Inspection on 17/05/06 for Fraser Drive

This inspection was carried out on 17th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Fraser Drive 23/06/08

Fraser Drive 10/11/05

Fraser Drive 12/05/05

Fraser Drive 23/03/05

Fraser Drive 05/07/04

Fraser Drive 09/02/04

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

CARE HOME ADULTS 18-65 Fraser Drive 9 & 11 Fraser Drive Woodseats Sheffield South Yorkshire S8 0JG Lead Inspector Jayne Barnett-Middleton Unannounced Inspection 17th May 2006 09:15 Fraser Drive DS0000002959.V292282.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 Fraser Drive DS0000002959.V292282.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. Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fraser Drive Address 9 & 11 Fraser Drive Woodseats Sheffield South Yorkshire S8 0JG 0114 274 5033 0114 274 5033 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) www.dimensions-uk.org Dimensions (UK) Ltd Mrs Carol Loftus Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 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 DS0000002959.V292282.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Jayne Barnett-Middleton carried out this unannounced key inspection. Prior to the inspection contacts made to The Commission For Social Care Inspection and the homes service history were examined. A visit to the home was carried out from 9.15 to 15.15. Carol Loftus, manager was present during the inspection. Opportunity was taken to make a tour of the premises, examine a sample of records including care plans, training records, staff rotas and talk to 2 staff on duty in depth. It was not possible to formally speak to residents at the home on the day due to their high support needs. However, the inspector was able to observe the care provided and interactions between the staff and residents. The inspector wishes to thank the manager and staff for their time and cooperation throughout the inspection process. What the service does well: What has improved since the last inspection? Risk assessments have been developed for all residents, which identified the individual risks that are presented to residents on a daily basis and the action required to reduce the risk, enabling residents to live an independent lifestyle Previous requirements in relation to the environment have been completed to a good standard, the bathroom has been refurbished and the laundry floor Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 6 covering in house 11 replaced presenting a homely and well-maintained environment. The frequency of staff individual supervision has increased providing them with the appropriate levels of support and direction to support the residents appropriately. A service review was in process to seek the views of the residents, relatives and staff and to enable them to contribute to the development of the service. 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. Fraser Drive DS0000002959.V292282.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 Fraser Drive DS0000002959.V292282.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence during the inspection including a visit to the service. Residents’ needs and aspirations were assessed and their individual needs were reflected in their plan of care. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence during the inspection including a visit to the service. Three care plans were checked and these demonstrated that the residents care needs were assessed prior to their admission. The manager said that qualified professionals would also carry out a full needs assessment should a residents care needs change. One resident had recently had a re-assessment of their care needs, which had identified further support to improve their health and wellbeing. Fraser Drive DS0000002959.V292282.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence during the inspection including a visit to the service. All residents have individual care plans, which contain detailed information about their care and support needs. The staff were in the process of reviewing all resident plans using a person centred approach. Residents are supported and encouraged by the staff team to make decisions about their lives promoting independence. Risk assessments have been developed, supporting residents to take risks as part of an independent lifestyle. EVIDENCE: Three resident care plans were checked; which described the residents individual care needs. The format was detailed and included the residents preferred daily routine, communication needs and what was important to them, enabling staff to provide the appropriate level of support. The care Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 10 plans checked had not been reviewed on a regular basis. However the manager confirmed that all information provided within the care plan had been reviewed ensuring that all the information provided was up to date and that care plan reviews were taking place using a person centred approach. On the day the area manager and two staff were in the initial stages of reviewing the care plan for one resident. The staff were observed to have a good knowledge and insight of the residents individual needs and were giving positive suggestions to enable the resident to develop independent living skills. Through discussions with staff, observation and from reading three care plans it was evident that residents were encouraged to make decisions about their lives. The staff said that residents were encouraged to develop independent living skills including light cleaning and washing their laundry within their capabilities. One care plan detailed ways in which the resident could maintain their independent living skills by taking their clothing to the laundry and setting tables at mealtimes. Risk assessments had been developed for all residents, which identified the individual risks that were presented to residents on a daily basis and the action required to reduce the risk, enabling residents to live an independent lifestyle Fraser Drive DS0000002959.V292282.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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence during the inspection including a visit to the service. Residents have regular opportunities to access appropriate activities enabling them to lead fulfilling lives outside as well as within the home. The daily routines within the home are flexible and promoted independence, individual choice and freedom of movement. Residents are encouraged to eat a healthy diet, promoting their health and wellbeing. EVIDENCE: All residents have good opportunities to access appropriate activities. Discussions with staff and care plans demonstrated that several residents attended day centres and community groups during the week. Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 12 Regular trips are planned. On the day some residents were attending a planned day trip to Cleethorpes whilst others had gone out for lunch to Matlock. The staff said that residents were encouraged to pursue personal interests and activities provided within the home, which included crafts, social evenings and baking. A separate activity room was provided which the staff said was popular with residents who enjoyed board games and painting. One resident was eager to show the inspector their collection of board games and music, which they enjoyed listening to within the privacy of their bedroom. Residents are supported to maintain positive relationships with their family and friends. The staff reported that relatives did visit the home and that some residents visited their families at the weekend. Discussions with staff and observations demonstrated that the routines within the home are flexible. The residents who had chosen to spend their day at the home were spending time in the lounge or within the privacy of their bedroom. The staff have a good understanding of residents’ likes and dislikes and were able to describe individual residents preferred routines. Residents were offered and encouraged to eat a healthy diet. The staff spoken to have worked at the home for sometime they said that over the years they had developed a good knowledge of individual dietary needs and were able to give good examples of residents likes and dislikes. Fraser Drive DS0000002959.V292282.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, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence during the inspection including a visit to the service. Residents’ care plans detailed how personal support should be offered to each individual. Included in this information was how residents’ physical and emotional needs should be met. The medication systems in place were overall well managed promoting the safe administration of medication. However, records of some medication received into the home had not been maintained. EVIDENCE: Residents’ support and emotional needs were recorded in the individual plans checked. These were detailed and outlined the times that residents rose and retired and what level of support they required to wash and dress. Health action plans had been devised which detailed the support and actions needed for residents to lead a healthier lifestyle. Included in these were records of healthcare visits that the resident had received including their general practitioner, dentist and optician. Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 14 A previous requirement to asses the continence needs of one resident had been met. The manager reported that an independent advocate had been allocated and that this had proved positive in that their continence needs were met, and that the advocate was working further with the resident to improve their health and wellbeing. Policies and procedures were in place to promote the safe administration of medication to residents. Medication records in general were well maintained, the administration instructions on the MAR sheets were accurate and medication administered had been signed for. However, there were no records to evidence the amount of medication that had been received. The amount of medication received into the home must be recorded to ensure that accurate records can be maintained. Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence during the inspection including a visit to the service. The homes complaints procedure ensured that any complaints or concerns would be listened to and action would be taken to deal with complaints promptly and appropriately. The homes adult protection procedures promoted the protection of residents from harm or abuse. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence during the inspection. The complaints procedure ensured that residents and their relatives were aware of how to make a complaint and who would deal with them. The manager confirmed and records demonstrated that no complaints had been made to the home. There was an adult protection policy and procedure that promoted the protection of residents from harm or abuse. Two staff spoken to had a good knowledge of the types of abuse that could occur and the action to follow should they suspect any abuse at the home. All Staff had received Adult Protection and Protection of Vulnerable Adult training enabling them to identify and report any allegations or incidents of abuse to residents. Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence during the inspection including a visit to the service. The houses are well maintained, odour free, well decorated and homely, promoting a comfortable and safe environment for residents. Previous requirements in relation to the environment have been completed to a good standard, presenting a homely and well-maintained environment. The home was very clean and the laundry areas were all appropriately equipped to meet the needs of the residents. EVIDENCE: The environment within both houses was good. Both were well maintained and pleasantly decorated. All previous requirements had been met. The bathroom had been refurbished and the laundry floor covering in house 11 replaced. Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 17 All residents’ bedrooms were clean, individually decorated and personalised to meet their needs. There was a central garden area, which was well maintained and attractive. New seating and tables had been purchased which provided residents with a safe and accessible area to use when the weather was warm. The staff are responsible for the general cleaning of the home. This arrangement appeared to work well as all areas seen were clean, tidy and odour free presenting a hygienic and well kept environment. Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 18 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, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence during the inspection including a visit to the service. A training and induction programme is in place enabling the staff team to meet the general and specific needs of the residents. Overall the homes recruitment policy and procedure promoted the protection of residents. Sufficient staff are provided each day ensuring that the individual and collectives needs of the residents are met. EVIDENCE: The majority of staff employed have worked at the home for sometime. Two staff spoken to had a very good knowledge of the residents’ specific needs, their likes and dislikes and their preferred daily routines. Residents were observed to be treated with respect and were spoken about positively. The staff confirmed and records demonstrated that a good induction was offered to new staff enabling them to safely care for service users during their initial weeks of employment. Several staff had completed the LDAF induction Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 19 and foundation training enabling them to understand the needs of the residents. A previous requirement to ensure that all staff were up to date with mandatory training had almost been met. Training records had been updated and these demonstrated that the majority of staff had undertaken the required training including health and safety, food hygiene and adult protection. The manager confirmed that some staff were still in need of refresher First Aid and Moving and Handling training and that dates for them to undertake this training were planned. The staff confirmed that refresher training was planned later in the year ensuring that they are up to date with changing legislation and good practice. The frequency of staff individual supervision had increased. The staff said and records maintained confirmed that staff were receiving formal supervision on a regular basis providing them with the appropriate levels of support and direction to support the residents appropriately. A recruitment policy and procedure was in place. Two files checked contained a range of information including training and development undertake and identification. The files did not contain the staff application form or two references. The manager confirmed that this information was held centrally at head office. All staff employed had undertaken a Criminal Records Bureau check at the enhanced level to promote the protection of residents. Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 20 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. Quality in this outcome area is good. This judgement has been made using available evidence during the inspection including a visit to the service. The residents benefited from the ethos, leadership and management approach of the home. A service review was in process to seek the views of the residents, relatives and staff and to enable them to contribute to the development of the service. Policies and procedures were in place demonstrating that the health, safety and welfare of residents was promoted and protected. EVIDENCE: The manager has been in post at the home for over a year and has several years experience of managing a care home. She was in the process of Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 21 completing the NVQ4 care management award, which will enable her to develop managerial practice and practice skills. A service review was in the process of being conducted. This involved surveying residents, meeting with relatives and interviewing staff enabling them to give their opinion of the quality of service that was offered. Following the review an action plan was to be devised, regularly reviewed and updated. The manager felt that this was a positive move in further developing the service. She commented that she had already met with several relatives and that positive feedback had been given. Regular team and house meetings were held enabling staff and residents to contribute to the day-to-day running of the home. The manager felt very well supported by the area manager, who visited the home on a regular basis. On the day the area manager was spending time at the home talking to residents and supporting the staff to review and develop the care plans that were in place. Policies and procedures were in place to promote the health, safety and welfare of staff and residents. Fire records demonstrated that fire checks were being carried out on a weekly basis and staff had received regular fire drills to ensure that they were conversant with the action and procedures to follow in the event of a fire. Systems were in place for the maintenance and servicing of appliances and equipment, which had been checked at the required frequency. Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes 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. (Requirement first made on 27/4/05) Timescale for action 01/07/06 2. 3. YA20 YA35 13 18 Records of medication in stock at 30/06/06 the home must be maintained All staff must receive appropriate 31/07/06 mandatory training at the required frequency. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA37 Good Practice Recommendations The registered manager should hold a level 4 National Vocational Qualification in care and management or equivalent. Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Fraser Drive DS0000002959.V292282.R01.S.doc Version 5.1 Page 25 - 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. 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