CARE HOME ADULTS 18-65
Fraser Drive 9 & 11 Fraser Drive Woodseats Sheffield S8 0JG Lead Inspector
Shelagh Murphy Unannounced 12 May 2005 09:30am 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 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 Stationary 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. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Fraser Drive Address 9 & 11 Fraser Drive Woodseats Sheffield S8 0JG 0114 2745033 0114 2745033 None New Era Housing Association Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Debroah Jayne Bayley Care Home 12 Category(ies) of LD Learning disability - 12 registration, with number of places Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 23 March 2005 Brief Description of the Service: Fraser Drive is a purpose built 12-bed home for adults with learning disabilities aged between 18-65 years. Residents live in two separate detached houses that share the same grounds. The home is in a residential area of Sheffield with good access to public services and amenities (e.g. bus services, shops, libraries etc). Each house has 6 single bedrooms, based on the ground floors, a communal lounge and dining room and a domestic style kitchen. Sufficient bathing facilities are provided. The gardens have lawned and paved areas, a variety of seating is provided. There is a small car park. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Shelagh Murphy carried out this unannounced inspection over three hours from 9:30 to 12:30. Carol Loftus, acting manager was present during the inspection. Opportunity was taken to make an inspection of the home, examine a sample of records and policies and talk to staff and residents. The inspector had the opportunity to speak to 2 staff on duty and speak in depth to 2 residents. What the service does well: What has improved since the last inspection?
The acting manager has been in post for four months and in this time the staff felt that the home had made improvements in many areas including staff support and improving communication within the team. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 6 Three residents with high support needs had recently had their needs reassessed by social services as their support needs had changed over the year. Practices within the service are being developed to be in line with current good practice in learning disability services. Three residents have had person centred plans developed with support from staff and relatives. Eventually all residents will have the opportunity to have these plans developed. Confidential information was all found to be stored securely to protect the resident’s confidentiality. Staff sickness levels had decreased and this ensured that more staff were on duty to support residents to take part in off site activities. Many areas of the home had been redecorated or refurbished, which made the houses very comfortable for the residents. What they could do better:
All of the residents care plans need to be reviewed to ensure all of the information required by the regulations is recorded. The care plans should then be monitored and reviewed on a six monthly basis to ensure the staff know how to meet the residents needs. The acting manager and staff need to review whether some of the residents could be encouraged to become more involved in preparing meals and other independent living tasks as they had limited input in to some activities within the home. One of the residents cultural needs should be reviewed to ensure their needs in this area can be met. The acting manager and key-workers need to review the weekly planned activities with the three residents identified during the inspection, as these people have limited opportunities at the present time. The risk assessments devised for the individual residents need to be reviewed on a regular basis to ensure the residents are protected from unnecessary harm. Fire doors within the home need to be checked to ensure they all close properly to protect the health and welfare of the residents and staff in the home. The acting manager needs to increase the number of formal staff supervision meetings to ensure the staff team are properly supported.
Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 7 The Learning Disability Award Framework (LDAF) training programme needs to be offered to all newly recruited staff to ensure they are able to meet the resident’s needs. The acting manager needs to ensure that an appropriate number of staff who work at the home have completed the NVQ2 care award to ensure they have a suitably trained staff team to support the residents. 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. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 9 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 standard(s) 2. The service demonstrated it was able to meet the needs of the resident with medium to low support needs. Three residents with high support needs had just had their needs reassessed as the staff thought that these residents needed extra staff support to meet their needs. Two residents users said they enjoyed living at the home. EVIDENCE: Needs assessments for residents were found in residents care plans. They contained sufficient information to allow staff to meet the care needs of the residents. Three residents had recently had their needs re-assessed by social workers. The acting manager was still waiting for the completed needs assessments to be returned. The staff felt that these three residents had limited opportunities to pursue activities away from the home and after discussions with the acting manager it was agreed that a review of their daily activities needed to take place. Two residents were interviewed and said the staff supported them to carry out the activities they wished to pursue; this was evidence that the residents were able to exercise choice and control over aspects of their lives. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 and 10. The residents care plans did not meet the required standards for content and needed to be reviewed. Three residents had had person centred plans devised over the last few months. The residents are supported to shop for food and toiletries, but needed to be more involved in cooking meals. Joint resident and staff meetings were taking place at the home. The residents were supported to take some risks as part of an independent lifestyle. The risk assessments needed to be reviewed. Systems were in place to ensure the resident’s confidentiality was maintained in the home. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 11 EVIDENCE: The residents care plans checked did not contain enough details in order to ensure that all staff were aware of the residents social and health needs and how these were to be met. The care plans checked had not been reviewed within the last six months. They needed to be updated to reflect any changes in the residents needs. Three of the residents had had person centred plans devised over the last few months. The acting manager said the residents had been directly involved in this process and staff reported they felt the residents had benefited from the process as they now had a more detailed understanding of their needs. The acting manager said that eventually all residents would have an individual person centred plan. The residents were supported to shop for food; the staff cooked and served the meals. One resident said, “We go to Tesco’s with the staff” and said they enjoyed shopping for the food and liked the meals at the home and could choose their meals. The residents likes and dislikes in relation to food was recorded in care plans to ensure the staff knew the residents personal preferences. After discussions with the acting manager it was agreed that a review of the residents involvement in carrying out day-to-day tasks with staff should take place. Residents meetings are organised on a monthly basis and the residents said, “I liked to go to meetings with staff”, “we talk about holidays and outings”, the staff said this gave residents the opportunity to be consulted on how the home was organised and run. Risk assessments were found on the resident’s files, those checked had not been reviewed on a regular basis and therefore, staff were unsure of whether they were still appropriate. Resident’s files were found to be stored securely and staff showed an awareness of confidentiality issues. The staff said that residents could see their files with staff support. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 15, 16 and 17. Most of the residents were supported by staff to take part in age, peer and culturally appropriate activities, however, those service users with high support needs had limited opportunities in these areas. Resident’s were supported by staff to develop and maintain appropriate, personal and family relationships. The staff showed respect for the resident’s, in the way they spoke to and addressed them. The residents were observed to be offered choices and were supported to make everyday decisions. The meals in the home offered a nutritious and balanced diet to the residents. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 13 EVIDENCE: Through discussions with staff it was clear that some residents who had high support needs may benefit from more individualised support to meet their cultural needs. One member of staff said that one resident from a minority community, would benefit from extra staff support to spend more time doing activities with people from and within in their own minority community. Other residents with high support needs had very few planned activities each week. Two residents only had one half day planned activity per week. The acting manager agreed to review these resident’s needs, in order to enable the service users more opportunities to take part in meaningful activities. Residents told the inspector that they took part in a range of leisure and daily activities on a regular basis. They said they attended college courses, day services and other related daily activities, and these included art and horticultural classes. One resident said “I go to art classes, “ I go out to the countryside with staff and to the pub for a lager, my key-worker takes me to the hospital to see my Mum”. This confirmed that residents were enabled to take part in their local community and to maintain relationships. One resident told the inspector, “I like it here, because I like (another resident), he’s my friend and we spend time together”. They went on to say, “the staff are nice, and my key-worker is my favourite person”. Staff were observed to treat resident’s with respect as they knocked on the service users doors before entering, addressed service users by their preferred names and spoke of the residents with regard. There was a good supply of nutritious food in the home. The menus showed that a varied diet was offered to the residents. This enabled the residents to make choices at each meal- time. The residents said they enjoyed the meals on offer at the home. One of the residents said, “I like the food here, we had fish pie and vegetables last night”, another person said, “My favourite meal is fish and chips and we go to the chip shop on Friday to buy them”. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 21. The residents and their supporters had been asked about their individual choices and wishes in the event of illness and death. EVIDENCE: In the care plans checked there was evidence that staff had sought the residents views and where appropriate the relatives and supporters views on the issues of ageing, illness or death of a service user. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 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 standard(s) 22 and 23 The home had a formal complaints procedure. The residents who were able to verbalise their concerns to staff, knew how to make complaints. The residents who had high support needs may need more support from relatives and key workers to advocate on their behalf, as they were the people who appeared to receive less opportunities from the service but could not voice any concerns about this. Procedures were in place to protect the residents from abuse, neglect and selfharm. Staff had received some awareness training in the management of challenging behaviour and adult protection issues. EVIDENCE: There was a formal complaints procedure in place at the service. This promoted the wellbeing of the residents. Records of all complaints were kept. The acting manager said that complaints procedures had been devised in accessible formats to meet the residents needs. The acting manager said that no complaints had been made at the home over the last six months. The residents both felt confident that staff would listen to their views and support them to take appropriate action if they had any concerns or complaints. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 16 The home had adult protection procedures, which met the regulations. The service users said they felt happy and safe at the home. Some of the staff said they had been trained in adult protection awareness training and in the management of challenging behaviour. The acting manager said that no allegations of abuse had been made over the past year. The staff said that they did not use restraint techniques or sanctions with any of the residents who lived at the service and therefore there were no risk assessments on these issues. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25 and 30. The environment within the home is clean, well decorated, comfortable and homely. Fire doors in the home needed to be checked, as one was not closing properly. The resident’s bedrooms are all well decorated, comfortable and reflected personal choice. Laundry facilities were appropriate to meet the needs of the residents. EVIDENCE: One of the residents said they enjoyed living at their home, because it was “tidy” and “cosy”. The environment within the home is clean, well decorated and comfortable. A fire door in to the laundry room in House 11 was not closing on its rebate correctly. This could affect the safety of the residents and therefore this was reported to the acting manager for remedial action to be taken. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 18 The staff said that residents are encouraged to help choose décor and furnishings. This ensures that the residents exercise some control over the environment they live in. The dining room in House 9 had been redecorated since the last inspection. The acting manager said that where furnishings and fittings required by the regulations had not been supplied in the residents bedrooms these had been supplied or it had been recorded in the care plans the reason for this. Several residents were keen to show the inspector their rooms and said they had chosen the colour schemes and furnishings. Laundry facilities are sited away from food preparation areas. The home had a washing machine with a programme to meet disinfection standards. The staff said that they felt the environment in the home was safe and that a risk assessment had been devised regarding the risk of tripping on the access ramps outside the house. This promoted the health and safety of staff and residents. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35 and 36. There is a new acting manager at the home, who has developed systems within the home, which have improved communication within the staff team. The home has a stable staff team, who know the residents very well and who have developed supportive relationships with residents and relatives. The acting manager and staff said that sickness rates in the staff team had improved considerably over the last few months. Staff morale has gradually improved over the last few months. Regular staff supervision and annual appraisals had not been not carried out. LDAF training had not been offered to any of the newly employed staff. Fifty percent of the staff team were not on target to complete the NVQ2 training by the end of 2005. EVIDENCE: The residents and staff spoke highly of the acting manager. The staff said that the service had improved in the short period of time she had been in post. The residents said they liked the acting manager and the staff who worked at the home.
Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 20 All of the residents had named key-workers who supported them. One resident said she liked the staff and her key-worker. The staff said that communication within the staff team had improved and they had more information and now felt empowered to make some decisions within the service. The home has a stable staff team, who know the residents very well. The staff said they had close working relationships with the service users relatives. None of the staff had been offered the opportunity to complete the LDAF induction and foundation training. One staff member who had worked at the home for over ten years said they had not been offered the opportunity to complete the NVQ training. The acting manager said that the home was not on target to have 50 of the staff team with the NVQ2 award by the end of 2005. The staff reported that they had not received regular formal supervision for a long time. The acting manager said this was correct and that supervisions would be made a priority over the next six months. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were checked at this inspection. Not Applicable. EVIDENCE: Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 22 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 3 x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 2 3 2 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 x x x x 3 Standard No 11 12 13 14 15 16 17 x 2 x x 3 2 3 Standard No 31 32 33 34 35 36 Score 3 x 3 x 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Fraser Drive Score x x x 3 Standard No 37 38 39 40 41 42 43 Score x x x x x x x J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 23 Are there any outstanding requirements from the last inspection? No 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 15,17 Requirement All care plans must be reviewed to ensure they contain all of the information required by the regulations. As a minimum the care plans must then be reviewed every six months. In consulatation with the residents, a review of the individuals ability to be more involved in independent living skills must be carried out and any remedial action taken. The residents risk assessments must be reviewed on a regular basis. In consultation with the resident or their supporters the cultural needs of the resident identified must be reviewed and any remedial action required must be taken. In consultation with the residents identified a review of their opportunities to take part in leisure activities must be carried out and any remedial action required must be taken All fire doors in the home must be checked to ensure they close properly. LDAF induction and foundation Timescale for action 30.9.05 2. YA8 16 31.12.05 3. 4. YA9 YA12 17 12 30.9.05 31.12.05 5. YA14 16 31.12.05 6. 7. YA24 YA32 23 18 13.5.05 30.9.05
Page 24 Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 8. YA36 18 training must be offered to all newly recruited staff. All staff must be supervised on a regular basis. 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. 2. 3. Refer to Standard YA2 YA32 YA37 Good Practice Recommendations A review of the activities for three service users identified should take place and any remedial action required should be implemented. 50 of the staff team should have achieved National Vocational Qualifications (NVQ) in care by 2005. The registered manager should hold a level 4 National Vocational Qualification in care and management or equivalent by 2005. Fraser Drive J55 S2959 Fraser Drive V218816 12.05.05 UI Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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