Inspection on 13/02/06 for Dunelm

This inspection was carried out on 13th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dunelm 13/06/07

Dunelm 17/05/05

Dunelm 17/11/04

Dunelm 08/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Dunelm 115 Dunelm South Durham Road Sunderland SR2 7QY Lead Inspector Miss Andrea Goodall Unannounced Inspection 13th February 2006 02:00 Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dunelm Address 115 Dunelm South Durham Road Sunderland SR2 7QY 0191 522 7398 0191 522 7398 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) Tyne and Wear Autistic Society Mrs Brenda Nora Pearson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 2005 Brief Description of the Service: Dunelm is a family-sized house that is registered as a care home for 4 young people with Autistic Spectrum Disorder. The service is operated by Tyne & Wear Autistic Society (TWAS), which also operates a number of other similar smaller homes in the nearby area. The home is a semi-detached 1930s house on a main road near the City centre. The home has a short driveway, and a back garden. On the ground floor there is one bedroom, a comfortable lounge, a dining room and a large conservatory/sun room. There is also a family-style kitchen, a staff sleep-in room that also doubles as an office, and a small utility room. On the first floor there are 3 good-sized bedrooms, 2 of which have en-suite bathrooms. There is a third bathroom adjacent to the other bedroom. Dunelm is decorated and furnished to a very good standard in a style that suits the age and tastes of the people who live here. The home is not intended to provide accommodation for people with physical disabilities. There is a small step into the home at the front entrance. However a portable ramp could be provided if necessary for visitors with mobility needs to access to the ground floor only. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one afternoon and evening in February 2006. Some time was spent looking through care records and talking with the Acting Manager about the service and staffing. The rest of the time was spent with the 3 of the 4 people who live here, joining them for a tea-time meal and looking around some parts of the house. Due to the nature of Autistic Spectrum Disorder, the people living here find it very difficult to express views and opinions about the service they receive. Time was spent with staff and residents together, looking at how they get on, how residents are involved in their house, and how they are supported towards independent living. Throughout this report the people who live here are referred to as residents and the Tyne & Wear Autistic Society is referred to as TWAS. What the service does well: What has improved since the last inspection? Lots of areas of the house have been redecorated. The people who live here were asked what colours they would like. Staff used photographs to help residents see the different colours so they could make their own choices. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 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. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 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 Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 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. Prospective residents and their representatives have written information about TWAS services but not specifically about Dunelm. EVIDENCE: The home has a Statement of Purpose that gives detailed information about TWAS services, and the aims and objectives of the home. These are given to parents of residents and to professionals involved in the residents’ care. There is also a Service Users Guide that is kept in the office, although it can be accessed by residents if supported by staff. However, this information is about TWAS services and does not give any specific information about Dunelm. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 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): 6 & 7. Residents needs and goals are outlined in a plan of care, but do not show whether residents have been involved in their own care planning. Residents make decisions about their daily lifestyles, with support only where necessary. EVIDENCE: There are support plans in place for each of the 4 people who live here. These clearly outline their needs and also a small number of achievable independent living goals (SMART objectives) that they are working towards. Some residents have signed their care plan. There is a written statement in each persons support plans file that states whether resident can read or not, but only one care plan records that the support plan has been verbally explained to the resident and whether they understand it or not. In this way it is not demonstrated whether, or how, the other residents have been included in their own care planning. One persons assessment states that he requires pictorial symbols for him to understand his SMART objective. However there are no pictorial or other visual clues in the support plan files to support residents communication needs. This does not help them understand their own records. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 10 The nature of autism means that most service users can become very anxious when presented with too many choices. In order to support them, residents are offered a small number of choices based upon their known individual preferences, for example activities, and menus. Residents have a monthly meeting where they are encouraged to make suggestions about what they would like and group decisions about their home. All the residents were involved in making decisions about the décor in the house. The home uses photographs and pictures to help residents make informed choices. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 11 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): 16. Residents rights are respected and their responsibilities are promoted. EVIDENCE: The people who live here have information in plain language that outlines their rights and responsibilities whilst living here. All the residents are fully involved in the daily household tasks within their home, with support from staff. Residents also take responsibility for feeding their pet fish. Staff encourage and promote conversations with the residents to help their language and communication skills, but also to involve and include them in discussions and decisions about the home. Staff were seen to be respectful and supportive when talking with residents. Residents rights regarding their private mail are understood and it is clearly outlined in their care plans whether they need support to read this. Residents can choose to use their own bedrooms for privacy when they are not involved in another activity. Two people use keys to their keep their bedrooms Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 12 private. The other 2 residents have access to their own keys but tend not use them. Residents have unrestricted use of all communal areas of the home, but need supervision in the kitchen because of the potential risks involved. There are some set routines in the home because people with Autism benefit from structured programmes that helps them make sense of the pattern of their day. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 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. Residents are supported in the way that they prefer and require. EVIDENCE: The 4 young men who live here are physically fit and active. They do not require any physical assistance with their personal care needs, but they do need verbal prompts and guidance to wash, shave and bathe. Residents also need some supervision and guidance when using public changing rooms e.g. at the gym or swimming baths, and this requires genderappropriate support from the one male staff. The residents are able to choose their own appearance and clothes, though staff support them to ensure that their clothes are suitable for the weather conditions. The home clearly respects the cultural diversity and needs of the men who live here. One resident is muslim and the staff ensure that he is able to follow his prayer routines and avoids alcohol. He is also supported by staff to make suitable vegetarian meals in respect of his cultural beliefs. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 14 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. Residents, relatives and care professionals have information from the service about the method of making a complaint. Information is provided to residents in pictorial form to support their understanding of the complaints procedure. EVIDENCE: The home has a clear Complaints Procedure that has been provided to relatives and representatives. There is also a simpler pictorial version for the residents that supports their communication needs. A copy of the pictorial complaints procedure was seen to be in each of the residents’ care files and they can look at these at any time. (Some of the information in the complaints procedure is now outdated.) There is regular contact between the home staff and relatives, and the views of relatives are requested at annual reviews and through questionnaires. In this way the complaint procedure is advertised to residents and their representatives. Staff also ask residents for their comments at the Residents’ Meetings. All of the people who live here can express their dissatisfaction with an immediate situation, either verbally or through gestures and body language. Staff spend time with residents to learn their preferences and dislikes so that they can be aware of situations that residents would not enjoy. There have been no complaints about this service. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 15 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. Residents live in very good quality accommodation. The house is homely, well decorated, comfortable and safe. Residents bedrooms suit their individual lifestyle and needs. EVIDENCE: Dunelm is a detached family house that provides a very good standard of accommodation and furnishings for the people who live here. All areas of the home are decorated to a good standard, in keeping with the age of the residents. There is a small driveway to the front of the home and a good sized rear garden. The home is not intended for people with a physical disability, although visitors with such needs could be supported to access the ground floor via a temporary ramp, if needed. The home is well maintained and provides safe, homely accommodation for the people who live here. Since the last inspection most areas of the home have been redecorated, including one bedroom, the lounge, dining room, kitchen, conservatory and hallway. Residents were encouraged to be involved in choosing the colour schemes for the new décor in their home. The 4 residents bedrooms are large enough for them to use for private time and their own interests. All have lockable doors, which residents can choose to Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 16 use or not. All are well decorated and suit the lifestyle of the people who live here. Two have en-suite bathrooms, which allows even greater independence. The other 2 bedrooms share a third bathroom. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 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): 32 & 33. Residents are supported by competent staff. Residents receive maximum support at the time they need it from an effective staff team. EVIDENCE: Currently the staff team consist of the Acting Manager, 2 seniors and 2 support workers. The Acting Manager and 2 seniors have attained the NVQ level 3 care qualification. The 2 support workers are engaged in induction and foundation training that will lead to NVQ training later this year. In this way the home aims to provide a qualified staff team. The staff rota ensures that there is a minimum of 2 staff on duty from 12:45– 9:45pm during weekdays, and from 9am-10pm during weekends. In this way the home provides maximum support for the 4 residents at all times that they need it. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 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): 37, 39 and 42. Residents continue to benefit from a well-run service. Residents views are sought in order to review the service they receive. Overall the health & safety of residents is protected and promoted by staff training and practices. EVIDENCE: Currently the registered Manager is on sick leave and an Acting Manager has taken responsibility for the daily management of the home. The Acting Manager is a Deputy Manager of another similar home operated by TWAS and so is familiar with many aspects of the management of such a service. There are also 2 experienced senior staff to support him in the running of the home. There is a clear line of organisational management within TWAS Adult Services section. The Acting Manager is supervised and supported by a senior manager of TWAS. In this way the residents, and staff, continue to benefit from a wellmanaged, well-run service. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 19 TWAS has a quality assurance policy in place to review the service at Dunelm, and this includes the views of the residents through their annual reviews and Residents’ Meetings. Pictorial questionnaires are also given to residents from time to time for them to indicate their likes and dislikes. There is an Annual Development Plan for Dunelm, which outlines appropriate goals and future objectives for the service. In this way the home continues to review and develop its service to ensure that it is run in the best interests of the people who live here. Staff records demonstrate that all staff receive statutory training in all health & safety matters. Records of health & safety checks are also in place. There are a number of TWAS staff who carry out night-time sleep-in duties at Dunelm. One has not had the required 3 monthly in-house fire instruction for some time. The records of hot water temperature checks to the 3 baths indicate that the hot water has been too low for the past 3 months (although the temperature was satisfactory at the time of this visit). There was no record of what action, if any, was requested or carried out to address this. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 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 Standard No Score 1 2 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 4 25 3 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 2 X 3 X X 2 X Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4, 5 Requirement Timescale for action 01/05/06 2. YA6 15 3 YA42 23(4)d The Statement of Purpose and Service Users Guide must include details of the facilities and services provided in Dunelm. Support plans should include 01/05/06 written details of how the resident is involved and included in their care planning, or the reasons why this is not possible. (Previous timescale of 01/09/05 not met.) Night-time staff must have in01/05/06 house fire instruction at the required intervals of no less than 3 months. 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 YA22 Good Practice Recommendations Support plan goals should include a pictorial clue for residents information. The Complaints Procedure should be amended to reflect the correct name and telephone number of the CSCI. DS0000040712.V283837.R01.S.doc Version 5.1 Page 22 Dunelm 3. YA42 Records of hot water temperatures should include any action taken to ensure the correct temperature. Dunelm DS0000040712.V283837.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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