Inspection on 18/01/06 for Ferrers Drive (3)

This inspection was carried out on 18th January 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ferrers Drive (3) 19/12/07

Ferrers Drive (3) 23/10/06

Ferrers Drive (3) 21/09/05

Ferrers Drive (3) 28/02/05

Ferrers Drive (3) 21/09/04

Ferrers Drive (3) 11/02/04

Ferrers Drive (3) 17/11/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Ferrers Drive (3) 3 Ferrers Drive Grange Park Swindon Wiltshire SN5 6HJ Lead Inspector Bernard McDonald Unannounced Inspection 18th January 2006 09:30 Ferrers Drive (3) DS0000003196.V277545.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 Ferrers Drive (3) DS0000003196.V277545.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. Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ferrers Drive (3) Address 3 Ferrers Drive Grange Park Swindon Wiltshire SN5 6HJ 01793 875898 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) Ian Charles Miss Michelle Stephen Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: 3 Ferrers Drive is a modern two-storey house with a large garden. The homes philosophy states that the aim is to “…provide a warm homely atmosphere which is beneficial to our residents. Independence, freedom of choice will be encouraged while offering support without intrusion. We are committed to encouraging service users to reach their full potential wishes and dreams and to strive for as much independence as possible.” This service offers care and accommodation to both men and women who have a learning disability. The service replicates principles of ordinary living and strives to provide services that take account of ‘social role valorisation’ principles. Each service user has their own bedroom and share communal areas. The service is designed for people that can manage stairs and want to live with others. Any behaviour’s must be manageable within a small domestic environment. The home, which is located in the Grange Park area of Swindon, is a partnership that trades as Ian Charles. They have one other similar care home nearby. The home has a fulltime manager and a small staff team. Typically there are two members of staff on duty throughout the day with extra staff deployed at busier times. At night time the staff take in turns to sleep at the home and to be available to assist with any night time needs or emergencies as they arise. Service users are expected to engage in day activities during the week. Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was completed over six and half hours. The inspector met with all service users and had the opportunity to meet them in private to obtain their views on the care they receive. In addition the inspector met with two support staff and the registered manager. The inspector viewed all communal living areas and service users bedrooms and examined the care plans of all service users and two staff recruitment files. In addition health and safety records, risk assessments and the requirements from the last inspection were examined. What the service does well: What has improved since the last inspection? The home has improved the standard form of contract to enable service users and those who represent them to fully understand the terms and conditions of their stay. In addition the policy regarding service users holidays has been clarified. The recording of service users personal money is clear and provides a clear audit of outgoings and money received on behalf of service users. To ensure service users safety electrical safety checks on portable appliances have now been completed at the home. Ferrers Drive (3) DS0000003196.V277545.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. Ferrers Drive (3) DS0000003196.V277545.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 Ferrers Drive (3) DS0000003196.V277545.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, 5. Information is available to enable service users to make a choice of whether to live at the home and what the terms and conditions of their stay will be. EVIDENCE: The home has produced a statement of purpose and service user guide that covers the main points required of the standard. Following a requirement made at the last inspection the home has provided each service user with a standard form of contract between the home and the service user. Copies of the contract where held on service user individual files. There was evidence to demonstrate the contents of the contract had been explained to each service user, which was later confirmed by one service user. Ferrers Drive (3) DS0000003196.V277545.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, 9. The home is ensuring care plans are updated and risk assessments reviewed, but the lack of training provided to staff in meeting the needs of service users who challenge the service could put service users at risk. EVIDENCE: The inspector examined all service users care plans. Discussion with service users confirmed they had been involved in the development of their care plan. One service user said they “went to the meeting” another service user said, “they talked about things I wanted to do”. Another service user said their, “care manager was coming today”. Discussion with staff demonstrated an awareness of the needs of service users. Staff also confirmed they had attended a meeting to discuss the care needs of one service user who had recently returned to the home. A copy of the service users updated care plan was made available to the inspector. However staff had not had any training in managing difficult or challenging behaviour. All service users had a person centred plan that outlined how they wished to be supported. All care plans had been reviewed in the past six months. Risk assessments had been developed and updated in the past twelve months. One service users risk assessment had been updated following an incident at Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 10 the home. The manager confirmed that she speaks with staff about the contents of the risk assessments. As a matter of good practice staff should sign risk assessment to ensure they have read, agreed and understood the contents. Ferrers Drive (3) DS0000003196.V277545.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): 14, 17. The home is providing opportunities to enable service users access their local community but needs to provide more options to a menu that lacks variety. EVIDENCE: Discussion with service users confirmed they would like to go on holiday this year. To support this activity the home has improved their policy on service users going away and the support they may require. One service user stated they “want to go in a caravan”. The manager stated no final arrangements have been made on holidays this year. Staff confirmed they have opportunity to take service users out on a 1.1 or in small groups. One staff confirmed they are able to take service users out almost everyday. One service user confirmed they had joined a gym and another service user confirmed they go out for walks. Records are kept on service users daily activities. Residents meetings are held every month at which time the following months menu is agreed. One service user commented meals are “good”. Another stated they were “alright”. One service user stated that if the did not like the meal they would get something else. Examination of the menu showed there Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 12 was very little variety from week to week. The manager stated it was the choice of the service users, however with a little imagination and to enable service users to have a more informed choice more options could be offered. Ferrers Drive (3) DS0000003196.V277545.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): 20. Medication is accurately recorded but staff cannot demonstrate they are competent to administer medication. EVIDENCE: Examination of medication records show accurate records are kept when medication is administered. Discussion with the manager confirmed she has provided training to staff in administration of medicines. The manager stated they have not completed any medication training other than what is covered in the National Vocational Qualification (NVQ). There is no clear protocols or checklist to demonstrate how competency in administering medication is achieved. Ferrers Drive (3) DS0000003196.V277545.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, 23. The home is making every effort to ensure service users views are listened to but the failure to ensure staff are trained in abuse awareness puts service users at risk. EVIDENCE: The home has received no complaints since the last inspection. One service user stated they would “tell staff if they were unhappy”. Since the last inspection the home has reported one incident to the vulnerable adults team. This matter was referred due to an escalation of incidents between two service users. This should have been referred earlier. At the last inspection a recommendation was made to the ensure staff receive training in abuse awareness. Discussion with staff and the manager confirmed this training had not been provided. The failure of the home to report incidents as they occur clearly demonstrate a training need and it is a requirement that this is now provided. The home was holding money on behalf of service users and records show money was being accurately recorded. Ferrers Drive (3) DS0000003196.V277545.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, 27. Service users live in a clean and comfortable environment that provides sufficient space to meet their needs. EVIDENCE: The home is situated in a quiet residential area with easy transport links to the town centre. Accommodation is provided on two floors with two service users bedrooms on the ground floor and three bedrooms on the first floor. All service users have a single bedroom one of which has en suite facilities. In addition there is a staff sleeping in room on the first floor that also doubles as the office. Minor repairs have been completed to the bathroom on the first floor and the manager confirmed that quotes have now been obtained to decorate the living room. Further quotes have been obtained to decorate service users bedrooms. The manager confirmed work would commence in February 2006. The inspector viewed all communal living space and all service users bedrooms. The overall standard of accommodation is satisfactory though once the décor has been improved the overall fabric of the building will be greatly improved for the benefit of service users. Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 16 There was a general consensus amongst service users that they were satisfied with there accommodation and had everything they needed. Toilets and bathrooms are sited within easy reach of service user living and sleeping accommodation. Ferrers Drive (3) DS0000003196.V277545.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, 34, 35, 36. The home is failing to ensure staff are trained and supported to meet the needs of service users. EVIDENCE: Examination of the rota shows there is normally two staff on duty during the waking day. At the present time additional staff cover is provided in the evening due to the challenges currently presented by one service user. Discussion with staff raised concerns over the amount of training provided at the home. One member of staff recently recruited has received no formal induction training and as the staff member is new to learning disability services they should have access to learning disability award training (LDAF). The manager stated they had responsibility for the staff induction and provided the inspector with a checklist of tasks covered. However there was no evidence to demonstrate how these tasks were covered and how their competency was confirmed. The induction checklist did not meet the relevant “skills for care” standards. In addition staff stated they had received no training in the principles of caring for people with learning disabilities, managing difficult and challenging behaviour and physical intervention. There was no training plan in place for staff to work towards. No NVQ training was currently taking place. Staff were very keen to undertake training and it is vital this enthusiasm is captured for the benefit of service users. Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 18 Records show staff supervision is not being provided as regular as it should be. One member of staff had received one supervision session since September 2005 and one member of staff had received four sessions in one year. Staff recruitment records had been improved and contained all the necessary documentation except for one member of staff’s criminal records bureau check, which was not held on their file. The manager stated it had been received. In addition one member of staff expressed concern that the home had not applied for their work permit allowing them to work at the home. Examination of records demonstrated a work permit was in place but was not in the name of the service. It was a requirement at the last inspection to ensure all records are available in the home for inspection. In view of some improvements found in the records examined the Commission has agreed to extend the timescale. Failure to meet this requirement within the revised timescale will result in enforcement action being taken. Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 19 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, 42. The home is failing to ensure an effective quality assurance monitoring system is in place to seek the views of service users. The lack of staff training in safe working practices puts service users at risk. EVIDENCE: Since the last inspection the home has completed safety checks on portable electrical appliances. Discussion with service users confirmed an awareness of what to do in the event of a fire. Fire safety records confirmed safety checks are being completed within the required timescales. The last fire practice was held in October 2005. Infection control guidelines are in place though staff have yet to receive infection control training. There is a need to ensure staff receive training in safe working practices including moving and handling and food hygiene. Control of substances hazardous to health (COSHH) risk assessments have been completed and reviewed in the past year. Since the last inspection the home has purchased a detailed quality assurance package designed specifically for care providers. However no action has been taken regarding seeking the views of service users, their family, staff who work Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 20 at the home and stakeholders regarding the care provided. It was a requirement at the last inspection that a quality report must be compiled as to the way the home is meeting its main objectives. This requirement has not been met however in view of the purchase of the quality package the Commission has agreed to extend the timescale for complying with this requirement. The registered providers must also ensure monthly reports on the conduct of the home are sent to the Commission in such detail as to demonstrate how the service is meeting the needs of service users. Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 21 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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 X STAFFING Standard No Score 31 1 32 X 33 3 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 1 X X 2 X Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 22 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 YA6 Regulation 18(1)(c)(i) (ii) 16(2)(i) 18(1)(c)(i) (ii) 18(1)(c)(i) (ii) 18(1)(a) Requirement The registered person must ensure staff receive training in managing difficult and challenging behaviour. The registered person must ensure service users are offered a varied menu. The registered person must ensure staff receive training in safe handling of medicines. The registered person must ensure staff receive training in abuse awareness and its prevention. The registered person must ensure 50 of care staff have a minimum qualification at National Vocational Qualification level 2 in care. 50 of staff must be working towards the award by 01/04/06. The registered person must ensure staff receive training in the principles of caring for adults with learning disabilities. The registered person must ensure the use of physical intervention is made explicit and if necessary staff must receive training in physical intervention. DS0000003196.V277545.R01.S.doc Timescale for action 01/04/06 2 3 4 YA17 YA20 YA23 01/02/06 01/04/06 01/05/06 5 YA32 01/04/06 6 YA32 18(1)(a)(c) (i)(ii) 18(1)(a)(c) (i)(ii) 01/05/06 7 YA32 01/04/06 Ferrers Drive (3) Version 5.1 Page 23 8 YA35 9. YA34 10 YA34 11 YA39 12 YA39 13. YA42 The registered person must ensure all newly appointed staff receive structured induction within six weeks of appointment that meets “Skills for Care” standards and cover areas on the principles of care, safe working practices and needs of service users. 19(1)(b)(i) The registered person must ensure all records specified in Schedule 2 of the Care Homes Regulations 2001 are available at the home for inspection. This was a requirement at the last inspection with a timescale for compliance of 01/10/05. 19(1)(a) The registered person must ensure they have received work permits for staff who require them. 24(1) The registered person must ensure a detailed quality report is complied as to the way the home is meeting its main objectives. A copy of the interim report must be sent to the Commission by 01/04/06 26(2)(a)(3) The registered provider must (4)(5)(a) ensure the home is visited each month and a written report is compiled on the conduct of the care home taking into consideration the views of service users, their representatives and staff as to form an opinion on the quality of care provided. A copy of the report must be sent to the Commission. 18(1)(a)(c) The registered person must (i)(ii) ensure staff receive training in safe working practices including infection control, food hygiene and moving and handling. 18(1)(a)(c) (i)(ii) 01/03/06 01/02/06 01/03/06 01/04/06 01/03/06 01/05/06 Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 24 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 YA9 YA14 Good Practice Recommendations The registered person should ensure staff sign service users risk assessments to ensure they fully understand and agree with the contents. The registered person should ensure service users who wish to take a holiday in 2006 are supported to choose and book a suitable and safe holiday that takes account of their wishes and preferences. The registered person should ensure a staff training and development plan is put in place. The registered person should ensure staff receive formal and recorded supervision from a competent person a minimum of six times a year. 3 4 YA35 YA36 Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. Extracts may not be used or reproduced without the express permission of CSCI Ferrers Drive (3) DS0000003196.V277545.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!