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Inspection on 24/08/05 for SCIC - 184 Drayton Avenue

Also see our care home review for SCIC - 184 Drayton Avenue for more information

This inspection was carried out on 24th August 2005.

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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service provides a homely, small-scale, comfortable environment for people with learning disabilities. The two service users I met were clear that they were at ease and comfortable in their home. Support is provided in a low-key, discrete manner that nevertheless ensures that needs are met.

What has improved since the last inspection?

Work has been done on meeting requirements from the previous inspection. Even where they have not yet been fully met, work is ongoing to meet them.

What the care home could do better:

Care needs to be taken that staff are aware of service users` needs, and what is to be done to meet those needs. This should be done through proper briefing and appropriately stored guidelines, and not by notices on walls of the service users` home. Individual, service user-friendly `life history/life story` books may also help in this respect. The home must ensure that all situations involving known risk are properly assessed and managed.

CARE HOME ADULTS 18-65 SCIC - 184 Drayton Avenue 184 Drayton Avenue Stratford On Avon Warwickshire CV37 9LD Lead Inspector Martin Brown Unannounced 24 August 2005 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. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service SCIC - 184 Drayton Avenue Address 184 Drayton Avenue Stratford On Avon Warwickshire CV37 9LD 01789 298709 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) Stratford & District Mencap Mrs Alexandra Louise Arnold Care home 3 Category(ies) of Learning disability (3) registration, with number of places SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager achieve qualifications in both management and care including the Registered Managers award by 2005. Date imposed 31 July 2003. 2. The Registered Manager pursues a professional qualification in the field of learning difficulty undertaking the Learning Difficulty Award Framework Level 3 by 2004. Date imposed 31 July 2003. 3. The Registered Manager to notify the National Care Standards Commission upon successful completion of the above and immediately in the event that the Registered Manager ceases, for whatever reason , to undertake the stated training. Date imposed 31 July 2003. Date of last inspection 30 March 2005 Brief Description of the Service: Drayton Avenue is a three bed roomed semi-detached house which offers longterm accommodation for adults who have learning disabilities. The house has a lounge, dining room, kitchen, toilet and utility room on the ground floor. On the first floor it has three bedrooms, a bathroom and a staff sleeping in room. It has an open front and enclosed rear garden and is situated on the outskirts of Stratford on Avon within a large estate of social housing. The town centre is accessible by bus. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday, 24th August 2005, at 3.30pm,and lasted for two hours. The inspector was made welcome by service users and staff. Two service users were at home during the inspection. What the service does well: What has improved since the last inspection? 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. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 6 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 SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 7 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) EVIDENCE: These standards were met at the last inspection, and were not assessed on this occasion. There have been no new admissions to the home within the past year. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 8 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) 6,7,9 Clear and to the point individual care plans help service users’ needs and wishes to be met. Individual, service user-friendly ‘life history/life story’ books may further assist in empowering service users. If filled with photographs and souvenirs, and written in the first person, these could be a useful reference point for service users, and an indicator of what has been enjoyed, and possibly what has not been so successful. EVIDENCE: Care plans are clear and concise, and include risk assessments, primarily in the form of individual guidelines for managing particular risks. The information is aimed primarily at staff, although one service user got satisfaction from reading out a phone number on her plan. Service users make decisions about their everyday lives, particularly what activities they undertake. When asked if they have a choice in activities, one service user gave a resounding “I do!” as her response. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 9 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) 12,13,14,15,16,17 Service users are supported by the home in maintaining a varied lifestyle, in accordance with their needs and wishes. EVIDENCE: Both service users were keen to show me their CDs; music was evident throughout the inspection, being preferred by the two service users to television. Service users and staff talked of outings over the past fortnight, and of holidays planned and undertaken. The two service users present were both enjoying a two-week break from the centre they normally attend. One service user was away, and due back the next day. Discussion with service users and staff, and reference to individual files showed that local facilities such as shops, pubs, and churches were used. Staff and service users spoke positively of the friendliness of local people. Family contacts were maintained; one service user was preparing for her mother’s visit. Dietary preferences were recorded; service users had eaten out that day and were to have a light tea. Menus were recorded and evidenced the provision of a variety of good wholesome food. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 10 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) 18,19,20,21 The home is able to meet service users’ support needs; where these are changing, it needs to ensure training and outside professional support is always readily available to anticipate and meet any changes. EVIDENCE: Observation, discussion with staff and service users, and examination of individual plans, demonstrated that personal support was provided as needed and wished, meeting personal and health needs. Training is provided to assist staff in meeting specific needs. Medication recording and administration, done via ‘blister’ packs, was seen to be satisfactory. A service user-friendly format for gathering wishes in respect of illness, aging and death has been produced by the organisation, but has not yet been implemented in the home. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 11 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) 23 Service user protection is compromised by the lack of a policy regarding the care of female service users by male staff. EVIDENCE: All the service users are female; there are some male staff. Although this issue is addressed in some risk assessments relating to aspects of personal care, no general guidelines or policy were seen to help ensure safe, good practice in this area. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 12 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) 24,25,26,27,28,29,30 The small-scale, domestic, ‘homely’ feel of the service is slightly compromised by the excessive number of notices and other items stuck on walls, particularly in the kitchen area. Specialist advice may assist in making the environment better able to meet the needs of someone with dementia. EVIDENCE: The decorators were in on the day of the inspection, repainting the staff sleeping-in room, and were due to return the following day to redecorate the dining room. Service users were not unduly concerned about their presence. The other rooms were clean, tidy, and well-maintained. There is a downstairs toilet, and an upstairs toilet with shower. The service users spoken to said they preferred a shower to a bath, which had been removed to make room for a full shower. Service users were happy to show me their bedrooms, which were personalised to meet their needs and wishes. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 13 Service users do not have lockable storage facilities in their rooms; when asked, one service user made it clear that she did not want one and said she felt her things were quite safe in her room. Like the rest of the home, the kitchen was clean, tidy, and well-maintained. There were a number of notices detailing such things as key workers, staff duties, and service user food preferences. The garden is well-maintained and attractively laid-out for use when people living at the home so wish. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 14 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) 33,35 Service users benefit from a service provided by an effective staff team. To ensure changing needs of service users are able to be fully met, staff training in relevant specialist areas should continue. EVIDENCE: A staffing matrix was seen, showing staff training was on-going and covering required and specialist areas. Dementia training had been undertaken by a majority, but not all, of the staff. A recently recruited member of staff stated that she was finding doing the Learning Disability Award Framework interesting and useful. I was informed that staff records are now kept safely on the premises of the main home at which they work. These will be inspected when that home is inspected. Extra staff are now on the rota, to enable double staffing at key times to enable 1 to 1 activities to take place. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 15 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) 39,40,42 The home is working to ensure that service users’ views are heeded and acted upon. The safety and security of one service user is compromised by a potentially inconsistent approach to the use of the front door alarm. EVIDENCE: Records of service user meetings were seen. The manager advised that Quality Assurance surveys, in the form of ‘My House’ booklets have been completed, and that the results are being collated by the head office before being made more widely available and responded to. The process of making relevant policies and procedures service user –friendly has not yet been completed, although the complaints and abuse policies are now in such a format. Fire procedures were explained satisfactorily by staff. There is a alarm on the front door that can be set to be triggered when it is opened. Staff said that it is there in case a service is confused in the night and goes to leave the building, and that the decision whether to activate the alarm is up to individual staff. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 SCIC - 184 Drayton Avenue Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score x x 3 2 x 2 x E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 17 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 24 Regulation 23 Requirement The home must do an audit of notices on walls, particularly in the kitchen, and find more appropriate housing for those that are not currently needed or displayed for valid reasons. A risk assessment/policy regarding the care of female residents by male staff is required. A statement regarding the wishes, or otherwise of service users or significant others in event of illness, aging, or death is required.(this is an outstanding requirement from the previous inspection). There must be a clear policy, adhered to by all staff, concerning the use of the front door alarm. All staff must have up-to-date trianing in dementia care. Timescale for action 1/10/05 2. 23 12 1/10/05 3. 21 12 1/11/05 4. 40,42 13 1/10/05 5. 35 18(1) 1/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 18 No. 1. 2. Refer to Standard 6 24 Good Practice Recommendations Life story/history books are recommended. it is recommended that advice be sought from a dementia specialist regarding any environmental adaptions to help meet the needs of a service user with dementia. SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 SCIC - 184 Drayton Avenue E53 S4467 SCIC 184 Drayton Avenue V246007 250805 Stage 4.doc Version 1.40 Page 20 - 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. 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