Inspection on 14/11/08 for Creykes Lodge

This is the latest available inspection report for this service, carried out on 14th November 2008.

CSCI found this care home to be providing an Good service.

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

Creykes Lodge 01/11/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

CARE HOME ADULTS 18-65 Creykes Lodge 2 Rawcliffe Road Rawcliffe East Yorkshire DN14 8SE Lead Inspector Janet Lamb Key Unannounced Inspection 14th November 2008 90:30 Creykes Lodge DS0000062522.V373375.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 Creykes Lodge DS0000062522.V373375.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. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Creykes Lodge Address 2 Rawcliffe Road Rawcliffe East Yorkshire DN14 8SE 01405 839198 01405 839012 andrea@st-annes.org.uk www.st-annes.org.uk St Anne’s Community Services 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) Andrea Sanderson. Emma Tomlinson is currently Acting Manager. Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2006 Brief Description of the Service: Creykes Lodge provides personal care and accommodation for up to six adults with a learning disability. The premises consist of a detached bungalow on the main road in the village of Rawcliffe, on a bus route, close to local amenities, and the towns of Goole and Selby. The home offers only single room accommodation, and well-maintained communal areas. There are well-maintained gardens to the front, side and rear of the property. There is level access to all entrances and car parking space for approximately six vehicles is available to the front of the property. The grounds are fully enclosed and accessed by a secure gate, providing a safe environment for the people living there. Care, support and accommodation are provided for between £913.62 and £1517.10 per week. This information was obtained from the Acting Manager on the day of the site visit. Details of the service are available in the home’s statement of purpose and service user guide, which can be obtained from the home upon request. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2-star. This means the people who use the service experience good quality outcomes. The Key Inspection of Creykes Lodge has taken place over a period of time. It involved electronically requesting an ‘annual quality assurance assessment’ (AQAA) document in August 2008 supplying information about people and their family members, and the health care professionals that attend them. It also asked for numerical data held in the home. The home sent us their AQAA in September 2008 and surveys were sent to the relatives of people living in the home and to staff working there. Information taken from the previous key inspection report, from returned surveys and from notifications sent to us by the home, was used to determine what it must be like living there. On 14th November 2008 Janet Lamb carried out a site visit to talk to and observe people living in the home, staff and the manager, as well as to inspect records and documentation. This was to assess all of the information already received and to determine what it must be like to live at Creykes Lodge. All of the key inspection standards were assessed in sections and the following report provides a judgement on each section. Where a shortfall is identified a recommendation has been made. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: The use of extensive needs assessments means people’s diverse needs are well identified and planned for before they move to the home, so they are confident their needs are met. The supported living agreement and service notification provides people with good protection that the service on offer meets their assessed needs. Care plans meet specific and identified needs well and these are reviewed as requested, necessary or in line with the requirements of the providing authority. People enjoy making many of their own decisions in life, with risk assessments being in place where necessary to enable them to lead lives of reduced risk. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 6 People enjoy a good level of satisfaction in their lifestyles that are partly of their choosing, with much support from staff where necessary. People benefit from robust medication administration systems and trained staff, and they receive the right levels of support to assist them with personal and health care needs and issues. People and relatives have good opportunities to make complaints, handling of them is effective, and so people are confident that concerns are dealt with properly. Allegation referrals are well made in accordance with safeguarding adult referral procedures and staff are appropriately trained in this area, so people know they are properly protected. People live in a well furnished and equipped home, that is clean, hygienic, safe and comfortable. The home offers good space and facilities so people are able to lead independent lives where possible. People are cared for by staff in sufficient numbers to meet their needs, most of the time, but not always at weekends. Staff are satisfactorily recruited and trained. Staff are satisfactorily supervised to do the job. Overall people are confident that safe staff are caring for them. People enjoy the benefits of a well run home. The quality assurance systems are effective at determining the quality of the service provided. People are confident the conduct and management of the home is good and that promotion and protection of their health, safety and welfare is also good, which means people’s care needs are well met and they lead fulfilling lives. What has improved since the last inspection? What they could do better: The service could make sure staff follow the home’s medication administration procedures and always mark on the MAR sheet when a new packet or bottle of medicines is started, so an accurate stock control is maintained. It could make sure the requirements of the local fire department to fit intumescent seals on fire doors is carried out in the timescale proffered, so people are not at risk of harm from fire. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 7 The service could consider providing staff with a shower facility, and should repair the office desk or replace it. It could carry out an ongoing review of the staffing levels and make sure there is sufficient staff on duty at weekends to meet people’s needs. As part of this the registered provider should also consider employing cleaning staff to enable support workers to spend more time with people in the home. 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. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. The use of extensive needs assessments means people’s diverse needs are well identified and planned for before they move to the home, so they are confident their needs are met. The supported living agreement and service notification provides people with good protection that the service on offer meets their assessed needs. EVIDENCE: Though the ‘statement of purpose’ and ‘service user guide’ was not assessed on this site visit, it is understood they have been updated recently, were satisfactory at the last key inspection, and are therefore accepted as being appropriate and informative. People receive initial assessment from their placing local authority or local health authority to determine whether or not residential care is required. Referrals to the home can only be made if there is a vacancy, which is very rare. People have their care needs fully assessed once they become resident in the home, through the use of an ‘assessment passport’ tool, which involves Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 10 observation of the person in their environment, as well as the use of a ‘functional assessment’ tool, which is a risk assessment document that covers all of the areas in standard 2.3, or ‘activities of daily living.’ All assessment of people is in conjunction with the placing joint commissioning services of the local authority and the local health authority. People’s needs are well met through the careful observation of their behaviour and demeanour, and the use of comprehensive assessment tools, which lead to the compiling of clear person centred plans of care and health care plans, which in turn are carefully followed, reviewed and amended as necessary. People have contracts of residence in place between the commissioning services and the home and these are called ‘residential service notifications.’ People also have ‘supported living agreements.’ Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 11 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 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. Care plans meet specific and identified needs well and these are reviewed as requested, necessary or in line with the requirements of the providing authority. People enjoy making many of their own decisions in life, with risk assessments being in place where necessary to enable them to lead lives of reduced risk. EVIDENCE: People have their assessed needs well recorded in a person centred plan of care or ‘support plan,’ which only covers identified areas that are an actual issue to the person. For example one person’s plan of care viewed in the case file, shows there are three major areas of need, at the moment, eating and drinking, sleeping and behaviour. Until this person has completed a full period of assessment in the home, these will remain the main areas of the plan. Such as mobility is not an issue and therefore does not and will not feature in the Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 12 plan of care. Such as pastimes, activities, religious, cultural or emotional needs take longer to assess and therefore will be added at a later stage if they prove to be an important need to be met. Every aspect of a person’s lifestyle is assessed and features in the plan of care if there proves to be a need to assist or support the person with it. Otherwise areas of living that are not problematic do not feature. This makes all of the plans of care extremely individual to the people they are compiled for. Plans of care are reviewed every six months in-house or sooner if changes in need arise, and in conjunction with the commissioning services every year. Evidence of plans, reviewing of them and how people’s needs are met, is available in case files, the actual plans, review meeting minutes, diary notes, and records of support etc. Where possible people make daily decisions, often supported and advised by staff though. People never go out alone, but always travel on the home’s bus or via taxi or ambulance. People choose when to get up, go to bed etc., but are again advised by the staff. People make choices at meal times, as was observed on the site visit: one left the salad on their plate, while another chose fruit, and another yoghurt, for dessert. People often act on impulse and by following learned behaviour and they are encouraged in making decisions that are sociable and acceptable to others. Behaviour is developed through reinforcement of acceptable actions and clear messages given out to that, which is unacceptable. Behaviour support plans are also in place and staff spend a lot of time assisting people to make changes in an attempt to improve their development and to improve their behaviour to maintain its acceptability. Staff are trained, experienced and skilled in working this way, and always work for the best interests of the people living in the home. Risk taking is encouraged and always accompanied by full and detailed risk assessments and risk management strategies being in place. Risk assessment documents are available in case files that cover, where necessary to individuals, the aspects of standard 2.3. Again these only feature if they are an element of the support plan and a concern for action etc. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 13 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 and 17. People who use the service experience excellent quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People enjoy a good level of satisfaction in their lifestyles that are partly of their choosing, with much support from staff where necessary, so they are confident their needs are well met. EVIDENCE: Education and occupation opportunities for people are few because of their limited abilities, but one person does attend a resource centre and other people do engage in indoor and outdoor activities, such as watching television, listening to music, eating out in the garden in warmer months, taking village walks, going shopping and taking rides in the minibus, trips and meals out at garden centres and visits to the coast in summer, etc. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 14 People maintain good community links through walks in the village and use of local shops, churches etc., as well as taking drives to Goole to use shops, pubs, restaurants and other facilities there. Relationships are usually good, but can be difficult between people in the home, depending on their background and their temperaments. Staff observe people well though and comment on people “taking to one another” and sharing their company together. Generally people tolerate one another very well and tend to share moments of mutual companionship. There are also moments of uncertainty sometimes. Staff are aware of the possible effects these moments may have on people and they continue to monitor and support everyone. Family support is very good where people have family contact, but not everyone does have contact. Diary notes show how people interact and what contact they have with significant people in their lives. Some daily routines around mealtimes, cleanliness, and such as activities are in place for people’s comfort and for the consistency of their care, but people do make choices to return to their room, seek assistance with personal care and functions and what to or not to do or eat etc. Staff quickly tune in to people’s needs and observe and monitor their behaviour well so they know what each little movement means and are therefore quickly able to meet needs as they arise. Meal times have become more settled for people over time, as they are less hurried and involve everyone sitting down together to share some time and to eat well. Menus follow healthy eating options and offer specialist foods if necessary, for such as weight reducing diets or low salt, no gluten etc. People make choices about whether they want to eat the meal or not, and about such as pudding options. People are not left to decide entirely what they should or should not eat, especially if they require weight reducing or specialist diets, as they would not be in a position to make an informed choice. Staff must advocate for people most of the time to ensure they are leading a healthy and sensible lifestyle. People assist with shopping trips to obtain the foodstuffs required. People make some food likes and dislikes known by eating/not eating what is offered, but staff observe closely and make sure everyone has the opportunity to eat well and sufficiently for their needs. People are given discreet support and assistance they need to have their meals. It is very difficult for staff to achieve a balance between providing high levels of support and enabling people to achieve some self-determination, but they manage very well and where possible always look to people deciding for themselves first, before guiding them to taking action or making choices that are in their best interest. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 15 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 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People are benefiting from robust medication administration systems and trained staff, and they are receiving the right levels of support to assist them with personal and health care needs and issues. EVIDENCE: From observation of people in their routines and of their behaviour and temperament, and following discussion with staff, people are given good personal support in privacy and in a way they appear to prefer, as most of them are unable to say directly. One person that is able gave positive comments about living there and liking the staff and what she does, where she goes etc. Behaviour is often unpredictable and random and although people have freedom to be themselves, sometimes staff have to be very persuasive in guiding them into changing their behaviour for their own safety, comfort etc. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 16 and for that of the others. Three staff are general or psychiatric nurse trained, the rest are support workers, but all staff are aware of the physical and emotional care people need assistance with and when. This is all done sensitively and in people’s best interests, as observed and discussed on the day of the site visit. A visit from one person’s community nurse and discussion with him revealed he is very satisfied with the service that has been provided to his client so far. There is detectable improvement in the demeanour and tolerance of the person since his admission and the community nurse says he looks healthier and more relaxed. Person centred plans of care and health care plans are in place for everyone and those viewed with permission, show information only related to issues that present as a serious care need or health care need. Needs are very well recorded, monitored and met. There is evidence in the form of records for weight, chiropody visits, GP visits, hospital appointments, etc. and risk assessments back up each area of health need within the health care plan. Files also show what health screening is necessary for individuals and dates of appointments etc. are clearly recorded. Where people express absolute refusal to cooperate in any health care process, as does sometimes happen, health care plans have recorded details and again the issues are risk assessed. Each file has separate health care diary notes as well. The medication handling systems are good, following monthly reordering and a simple ‘straight from the bottle or packet’ administration. Medication administration record (MAR) sheets show when medicines are received, how many, when they begin to be used and when they are administered or refused etc. Some evidence on MAR sheets shows on a couple of occasions staff did not mark the start of a new bottle, so this is a recommendation of the report and the manager must make sure staff do follow the home’s written procedures. The MAR sheets are usually completed by a responsible and competent staff member, which is done by checking the bottles and packets received against the F170 prescriptions, counting the actual numbers of tablets, checking them against the prescription for accuracy of quantity, strength etc. and then recording them clearly on the MAR sheet. A second competent staff member also checks them before they are stored away in a wall-mounted cabinet for use. No one was observed receiving medicines on the site visit, as no one takes any at mid-day, but the process for giving them out was discussed and is considered satisfactory. Any not used are recorded on a separate sheet and signed for by the receiving pharmacist on return. There are currently no controlled drugs in the home, but a control drug register and appropriate locked facility are both available. Staff undertake Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 17 medication administration training with an outside agency and their competence is assessed externally after completing a five unit booklet on the subject. MAR sheets viewed for some people are satisfactory. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 18 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 and 23. People that use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People and relatives have good opportunities to make complaints, handling of them is effective, and so people are confident that concerns are dealt with properly. Allegation referrals are well made in accordance with safeguarding adult referral procedures and staff are appropriately trained in this area, so people know they are properly protected. EVIDENCE: There is a complaint system in place with policies and procedures and records. The situation is the same as at the last inspection, people are unlikely to fully understand the concept of complaining, but relatives are very aware of procedure and their rights as advocates of people in the home. People do demonstrate their displeasure to achieve desired outcomes and so have an understanding of their own and therefore receive the care and support they need. The home received one complaint since the last inspection, from a relative about some staff changes and the perceived anxiety experienced by the person in the home because of this. An appropriate response was provided and the complainant was satisfied with the outcome. Staff are very aware of people’s rights and advocate for them all the time in and out of the home. Staff observe behaviours and changes in people and take these to be complaints of a kind, so they act to help reduce changes in behaviour or to Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 19 restore confidence in people. Staff consider not meeting people’s needs and the resulting changes in their behaviour as a complaint, and handle these issues as they arise. No complaints have been received at the Commission or via the East Riding of Yorkshire Council. There is a clear and robust procedure for dealing with suspected abuse or allegations of abuse and all staff are clear about their responsibilities. Staff have done internal Safeguarding Adults training in the form of abuse awareness and handling safeguarding issues with the company, St Anne’s. Staff have also completed St. Anne’s induction and foundation training courses at the start of their employment. The evidence of this training is held in individual’s files at St Anne’s head office though, and was not viewed. There has only been one safeguarding referral made to the council in the last 12 months, which involved an incident between two people living in the home. This was appropriately stopped, recorded, handled, passed on and dealt with. Discussion with staff demonstrates they are fully aware of people’s right and their own responsibilities to keep them safe and to pass information on to the safeguarding team. Staff are observed protecting people in every day situations, from harm from each other because of relationships, by ensuring no one is neglected in any aspect of their care or health care, and from harming themselves because of particular behaviour. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 20 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 and 30. People that use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People live in a well furnished and equipped home, that is clean, hygienic, safe and comfortable. The home offers good space and facilities so people are able to lead independent lives where possible. EVIDENCE: The premises is purpose built for people with a learning disability, is on ground floor level only and has required ramps, aids etc. to meet individual’s needs. Space meets the requirements of the standards, and rooms are well decorated and furnished according to individual choices. The premises are close to local services in the village and a bus service to Goole, the nearest town. The grounds are secure with perimeter fencing, walling and wrought iron gates that open electronically from the house. The gate has a buzzer and intercom system. Some of the fencing has been vandalised over the past few months Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 21 and staff remain vigilant about ensuring people in the home are secure when using the garden. The home is clean, comfortable and well decorated, and has suitable light, ventilation and heating. Everyone living there has a single room, but shares the bathroom and toilets. There is a large garden surrounding the home, which is available to people at will. The home meets the requirements of the local fire service and environmental health departments, though there is still some work to do to meet fire safety standards following a visit from Humberside Fire and Rescue on 10/10/08, namely to fit intumescent seals to all fire doors. It is understood this work will be completed by April 2009. There is a planned maintenance and renewal programme, and generally the home is well maintained and safe. The home is clean, hygienic and free from offensive odours. There are sluicing facilities and washing machines with sluicing programmes available. The laundry has recently been altered to make it smaller and allow for the building and equipping of a ‘sensory’ room, which will soon be ready for use. The laundry meets requirements of the Water Supply (Water Fittings) Regulations 1999, and although smaller now has an extra washing machine. There is suitable hand washing facilities and surfaces are impermeable and cleanable. There is a contract in place since 07/07/08 with ‘Hi Care Environmental Services’ to remove all clinical waste. The only facility missing in the home is a shower for staff use, which staff say often proves to be a necessity and is being considered by the company. Also an observation made is that the office desk is unstable and needs replacing or repairing. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 22 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, 33, 34 and 35. People that use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People are cared for by staff in sufficient numbers to meet their needs, most of the time, but not always at weekends. Staff are satisfactorily recruited and trained. Staff are satisfactorily supervised to do the job. Overall people are confident that safe staff are caring for them. EVIDENCE: From discussion with staff, though staff files could not be viewed, it is evident staff do induction, LDAF and LDIA and enrol on NVQ level 2. Eleven from seventeen staff now have or are doing NVQ giving 65 with the recommended qualifications. Staff train in such as first aid, Health & Safety, epilepsy, medication administration, positive support behaviour, safeguarding adults, care planning, diabetes, autism etc. all as necessary and to meet individual’s needs. Courses are usually set and delivered by St. Anne’s trainers. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 23 Staffing levels have been reviewed in last 12 months and some new staff have been taken on. There is now a minimum of 4 support workers and the manager on shift throughout the week, but still only 2 support workers at the weekend. This needs increasing to make sure activities and outings can continue. It is recommended there be three support workers throughout the day at weekends. It is difficult to say if people’s needs are being met or not at all times, as from observation on the day of the site visit, with four staff and the manager available, it seems they are being met during the week. But we are unable to judge this at weekends, though staff report they cannot leave the premises to support anyone wishing to, or having to because of accident, when there is only two on duty. It is also recommended that a cleaner be employed to make sure the home remains clean and comfortable for people, but also to enable support workers to concentrate all of their working time on being with people in the home. Recruitment and selection systems are satisfactory. The home follows St. Anne’s policy and procedure and practice is generally quite good, though the home does not use the initial staff security check system available to them. It does undertake full security checks with the Criminal Records Bureau (CRB) though before anyone begins working. The home only keeps a document in reference to the full CRB having been done, containing the date and clearance number. Files seen, with staff permission, show copies of other recruitment documents, application forms, references, supervision and appraisals. Evidence of identification and the CRB proper and induction records are all held at head office. Training and development opportunities are reported to be good. Files seen and staff spoken to evidence they have good opportunities to do courses, learn new skills etc. People have training profiles and training plans and keep records of courses completed, some already listed above. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 24 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 and 42. People that use the service experience good quality outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People enjoy the benefits of a well run home. The quality assurance systems are effective at determining the quality of the service provided. People are confident the conduct and management of the home is good and that promotion and protection of their health, safety and welfare is also good, which means peoples’ care needs are well met and they lead fulfilling lives. EVIDENCE: The registered manager is currently absent from her post and the company has properly informed the Commission. There is an acting manager in post that has been since 01/11/08. The company requires managers to undertake either NVQ level 4, Leadership and Management for Care or NVQ level 4 in Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 25 Health and Social Care. Some managers in the company do hold the Certificate in Management Studies qualification. The acting manager is soon to start NVQ level 4 in management. The company has been informed the acting manager does not need to register as a new manager, as the temporarily absent registered manager is due to return to her post. The Commission’s registration team has approved these arrangements and so they are currently satisfactory. There is a quality assurance system in place, as last year’s, so it was not assessed on this site visit. Information provided informs us that relatives, health care professionals and staff are surveyed on a regular basis. Meetings for staff and a quality circle meeting for relatives are held regularly, and individual reviews are used to determine people’s satisfactions. There has been no concerns or dissatisfactions with the service highlighted for some time. Safe working practices under standard 42 are considered satisfactory on looking at a sample of safety and maintenance areas. The home’s Health & Safety file was viewed and contains many risk assessment documents all indexed. They cover many general subjects and areas of safety as well as identified risks for individuals. Staff sign a declaration to say they have read and understood and will abide by risk assessments. There is a Health & Safety policy statement, reviewed annually, and an emergency plan. Chevin Housing Association, owners of the building, complete monthly safety checks. Areas sampled for this inspection include electrical safety, gas safety, environmental food standards with fridge and freezer temperature checks, fire safety, hot water storage and supply and Control Of Substances Hazardous to Health. There are no lifting facilities or lifting equipment in the home, as everyone is mobile/ambulant. Everything seen is considered to be satisfactory. Certificates of maintenance and safety were viewed, staff were spoken to about their practice and their responsibilities and generally systems in place are robust and offer good protection to people and staff and good promotion of their health, safety and welfare. Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 26 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 3 4 X 5 3 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 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Creykes Lodge DS0000062522.V373375.R01.S.doc Version 5.2 Page 27 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. 1 Refer to Standard YA20 Good Practice Recommendations The registered person and manager should make sure staff follow the home’s medication administration procedures and always mark on the MAR sheet when a new packet or bottle of medicines is started, so an accurate stock control is maintained. The registered person should make sure the requirements of the FPO to fit intumescent seals on fire doors is carried out in the timescale proffered, so people are not at risk of harm from fire. The registered person should consider providing staff with a shower facility, and should repair the office desk or replace it. The registered person should carry out an ongoing review of the staffing levels in the home and make sure there is sufficient staff on duty at weekends to meet people’s needs. As part of this the registered provider should also consider employing cleaning staff to enable support workers to spend more time with people in the home. DS0000062522.V373375.R01.S.doc Version 5.2 Page 28 2 YA24 3 4 YA24 YA33 Creykes Lodge Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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