authorities. Discussion with service users and case tracking of files clearly identified that individuals have the opportunity to maintain family and personal relationships of their choice. The family contact is supported at the request of the service user to include transport to and from the family home. Regular telephone contact is encouraged also. A high percentage of bedrooms within the home have an en suite lounge area to enable service users to meet with their company in private. There is also a large family room with facilities available for making drinks located to the rear of the building. This is often used for large family parties. The service has one couple who are married and another couple who are currently living together. One relative comment card received outlined thy are always made welcome, they can visit heir relative in private and are kept aware of important matter, They did document that the staff team were often short staffed, but work hard to overcome this. One service user was interviewed and outlined they had resided within the service for 33 years, they spoke highly of the staff team, and outlined how friendly they were and they had enjoyed living at the home. They enjoy a variety of course, including computer studies. They also enjoy the local public house and the trips out to London as an example. They access holiday facilities twice a year supported by staff from the home. Individual bedrooms are completely personalized to individual taste. Doors are lockable and observation of excellent interaction on variety of occasions between service users and supporting staff was witnessed. There were positive examples of group activities and also individuals choosing to remain in their rooms and listen to music or read. A variety of nutritious meals are on offer. One of the cooks spoken with outlined that the group they cater for meet and decide the meals for the forthcoming week. The meals dished up during the inspection were well balanced and presented, with alternatives on offer. The mealtimes were unrushed and individual nutrition charts were completed daily for each service users.1 to 1 support was clearly evident for those individuals that required that support. Protocols for individuals support needs around mealtimes were readily available for supporting staff. Food is purchased locally at the supermarket. The cooks provide the main meal and the breakfast and tea are prepared by the staff team. Four service user Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 12 comment cards received indicated that they liked the food on offer and one individual stated they like the fact they had choices and were involved in the menu planning. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20 Service users receive support in the way they prefer and require. Service users retain and control their own medication where appropriate and are protected by the homes policies and procedures for dealing with medication. EVIDENCE: One service user was interviewed and clearly outlined that the choice of retiring to bed and getting up is very much individual and respected. They are able to voice their preferences around washing dressing and this is documented clearly to the care plan to support this choice and is provided by staff of the same gender. Support in additional areas such as make up application and access to the hairdressers is supported in the wider community. The individual did voice that staff on the whole are very nice but 1 to 1 time is limited. Four service users comment cards were completed and returned, all of which indicated they liked living at the home, felt well cared for and that the staff treated them well, along with their privacy being respected. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 14 The service has a robust medication policy in place. One individual self medicates, and consent forms for medication were observed within the service users file. Also consent for administration to all service users is located in individual care plans. There is a monitored dosage system in place. Good practice indicated that all drugs were listed with their name and side effects. The service should ensure that previous medication still held is documented to the new MAR sheet. On observation of the medication cabinet, blister packs of medication were lying loose these should be retained within their original packaging to ensure no misadministration of medication.. No controlled medication is currently prescribed an in use within the home. The staff team receive training from an accredited training resource. This takes the form of basic and advanced care of medicines. The General Practitioner reviews service users medication annually, unless other wise required. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 15 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 Service users feel their views are listened to and acted on. EVIDENCE: The service has a robust complaints procedure that includes the appropriate stages and timescales. The staff receive training around the area of complaints. The full complaints policy is displayed on the main notice board for service users who are made aware of this during service user meetings. The service has to date not received any complaints this year, with the last recorded incident being 2004. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 16 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): 30 The home is clean and hygienic. EVIDENCE: The unit presented as clean and free from odours. The service has an in depth policy around infection control. The laundry room is situated to the rear of the main building and is generally in good order. There is some minor work required to the laundry room floor. The unit is equipped with two industrial washing machines and two industrial tumble dryers, including the facility to wash laundry at 65’c Appropriate hand washing facilities are situated and accessible within the laundry room. Appropriate systems are in place for the collection of and laundering of clothes. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 17 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): None of these standards were looked at during this inspection. EVIDENCE: Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 18 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): 39 Service users are confident their views underpin all self monitoring, review and development by the home. EVIDENCE: The current service users guide is outstanding in its format, through the use of symbols and photographs. It clearly defines the standards to be expected from the service. This year parents have received a “listening to you” questionnaire, for them to complete. This is handed out at annual reviews and service users meetings. The service has also enabled the introduction of a service users satisfaction survey. This was undertaken independently by a local tutor from the adult education department and is currently being produced as a graph of the results and will be fed back at the service users meeting. It outlines the quality of life and associated standards individuals should expect, for example covering the areas of living arrangements, personal care, dignity, respect and risk taking. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 19 Two health and social care professional survey sheets received, commented on how the home communicates clearly and works in partnership with the organisation. There is always a senior member of staff to liaise with and any specialist advice given is incorporated into the service users plan. One individual stated, “I am fully satisfied with the care they provide”. Drummonds DS0000017806.V265807.R02.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Drummonds Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x x x DS0000017806.V265807.R02.S.doc Version 5.0 Page 21 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(2) Requirement The registered person must ensure that all medication is recorded, and stored safely (This refers specifically to loose medication within the medication cabinet) Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA30 Good Practice Recommendations The registered manger should ensure that the flooring in the laundry room receives attention. 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