Inspection on 04/11/05 for John Darling Mall

This inspection was carried out on 4th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

John Darling Mall 24/10/07

John Darling Mall 12/12/06

John Darling Mall 05/08/05

John Darling Mall 09/12/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 John Darling Mall Selborne Drive Eastleigh Hampshire SO50 4SE Lead Inspector Ms Wendy Thomas Unannounced Inspection 4th November 2005 10:00 John Darling Mall DS0000040678.V263994.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 John Darling Mall DS0000040678.V263994.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. John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service John Darling Mall Address Selborne Drive Eastleigh Hampshire SO50 4SE 023 80613101 023 80611497 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) Hampshire County Council Wendy Frances Burkill Care Home 24 Category(ies) of Physical disability (24), Physical disability over registration, with number 65 years of age (2) of places John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Two service users may be accommodated between the ages of 65 and 70 years. One service user may be accommodated who has a sensory impairment. 5th August 2005 Date of last inspection Brief Description of the Service: John Darling Mall is a purpose built unit for up to 24 service users who have physical disabilities. The service users are mainly there for short breaks or in preparation to moving to more independent living. There are, therefore, both long and short-term service users in residence. Assessment and rehabilitation facilities are also available. The building is single storey, split into four units with a central communal area and some smaller communal lounges. There is a central dining room, and each unit has its own kitchenette and dining area. John Darling Mall is close to local shops, pubs and other amenities that are accessible to service users. John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited the home from 10:15 to 16:30 on Friday 4 November 2005. In depth discussions were held with five service users. Time was spent with the senior residential care officer who had management responsibility on that day, the manager and deputy manager being off duty at the time of the inspection. The inspector followed up the requirements from the previous report. Satisfactory progress was being made with these. Care plans and risk assessments were also viewed. What the service does well: What has improved since the last inspection? The introduction of more detailed care plans continues. One service user described how they were fully consulted in the drawing up of their care plan. The management team discussed their risk management strategy and systems at a recent away day. The process of assessing risks for service users continues. Long-stay service users were very appreciative of the key-work time they were now getting with members of staff. This gave them the opportunity to have support to sort out personal matters such as benefits and contacting care managers, or to take up opportunities or activities outside the home. There was a higher level of service user satisfaction with the number and range of activities and opportunities on offer than at the previous inspection. John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 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. John Darling Mall DS0000040678.V263994.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 John Darling Mall DS0000040678.V263994.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): EVIDENCE: John Darling Mall DS0000040678.V263994.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 Long-stay service users benefit from having detailed care plans enabling their needs to be met. Short-stay service users will benefit similarly once they have care plans in the new format. Service users will benefit from the risk assessment and management strategies and tools that are currently being developed. EVIDENCE: Despite discussions at the previous inspection about the introduction of a new format for care plans, the old format was still being used for some service users. The new comprehensive care plans were in place for most of the longstay service users. Although one of the short-stay service users had the comprehensive format in order to meet their complex care needs, the briefer older version was still being used for most short-stay service users. The senior residential service officer on duty at the time explained that the new format with its more in-depth description of meeting service users’ needs was being used for short-stay service users with high support needs and was not yet being used for all short-stay service users. It was reported that it was the senior residential service officers who were responsible for developing care plans with service users and that due to the nature of the service, some of the John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 Page 10 long-stay service users with whom detailed care plans had been developed, had now moved on. Opinions amongst the long-stay service users about their care plans varied. Most said that they had been very involved in their development. One was not aware of what was in theirs. One thought theirs had changed since it had first been drawn up, but they had not been involved in the changes. They did say that they were happy with their care and that it had evolved as they and the carers got used to each other and found satisfactory ways to meet their needs. They commented that it needs give and take on both sides to establish satisfactory ways of working. They said that they were, “comfortable with my treatment.” Another service user said that the process of developing their care plan had been, “thorough” and that it was, “An accurate reflection of my needs.” They stressed how important the detail was saying that it is, “the little things that are important.” Such as needing drinks within reach when on their own in their room. One said that, “I have no fault with the John Darling Mall staff in helping me with personal needs.” The previous inspection report made a requirement that, areas of potential risk for service users must be identified and management strategies developed. Progress continues to be made in this area. It was reported that the management team had had an away day when they had looked at this and other policies. A bullet point summary had been developed outlining the home’s risk management strategy. Generic risk assessments have been developed for manual handling and access to the community. It was reported that one for self-administration of medication was in production. Although the timescale has not been met in that individual service users have not had all areas of potential risk assessed, progress is being made and there is an intention to follow this through. Therefore the requirement is not being repeated. John Darling Mall DS0000040678.V263994.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): 12, 13 and 15. Service users benefit from a range of opportunities to participate in activities in and out of the home, and their friends and relatives are welcome in the home. EVIDENCE: Talking to staff and service users it was clear to the inspector that the home is working hard to improve the opportunities available to long-term service users. One service user said that they were bored at times, but four others spoken to about this were happy with the level of activities. Some described preferring to spend time in their rooms doing their own thing, others made use of the opportunities to go on occasional trips out in the minibus, to participate in weekly craft sessions, and to avail themselves of the additional key-work time now available to them to arrange courses, chase up future housing options etc. The senior residential service officer also informed the inspector that additional social time was now available one afternoon a week with the long-stay service users being given priority to have the support of a member of staff to do an activity of their choice. Service users are not all that involved in the local community due to the transitory nature of their stays at John Darling Mall. Volunteers from a local John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 Page 12 church run the bar on a Friday evening and a long-stay service user described going into the centre of Eastleigh independently. Those service users that wish and are able can go to the nearby shopping arcade with convenience shop and post office etc. One long-stay service user described how they were planning to start a course at the local college. Those service users spoken with were happy with the relationships with those within and outside John Darling Mall that they had. One described the home as having a “friendly homely atmosphere.” Exchanges between service users witnessed by the inspector indicated that they formed friendships within the group and looked out for each other. Service users informed the inspector that service users’ visitors were always made welcome and that regular visitors were on first name terms with the staff. A service user informed the inspector that a put-you-up bed was available if service users had gusts to stay overnight. One service user described how important it was to them that John Darling Mall was close to their home as family members could visit them daily. “It’s a really big significant difference.” Service users commented on the food. “The food is good. There is lots of variety. They cater for all needs.” Another said that it was, “Fairly reasonable. There is a choice. I couldn’t complain.” John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 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. The revisions being made to the medication policy should ensure service users are safeguarded by appropriate systems for the storage, administration and disposal of medication. EVIDENCE: The home has acted on the requirement and recommendation in the previous inspection report in relation to medication. It was reported that during the recent management team away day the medication procedure and risk assessment for people looking after or administering their own medication was discussed and action is being taken. This is still in progress. Two of the service users spoken with looked after their own medication. They were clear about the expectations on them to keep this securely. One explained that although they had staff support to keep their medication in a locked drawer they were not able to lock their bedroom door. A risk assessment form is also being developed for service users wishing to look after their own medication. Inspection of the medication records, trolley and cabinet showed that medication was being stored and administered appropriately. John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 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): 23. The “procedure for supporting service users to manage property, valuables and finances (money)” to be introduced will provide service users with safeguards should they require support to manage their money whilst staying at John Darling Mall. EVIDENCE: Following a requirement in the previous inspection report requiring a policy for the safekeeping of service users’ money and valuables, it was reported that this was discussed at the management team’s away day. A draft of the policy was shown to the inspector. John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 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. A suitably equipped and maintained environment ensures that service users have a safe, comfortable service to meet their needs. EVIDENCE: The inspector looked at five long-stay service users’ bedrooms. All said they found their rooms satisfactory. One service user had personalised their room to their taste and another who had been there several weeks was starting to. Others did not wish to as they viewed their stay at John Darling Mall as being temporary. One service user who hoped to be moving on once they had found appropriate accommodation commented that, “Its not like having your own home.” One service user had been able to install an Internet link to their computer in their room. A service user told the inspector that they were aware that new beds had been installed in the last year. Some of the bedroom furniture looked new. All was functional, with all rooms having an adjustable bed, wardrobe, shelves, washbasin, mirrors, call bell, bedside cabinet and touch sensitive bedside light, and, where appropriate, a chair. The rooms are dark with it being necessary to use electric light during the day. Cleaning the high level windows, which looked dirty, and the roofing of the mall may improve this. One service user John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 Page 16 commented that the roofing material over the mall made it noisy when it rained. Furnishing, décor and the level of cleanliness were satisfactory throughout the home. Service users were observed moving freely around the home and the mall. The lounges, dining room and kitchenettes provide through access to other parts of the building, so people often pass through them on their way to other parts of the building. A service user told the inspector that the carpet in their room had been steam cleaned during the last week. John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 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 and 34. Service users benefit from staff having ongoing training and updating their skills and knowledge. Recruitment practices are good, however improving recording will provide further protection to service users. EVIDENCE: A service user described the staff as being, “Very friendly, they all say hello.” Another when asked about the staff said, “I have no criticism of them at all only the very highest praise.” Another accepted that it would be unrealistic to expect to get on well with all the staff, and another was aware that there was sometimes friction within the staff team. The home meets the expectation that at least 50 of staff are qualified to at least NVQ level 2 with twelve of the twenty care staff being thus qualified or in the process of obtaining a qualification. There is a rolling programme of mandatory training and all staff have had updates to their moving and handling training since the last inspection. Members of staff have also attended the following courses; Hampshire County council induction, diabetes, health and safety, basic food hygiene, advocacy, autism awareness, physical disability and possible psychological effects, moving and handling risk assessments, and applying the value base of care. John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 Page 18 The inspector was informed that the following week all staff would be trained by the police in the protection of vulnerable adults. The inspector examined the files for four members of staff. Three had all the expected documentation, however the references for one did not provide sufficient information for a judgement to be made about their suitability for the post. This was discussed with the manager in a follow up conversation who explained the situation and how a decision had been reached, and acknowledged that this had not been recorded. She gave assurances that recording would improve in such circumstances. John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 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): 42. Tests and checks are being carried out regularly to ensure that service users’ health and safety are being protected. EVIDENCE: A long-stay service user informed the inspector that the fire bells were tested every week. Health and safety procedures were sampled. Fire drills, fire detection and alarm system checks, visual checks of fire fighting equipment, water temperature checks, legionella precautions were all being carried out satisfactorily. The staff on duty were unable to find the Landlord’s Gas Safety Certificate when requested, however this was subsequently located and faxed to the inspector. John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 John Darling Mall Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000040678.V263994.R01.S.doc Version 5.0 Page 21 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations John Darling Mall DS0000040678.V263994.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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