CARE HOME ADULTS 18-65
Fch - Derwent Road, 39 & 41 39 & 41 Derwent Road Bedworth Warwickshire CV12 8RT Lead Inspector
Sheila Briddick Unannounced Inspection 11th October 2005 09:30 Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.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 Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.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. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Fch - Derwent Road, 39 & 41 Address 39 & 41 Derwent Road Bedworth Warwickshire CV12 8RT 02476 314504 02476 314504 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) FCH - Housing and Care Mrs Claire-Louise Groom Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Claire Louise Groom must achieve the Registered Managers Award Level 4 by 30th September 2005. Claire Louise Groom must have opportunity to manage a New Admission Referral to a Care Home by March 2006. 27th June 2005 Date of last inspection Brief Description of the Service: 39 and 41 Derwent Road is a registered care home for six adults with a learning disability. FCH Housing and Care, (FCH), provides personal support on a 24 hour basis for the people living in the home. The service is located in Bedworth, and is within walking distance of the small town. It is situated in a quiet lay by, with its own parking area. It has been designed and adapted for people with profound physical disabilities. The two bungalows, 39 and 41, are each home to three people, staff are employed to work across the service. Service users each have their own bedroom. Shared space consists of a bathroom, toilet, a lounge and kitchen. There is a dining area in the kitchen at number 41, and in the lounge at number 39. Each bungalow has a separate laundry room. The link between the two bungalows houses the office/sleeping room for staff. There are well presented gardens to the rear of each property, which can be accessed by service users from the lounge. There is wheelchair access to the garden areas. Parking is available at the front of the property. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 11th October 2005 between the hours of 8.30am and 12.00 midday. During this time the inspector had opportunity to meet with service users, observe the interactions between service users, staff and their environment, tour the home and examine documents relating to service users and the management of the home. Three staff members were involved in the inspection process and their views are included in this report. There are currently 2 Conditions in place regarding the Registration of the Manager for this service. The manager is shortly to be taking maternity leave and therefore will not be able to evidence meeting the Conditions in the timescales imposed. The manager intends to inform the Commission of this in writing and the timescales will be amended to accordingly to include the leave period. What the service does well: What has improved since the last inspection?
The service is working more closely with other healthcare professionals when implementing guidelines to be followed when supporting service user’s specific needs, including administering medicine ‘as required’ PRN. Medicine management in the home is ensuring that medicine is being administered more safely and by competent staff. All incidents that affect the health and well being of service users are being reported to the Commission for Social Care
Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 6 Inspection. The Provider has ensured that the unstable boundary wall and surrounding area is safe and continues to keep the Commission informed of the action being taken for the full repair of the wall. Carpets and furniture are being maintained in a good condition. Staff are resourcing information that will develop their knowledge in supporting people living in the home as they grow older. Individual communication ‘passports’ for service users are being developed through use of photographs and symbols. 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. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.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 Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.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): 1. Information is not available for the people who may wish to come and live in this home in a style that would be meaningful to them, to allow them to make an informed decision about living there. EVIDENCE: The statement of purpose is not in a style that would meet the needs of people with specific communication needs. The home has purchased a digital camera however and intends to develop a service user guide about life in the home using photographs and symbols. Friendship Housing and Care, (FCH), are reviewing and amending the home’s statement of purpose so that it is applicable to the care home setting. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.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): 6 and 9 There is a clear and well documented care planning system in place which adequately provides staff with the information they need to satisfactorily meet individual service user’s needs safely and consistently. EVIDENCE: The two care plans seen contained sufficient information about individual needs, wishes and choices of the service user so that staff are able to meet needs satisfactorily. All areas of health and social care needs are identified and there is written evidence of consultation with other professionals in agreeing care plane programmes to meet specific needs. This included psychologists, dieticians, occupational and physiotherapy services. Key workers are meeting regularly with service users to review care plans and a record is made of the service users contribution during the meeting. Care plan review meetings are held with service users, their family members and other professionals involved in their care provision on a regular basis. Staff said that they attend day service reviews with service users and have developed good professional links with the day service staff. The care plan records seen were in good order, well organised and up to date however, a photograph of the individual was not attached on either record. The manager said that photographs are ready to be
Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 10 attached using the computer system that care plan programmes have been produced with. Risk management strategies are well established and staff have developed positive working relationships with psychology services in developing written guidelines to follow when supporting specific needs. This includes maintaining monitoring charts as requested by psychologists. Risks are being reviewed as needs change and on a regular basis. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 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): These standards were not looked at on this occasion. EVIDENCE: Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 12 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): 20 The systems for medicine management are good ensuring that people receive their medicine safely by trained and skilled staff. EVIDENCE: The Boots Medi-Dose System, (MDS), has recently been introduced to the home for the administration of medicine. As part of this introduction all staff received certificated training in the system and certificates were seen. The manager is completing assessment of staff’s ongoing competency once trained in the administration of medicine using a comprehensive system. This practice is documented is taking place regularly. Written protocols for staff to follow when administering medicine to be given ‘as required’ were seen to be up to date and showed that they are reviewed as needs change with GP’s and psychologists. Staff were observed giving medicine to service users and did so sensitively with good communication to individuals about what they were doing. Medication records did not have photograph identification attached, which would enable service users to recognise their medicine record. Service users, or their representative, have not signed consent for medicine to be given as indicated on care plans. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 13 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): 23 There are established systems in place to ensure that people living in the home are protected from harm. EVIDENCE: Records are maintained of all incidents or accidents in the home and these are monitored by senior managers of Friendship Housing and Care. The registered manager also forwards notification of incidents that affects the well being of service users to the Commission. There are policies and procedures for the management of service users finances and records show that this includes risk assessment, training for staff, including Protection of Vulnerable Adults, (POVA), and agreeing care plan programmes which promote as far as possible service user involvement in their money management. Family members, or advocates are included in assessments of financial management although signatures of consent from the service user if able, were not seen on care plans. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 14 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 The people in this home are living in a welcoming, warm and comfortable environment that meets their individual needs and choices. EVIDENCE: This visit was at an early hour of the day and the home was found to be clean, warm and welcoming. Shared areas were bright and cheerful and service users were seen to be able to freely access all areas comfortably. Equipment service users can safely use is at a height suitable for wheelchair users also to access. One service user was seen to access the television set easily to change channels when they wished. Staff said that equipment in bathrooms is appropriate to meet needs safely. Each house reflects the lifestyle of the people living there and photographs are displayed of family and friends. Cleaning schedules in place now includes professional cleaning of flooring which promotes infection control and supports the service aim and objective of providing an environment that is homely, clean and safe. Action has been taken by the provider since the inspection on 27th June 2005 to make the unstable boundary wall between 41 Derwent Rd and the adjacent land safe until ownership of the wall can be established. Friendship, Housing and Care are keeping the Commission fully informed of their progress with this. Records in the home show that regular visits are made by surveyors to
Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 15 ensure that the action taken to stabilise the wall continues to be satisfactory. The area remains restricted to people and the advice of the fire service has been sought regarding emergency evacuation and storage of refuse. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 16 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): These standards were not looked at on this occasion. EVIDENCE: Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 17 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): 42 The manager of this home is ensuring that people are living in a safe environment through safe working practices and compliance with current legislation that promotes the health and safety of the people living and working there. EVIDENCE: Records show that staff are trained in safe working practice as part of their induction and at regular intervals to refresh knowledge and skills. This includes fire safety, moving and handling, first aid, food hygiene and infection control. Health and safety checks in the home take place regularly including checking fire safety equipment, heating and water systems and hoists, although slings used with hoists are not checked for wear and tear routinely. All health and safety checks are documented. The environment has been assessed for risk and these are reviewed annually. The assessments include identifying risks regarding the gas fires and fire surround. A fire guard was in place at 41 Derwent Rd but not at 39 Derwent Rd, the manager could not be sure why this was so. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 18 Friendship Care and Housing are currently reviewing their policies and procedures. Records show that the Food Hygiene and Moving and Handling policies have not been reviewed since 1998 and should be included in this review. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 19 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 2 X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Fch - Derwent Road, 39 & 41 Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000004327.V258157.R01.S.doc Version 5.0 Page 20 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 Requirement The statement of purpose and service user guide must be made available in a format suitable for service users needs. (Previous timescales of 1/4/05 and 30/9/05 not met) A photograph of the service user must be on their care plan. Service users consent to medication must be sought when possible and documented on their care plan. Service user when able, or relative, or their advocate, must sign agreement to management of personal monies where indicated on financial contracts in place on the care plan. The registered provider must take action for the repair of the wall between 41 Derwent Road and the adjoining property and keep the Commission for Social Care Inspection informed of the action being taken. Action must be taken to ensure that service users living at 39 Derwent Road are free from harm and injury from the gas fire and fire surround in the
DS0000004327.V258157.R01.S.doc Timescale for action 01/01/06 2 3 YA6 YA20 15 12 30/11/05 30/11/05 4 YA23 15 30/11/05 5 YA24 23 30/03/06 6 YA42 23 20/10/05 Fch - Derwent Road, 39 & 41 Version 5.0 Page 21 living room. 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 3 Refer to Standard YA20 YA42 YA42 Good Practice Recommendations It is recommended that photograph identification of a service user be attached to their medication administration record. It is recommended that regular and recorded monitoring of the condition of slings being used with hoists be included in the regular health and safety checks for the home. It is recommended that the Food Hygiene and Manual Handling Policies for the home are reviewed against any changed legislation and amended accordingly. Fch - Derwent Road, 39 & 41 DS0000004327.V258157.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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