Inspection on 22/06/05 for 134 Newtondale

This inspection was carried out on 22nd June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

134 Newtondale 14/10/08

134 Newtondale 30/11/06

134 Newtondale 31/10/05

134 Newtondale 21/03/05

134 Newtondale 09/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 134 Newtondale Sutton Park Hull HU7 4BP Lead Inspector Tina Bettison Unannounced 22 June 2005 9:30 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. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 134 Newtondale Address Sutton Park, Hull. HU7 8DT 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) 01482 329226 Avocet Trust CRH 1 Category(ies) of LD 1 registration, with number of places 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21/3/05 Brief Description of the Service: The service at 134 Newtondale is owned and managed by Avocet Trust. It is one of a small number of similar services that Avocet provides. Avocet Trust is a registered charity. 134 Newtondale is registered to provide care and accommodation for one adult with a learning disability. The home is on Sutton Park close to the North Point Shopping Centre on Bransholme. 134 Newtondale is a bungalow with two bedrooms. There is a sitting room, kitchen, a large bedroom and the second small bedroom has been utilised as a dining room. There is a driveway to the side with space for car parking and a garage. There is a small garden to the front and rear. There are shops, public houses, a medical centre and a post office all within walking distance. Public transport to various parts of the city is easily accessible. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 1 hour and was an unannounced inspection. A tour of the premises took place, staff files, care records, policies and procedures, staff lists and training records were all examined. 1 of the staff, the service manager and the service user that lives at the home were spoken to. Care practices and interactions were observed during the inspection. What the service does well: What has improved since the last inspection? A quality monitoring system has been introduced to make sure that key people are consulted about the running of the home and continuous improvements are made, however this requires further development. There is an up to date maintenance certificate relating to the home’s electrical systems (wiring etc) ensuring that the service users health and safety is maintained. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 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. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 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 standard(s) EVIDENCE: There had been no admissions to the home since the previous inspection; therefore none of these standards were assessed. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 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 standard(s) 6,7.8,9,10 The Service user has a detailed individual plan that ensures his specific needs and goals are met and enables him make decisions as much as he can. Measured risk taking is seen as an essential part of life in order for the service user to try out new things and stretch himself to meet his identified needs and goals. EVIDENCE: The service users Individual plan was examined as part of the inspection process and had been developed to cover all aspects of assessed needs. Staff were able to confirm that the plans were kept under review and that they were formally reviewed every 6 months. Copies of the notes from reviews were seen to support this. Risk assessments were in place for any areas that posed a risk and measures put in place to minimise the risks, e.g. personal safety, access to the kitchen and leisure activities. There was evidence of behaviour management plans in relation to the service user’s challenging behaviour either whilst out in the community or at home. The service user was enabled to be as independent as possible within his capabilities this was confirmed by talking to staff. It is evident from interaction 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 10 with the service user and staff that he makes daily decisions about what happens in his life. Food, clothing and other items purchased reflect the service users choices. Records indicate the service user’s choices or where others have made them on his behalf. It is evident that staff make an effort to ensure the service user is given the chance to make informed choices. Information was observed to be securely kept and handled in accordance with the Data Protection Act. Lockable facilities were used. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 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 standard(s) 11,12,13,14,15,16 The service user is enabled to be part of his local community by the provision of an ordinary bungalow located in a residential area and access to a wide range of community activities. Staff focus on the individual person and ensure that he is listened to and have a say in his daily life by the use of his individual plan that details the way in which he likes to be supported and his likes and dislikes thereby promoting his rights and responsibilities. EVIDENCE: The service users social, emotional, communication and independence skills are developed and maintained by the use of detailed care plans and risk management guidelines and risk assessment. Staff in the home support the service user to take part in age and culturally appropriate activities. The service user is supported to develop his skills e.g. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 12 daily living skills, gardening, art and craftwork. The service user’s art and craftwork is displayed in the home. From discussion with the service user and examination of records it is evident that he accesses the community on a regular basis, making use of local shops, community facilities and the countryside. From discussion with staff and the service user it is evident that leisure activities are organised based on the things he likes to do. The service user has a weekly timetable of activities that staff support him to follow. Specialist staff from the community team learning disability offers specialist intervention and support. From discussion with staff and the service user it is clear that he visits friends in other homes and is also visited by them. Staff reported that the service user has an advocate who visits and takes him out. The service user had unrestricted access to the house and garden. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 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 standard(s) 18,19,20 The service users privacy, dignity and respect is promoted by a caring team of staff. The service users physical and emotional needs are met, by the provision of a wide range of healthcare professionals and outside agencies, however the inadequate medication training provided to staff compromises this. EVIDENCE: The service users care file was examined as part of the inspection process. There was evidence that contact with GP, dentist, optician, audiologist, chiropody, community nurses and therapists was being facilitated on a routine basis. It was evident from time spent with the service user that he is happy with the manner in which staff support him. The home has policies and procedures for the administration of medication however training for staff administering medication is still not accredited. New staff are instructed in medication administration by existing staff. To meet this part of the standard there must be written evidence that staff training in safe practice has been provided for all staff involved in the handling of medication from an external creditable source with relevant knowledge 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 14 about medication. This must include a competency check or a workbook to complete at the end to ensure staff understand their responsibilities. This remains an outstanding requirement from the previous inspection. Times for going to bed and getting up were flexible. Individual likes and dislikes were recorded on the individual plan. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Avocet had a complaints procedure. The service user is listened to and his views acted on by a wide range of methods. The staff team are not fully aware of the Protection of Vulnerable Adults policies and procedures and their responsibility within these therefore strategies are not in place to ensure that service users are protected from abuse, neglect and harm EVIDENCE: From discussion with the staff and observation it is evident that the person centred approach to care by the home ensures that service user’s views are acknowledged and responded to. This is evident through individual plans and daily notes. There was a simple and clear complaints procedure. From discussion with staff it was apparent that they were not fully informed about the Protection Of Vulnerable Adults Policies and Procedures and their responsibilities within this. There was no evidence to support that all staff had received any training or briefings. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30 The service user lives alone in a bungalow in the community, which provides him with a safe, comfortable and private environment that suits his needs and lifestyle. EVIDENCE: 134 Newtondale is registered to provide care and accommodation for one adult with a learning disability. The home is on Sutton Park close to the North Point Shopping Centre on Bransholme. 134 Newtondale is a bungalow with two bedrooms. There is a sitting room, kitchen, a large bedroom and the second small bedroom has been utilised as a dining room. There is a driveway to the side with space for car parking and a garage. There is a small garden to the front and rear. There are shops, public houses, a medical centre and a post office all within walking distance. Public transport to various parts of the city is easily accessible. Furnishings and fittings are domestic in style and of good quality. The service user is involved in choosing furniture for the home. The service user has sole 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 17 use of the bathroom which also has an over bath shower. This is opposite his bedroom and provides him with the necessary privacy to meet his needs. Staff do not work the night duty sleeping in and therefore only need to share the toilet facility with the service user. The service user likes his privacy and makes use of the rear garden, which is not overlooked by any of the neighbours. The service user is physically independent and has no assessed sensory needs that required any special adaptations. A grab rail has been installed in the bathroom to support him getting in and out of the bath. The home has a domestic kitchen where the service user is supported to do his laundry. There is an infection control policy for the home. The home was clean and tidy and there were no malodours evident on the day of the inspection. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 Service users are cared for by a staff group, which is sufficient in numbers to meet their needs, however staff recruitment procedures are inadequate and do not ensure that service users are protected from people who are unsuitable. EVIDENCE: From examination of records, discussion with staff and observation it was evident that staff work to support the written aims and objectives of the home. It was also evident from discussion with staff that they knew how to meet the needs of the service user and there was good evidence in case records of the involvement of other agencies with specific expertise. It was evident that the staff had a well-developed relationship with the service user. The service user had 1; 1 staff at all times. Throughout the inspection it was evident that staff respected the service user and were seen to be accessible, approachable, and comfortable with him. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 19 The Service manager did not have an up to date list of the staff working at 134 Newtondale and when this was requested from head office this was not an accurate list either. It was difficult to ascertain the numbers of staff that have achieved NVQ level 2 due to poor records; therefore a requirement has been made in respect of this. A sample of staff recruitment records were examined, including staff appointed since the previous inspection. Not all staff had an up to date CRB disclosure, three staff had only one written reference obtained. For two workers from overseas there was no evidence that they had the appropriate work permits to work in this country. Some staff files did not contain all the ID required by schedule 2. This did not support a thorough recruitment process. The manager reported that within Avocet Trust there is a Human Resources section responsible for organising training. From examination of records and discussion with the manager and staff there was some evidence of training and this was linked to the needs of service users, e.g. moving and handling, epilepsy, use of stesolid, basic food hygiene and first aid, however not all staff were up to date with their mandatory training and had not received appropriate medication training. New staff are supposed to complete Learning Disability Award Framework – accredited training to meet the Sector Skills Council targets for staff induction. New staff were not doing so and some staff spoken to were not clear about their responsibilities with regard to the Protection of Vulnerable adults, therefore all staff must receive updated training. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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) 37,38,39,40,41,42,43 The Service user is encouraged on an informal basis to contribute to how the home is run. A formal approach has been devised but not yet fully implemented. The policies and procedures are out of date and do not reflect current practices in the home. The Service user lives in a safe environment. EVIDENCE: 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 21 The Service Manager presented herself as friendly and approachable throughout the inspection, she had a clear sense of direction and aims for the home. The manager still needs to be approved and registered with the CSCI. The Service Manager reported that budgets are set by the provider and she has responsibility for managing a range of budgets e.g. staffing, food, petty cash,and training. There was suitable insurance cover in place. Avocet have developed a quality assurance system however this has not yet been fully implemented within the home, this means that the service users and others views are not yet utilised to help shape the way the service is provided in the future. As part of the inspection the maintenance records were examined and those seen were in order. The home had an up to date electrical wiring certificate, however the deficiencies and recommendations from the inspection must be attended to. It was evident throughout the inspection that the service is centred around the service user. The Service Manager supported staff to ensure this was the case. Policies and procedures were examined as part of the inspection process, although some have been updated the majority date back to 1995/98 with no evidence of update or review. The registered person must ensure that Avocet,s policies and procedures are reviewed and amended in line with changes in legislation and best practice guidance. 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 2 3 1 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 134 Newtondale Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 2 3 3 3 J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 23 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 20 Regulation 13 Requirement The registered person must ensure that all staff have training in the safe handling of of medication and that they have been assessed as competent and written records kept (Timescale of 30/6/05 not met). The registered person must ensure that all staff have received training in the Protection of Vulnerable Adults The registered person must ensure that at least 50 of staff are qualified to NVQ level 2. The registered person must ensure that all new appointments have 2 written references prior to commencement and that all ID as required by schedule 2 is retained on file. Any overseas workers must have a copy of a valid work permit on file. The registered person must ensure that all staff are up to date with mandatory training The registered person must ensure that a training audit is undertaken and a training plan developed for the staff team in the home. Timescale for action 30/9/05 2. 23 13 (6) 30/9/05 3. 4. 32 34 18 7,9,19 schedule 2 1/12/05 30/9/05 5. 6. 35 35 18 18 30/9/05 30/9/05 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 24 7. 35 18 8. 34 7,9,19 schedule 2 18 8 24 9. 10. 11. 35 37 40 12. 40 24 The registered person must ensure that all new staff receive induction training that meets LDAF standards The registered person must ensure that documentary evidence is maintained on staff files of staff qualifications. The registered person must ensure that all staff have an individual training profile The registered person must ensure that the manager of the home is registered with the CSCI The registered person must ensure that Avocet,s policies and procedures are reviewed and amended in line with changes in legislation and best practice guidance. The registered person must ensure that the policy and procedure for the use of restrictive physical interventions is reviewed and amended 30/9/05 30/9/05 30/9/05 30/10/05 1/12/05 30/9/05 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 Good Practice Recommendations 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 134 Newtondale J54 134 Newtondale V235768 22 June 05 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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