CARE HOME ADULTS 18-65
South Avenue, 1 1 South Avenue Chellaston Derby DE13 1RS Lead Inspector
Vanessa Davies Key Unannounced Inspection 16th April 2007 09:30 South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 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 South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 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. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service South Avenue, 1 Address 1 South Avenue Chellaston Derby DE13 1RS 01332 705136 01332 705136 1southave@robinia.co.uk 26stmarksroad@robinia.co.uk The Robinia Group PLC 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) Miss Donna Michelle Chetwyn Care Home 8 Category(ies) of Learning disability (8) registration, with number of places South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th November 2006 Brief Description of the Service: The home is registered to provide support and accommodation for 8 individuals with learning disabilities between the ages of 18 - 65 years old. The house is situated close to the centre of Chellaston, and within 2 minutes walk to local shops. The house has been furbished to reflect the style of a family home. The home is located on a private road and has a car park at the side of the building, and an enclosed secure garden. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Information for this inspection was gathered before during and after the visit to the home. The inspector read relevant files, service user questionnaires, spoke with the Registered Manager, members of staff, service users and a relative. Detailed below is a summary of the findings. What the service does well: What has improved since the last inspection?
The Statement of Purpose has been amended and ensures that potential service users are provided with the correct information. Care plans have been updated and now include how the staff should meet the needs of the service users in addition to what the needs are. All staff have received training in Safeguarding Adults and further courses arranged to update people. Behaviour management courses have also been arranged. The Registered Manager has arranged to update staff as necessary throughout the year.
South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 6 The organisation has revisited the changing of staffing hours and the Registered manager stated that they had been increased providing ample staffing to meet service users needs. Regular monitoring visits are now taking place. 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. The summary of this inspection report can be made available in other formats on request. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 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 South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 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. 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 including a visit to this service. Detailed assessments of need and care plans ensure staff are able to meet the changing needs of the service users. EVIDENCE: The home has a Statement of Purpose in place to assist potential service users and relatives with a choice of a suitable home. The Statement of Purpose has been amended since the previous inspection and provides up to date information. Each of the files examined had a detailed assessment of need in place. From the assessment of need the manager has developed personal service plans, the inspector spoke with service users at the previous inspection and it was confirmed that they are as involved as possible with the preparation and reviewing of their service plans. The care plans have be reviewed since the last inspection and include sufficient information for staff to work with the service users and meet their needs. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 9 South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Positive relations between staff and service users promote independence and assists service users to make choices and decisions affecting their lives. EVIDENCE: A service user spoken with was aware of her care files and her right to access them. One service user spoken with had recently been on holiday to visit family abroad, it was evident that she was encouraged and well supported to take risks and make her own decisions. Service users spoken with were confident that information relating to them was kept safely. All records seen were kept in the office, which is locked when staff are not in there. Service users felt that they could speak with staff and were confident that unless necessary, their confidence would not be broken.
South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 11 South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Appropriate social opportunities and a dedicated staff team ensures that service users are included as part of the local community and develop the necessary skills to prevent isolation. EVIDENCE: On the day of inspection the service users were engaging in a range of activities, some alone and others with the help of the staff. As at the previous inspection records read evidenced a number of activities on a daily basis, many ensuring that service users access the community both locally and further a field. Activities service users participated in include, swimming, visiting the local pub, shopping and college. On the day of the visit one of the service users was out at college. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 13 Each of the files had information relating to friendships the service users had, the information included addresses of friends, birthdays and other important dates. One service user spoken with discussed a range of activities she was involved in and also a recent holiday. The service user spoken with felt that staff treated her with respect and offered her as much support as she needed. The inspector observed a mealtime, it was very relaxed and service users ate at a pace which suited them. Service users are offered a choice of menu. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Input from a variety of other professionals as necessary ensures that service users holistic needs are met. EVIDENCE: Care files examined evidenced personal support service users may need, since the review of the care plans they now include how the staff are to support the service users, any risks which may be involved and how to best deal with the risk. Assessments and care plans ensured that physical and emotional needs were met. There was evidence of input from a variety of other professionals as necessary and this was confirmed by the service user spoken with. Each service user has a specific medical file which houses all necessary information relating to health. The home has a detailed medication policy and staff administering medication have all received appropriate training. All medication is stored, recorded and
South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 15 administered appropriately. Should a service user wish to self-administer an appropriate detailed risk assessment would be completed to ensure all risks are highlighted and eliminated as possible. The medication file did not have any photographs of service users or information relating to how they may take their medication. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A detailed complaints procedure ensures that service users and relatives feel listened to and able to raise any concerns. Appropriate training for staff ensures that service users are protected. EVIDENCE: Service users questionnaires stated that they felt listened to and felt that if they had cause for complaint it would be responded to appropriately. The service user spoken with felt confident that staff would listen to her complaint and would address it accordingly, although she did state that she had nothing to complain about. The home has a complaints procedure and a record of any complaints is kept along with the response. Training records seen evidenced that staff have completed Safeguarding Adults training. Team Teach is used by staff to manage inappropriate behaviour, and training has been arranged for staff as necessary, to ensure that all training is up to date. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A clean and tidy home with appropriate security ensures that risks to service users are limited as much as possible. EVIDENCE: The home is situated within a quiet residential area on a private road. The home is secure and provides a safe environment for the service users. The home was very clean and tidy on the day of the visit and service users questionnaires indicate that this is always the case. The inspector toured the home, it was evident that bedrooms are individualised to suit the service users needs. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. An increase to staffing hours and staff working with appropriate training ensures that service users are not put at risk of harm. EVIDENCE: The manager stated that the organisation had increased the staffing hours since the previous inspection, which enables the staff to meet the needs of the service users and support them to participate in a range of activities. The organisation offers a range of training and since the previous inspection courses have been booked for staff to attend any training which needs updating. The home has a rigorous recruitment procedure in place, which was updated prior to the last inspection. All staff have a Criminal Records Bureau check in place and this is obtained prior to appointment for all new staff. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A well-qualified and competent manager helps to ensure the home is run in the best interests of the service users and improved monitoring and staff training prevents service users being placed at risk. EVIDENCE: A competent, well-qualified and dedicated person manages the home. All staff and the service user spoken with spoke very highly about her and were confident that the home was run well whilst she was managing. The home has had monitoring visits in the past as stated in the previous report, however it was evident that the visits had improved since the last inspection. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 20 The manager and staff undertake regular fire alarm tests and drills and records are kept. Staff are aware of the need to report any health and safety issue. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 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 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 22 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. 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. 1. Refer to Standard YA20 Good Practice Recommendations Photographs of all service users should be placed in the medication file, along with information regarding how service users take their medication. South Avenue, 1 DS0000048582.V339859.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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