Inspection on 30/11/06 for 134 Newtondale

This inspection was carried out on 30th November 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

134 Newtondale 14/10/08

134 Newtondale 31/10/05

134 Newtondale 22/06/05

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 134 Newtondale Sutton Park Hull East Yorkshire HU7 4BP Lead Inspector Christina Bettison Unannounced Inspection 30th November 2006 10:00 DS0000056742.V322278.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 DS0000056742.V322278.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. DS0000056742.V322278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 134 Newtondale Address 134 Newtondale Sutton Park Hull East Yorkshire HU7 4BP 01482 829276 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) Avocet Trust Position Vacant Care Home 1 Category(ies) of Learning disability (1) registration, with number of places DS0000056742.V322278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2005 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. DS0000056742.V322278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection (although the inspector informed the registered manager a few days before that she would be coming on this day to ensure that staff and the service user would be in) and took place over 1 day in November 2006. Surveys were posted out of which none were returned. During the visit the inspector spoke to the registered manager, the service user and one staff member. In addition observations of care practices and interactions were made. The inspector looked around the home and looked at some records. Information received by us since registration was considered in forming a judgement. Prior to the visit the inspector referred to notifications sent to the Commission for Social Care Inspection, the event history for the home since registration and the completed pre- inspection questionnaire. Weekly fees are £1622.00 per person per week. Additional charges are made for the following: newspapers/magazines, hairdressing, chiropody. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report. The site visit was led by Regulation Inspector Mrs. C. Bettison and the visit lasted five hours. What the service does well: Avocet Trust provides accommodation and personal care support and is a good service for adults with a learning disability and other needs. The primary aim is to enable people to develop as much independence as possible, whilst helping them to be more confident and access community facilities. This service provides an individually tailored package of care on a one to one basis which meets the service users needs. The service user is provided with a house comprising of a lounge, dining room, bedroom, bathroom, and kitchen that is nicely personalised to their own taste, thereby providing them with private areas to their liking where they can spend private time or receive visitors. DS0000056742.V322278.R01.S.doc Version 5.2 Page 6 The house is located in the local community and is on a bus route making all leisure facilities and shops easy to get to. There was evidence that the service user was enabled to access health care provision and is supported to make and attend health care appointments and records are maintained to evidence this. Complaints are managed effectively and there was a record of complaints with detail of any investigation and action taken. Staff are assisted to know what the needs of the service users are due to detailed service user plans and the provision of training. The house is safe and comfortable providing a clean, comfortable and homely environment. The service user receives a healthy diet and their likes and dislikes are also taken into account. What has improved since the last inspection? What they could do better: All staff need to have had an annual appraisal that identifies what training they need for the next year and need to have regular recorded supervision. The manager needs to complete a training audit for the home to enable her to identify staff training needs and develop a training plan. DS0000056742.V322278.R01.S.doc Version 5.2 Page 7 A quality monitoring system must be introduced to make sure that everyone is asked about the running of the home and improvements are made. 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. DS0000056742.V322278.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 DS0000056742.V322278.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): Quality in this outcome area has not been assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There had been no admissions to the home since the previous inspection; therefore none of these standards were assessed. DS0000056742.V322278.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users had a detailed individual plan that reflects their full range of needs; choices etc, supported by a range of risk assessments ensuring that their complex needs will be met. EVIDENCE: The care file was examined as part of this inspection. It included a very detailed pen picture that gave a very good initial overview of the service user, their history, needs, likes and dislikes. The service users individual plan was very detailed to ensure that staff are aware of their needs and are able to provide appropriate and consistent care to meet their needs. All care records were in lever arch files and presented in a tidy and organised way. There were good diary records to indicate what care has been delivered DS0000056742.V322278.R01.S.doc Version 5.2 Page 11 on a daily basis. The manager is routinely monitoring the care files and conducting audits to ensure that they meet requirements. The files contained a wide range of risk assessments to cover all areas that may pose a risk to the service user and /or staff. Care had been reviewed by the LA and individual plans and been updated or amended following review. Reviews meetings included an advocate and relevant professionals and covered all of the pertinent issues. It was evident from the file and records that staff were introducing some specific teaching programmes to enable the service user to develop some independence skills however this was to be very small steps and led by the service user at their own pace. These had been produced in both written and pictorial format. A requirement had been made at the previous inspection asking that the manager look into the purchase of the service users new car and ensure that it had been made in consultation with the service user. The manager stated that she had looked into this and confirmed that previous staff employed had not given the service user the opportunity to choose however it was now too late to rectify this. The inspector was satisfied that the new manager and staff team would now ensure that the service user is offered choice regarding items to be purchased. DS0000056742.V322278.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. The service user is assisted to continue their personal development and have access to the community for a wide range of leisure pursuits. The service user enjoys a healthy diet that respects thier choices. EVIDENCE: The manager and staff were observed to be very respectful of the service user and engaged in positive interactions at all times. The inspector was informed that the service user would not be able to engage in a work placement however they participate in a wide range of activities to continue their opportunities for personal development. DS0000056742.V322278.R01.S.doc Version 5.2 Page 13 The service user enjoys an active social life which is detailed in their individual care files, such as bowling, shopping, visits to the neighbours, walks and out for meals at the pub. He has been referred to attend the walking club run by the local Mencap group. The activity timetable is produced in a symbolised version. The manager and staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. Any restrictions are clearly documented in the care file and agreed to by the service user. The service user has recently been on a holiday to a caravan at Skipsea, which he told the inspector he had enjoyed. The service user that lives in the house has a special interest in food. A varied menu is provided to follow a healthy eating plan whilst ensuring that the service user is enabled to make informed choices about the food he wishes to eat. The menu consisted of meat, fish, pasta, soups, sandwiches, quiche, and jacket potatoes. The service user informed the inspector that he likes spaghetti and he chose to have this for his lunch on the day of inspection. DS0000056742.V322278.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of the service user is assessed, identified, clearly documented and are being met by the service, health colleagues and staff. The medication at the home is well managed promoting good health. EVIDENCE: The service users care file was examined as part of the inspection process this evidenced that the service users healthcare needs are adequately being addressed. Health screening had been started and records evidenced that access to chiropody and the GP was being facilitated when required. However the service user had not had his eyes checked for quite some time. The staff had prepared a basic health action plan however the inspector advised that the Community Team Learning Disability be approached to assist DS0000056742.V322278.R01.S.doc Version 5.2 Page 15 in the completion of health screening and the preparation of a more detailed Health Action plan to ensure that all of the service users health needs are identified and services provided to meet these needs. The service user does not self-medicate. There are written policies and procedures in place for staff to adhere to regarding administration of medication and medication records were examined as part of the inspection and found to be in good order. The manager confirmed that all of the staff had completed the administration of medication provided by the local authority that includes a competency check or a workbook to be completed following the training to ensure staff understand their responsibilities. DS0000056742.V322278.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 adequate. This judgement has been made using available evidence including a visit to this service. The staff team are not fully aware of the Protection of Vulnerable Adults policies and procedures and their responsibility within these therefore strategies may not be in place to ensure that service users are protected from abuse, neglect and harm. EVIDENCE: There had been no complaints to the home since the previous inspection however the manager keeps a log book to record complaints with detail of any investigation and action taken. There have been some staff changes at 134 Newtondale since the previous inspection, from examination of personnel files the inspector was satisfied that robust recruitment had been adopted and all clearances had been sought. However from examination of the training records it was evident that not all staff have completed training in the Protection Of Vulnerable Adults Policies and Procedures and therefore may not understand their responsibilities within this and may not be able to ensure that the service user is protected from abuse, neglect and harm. DS0000056742.V322278.R01.S.doc Version 5.2 Page 17 Only the member of staff on duty on the day of inspection had completed the POVA training and the remaining staff had not. Therefore this remains an outstanding requirement from the previous inspection. DS0000056742.V322278.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user is provided with a safe, attractive and homely place in which to live that meets their needs. EVIDENCE: The service at 134 Newtondale is owned and managed by Avocet Trust. It 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 DS0000056742.V322278.R01.S.doc Version 5.2 Page 19 walking distance. Public transport to various parts of the city is easily accessible. The home presents as bright and cheery and suits the service user individual needs. All maintenance certificates were seen and were up to date meaning that the service user lives in a safe, comfortable and homely environment. DS0000056742.V322278.R01.S.doc Version 5.2 Page 20 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 and 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users needs are met by a competent staff team that are aware of the service users complex needs and are able to meet them, however the provision of NVQ training, POVA and supervision would further develop this. EVIDENCE: It was evident throughout the inspection from observation and discussion with the service user that the staff member on duty had a good relationship with the service user. The service user had 1; 1 staff at all times. Throughout the inspection it was evident that the staff member respected the service user and was seen to be accessible, approachable, and comfortable with him. DS0000056742.V322278.R01.S.doc Version 5.2 Page 21 There have been some changes to the staff team at Newtondale following some issues raised. One of the staff members has left the employment of Avocet trust and one of the staff members has been relocated to another part of the service. The staff team is now made up of 2 full time workers, one of these a “B” grade and the other a “C” grade and 2 part time workers both of which are “A” grades. After a period of monitoring by the home and discussion with the Local authority it was agreed that the service user no longer requires a member of staff to be awake during the night so now there is a sleep in member of staff through the night. Only one of the staff has achieved NVQ level 3; therefore there is an outstanding requirement in respect of this. Staff recruitment records were examined, all staff had an up to date CRB disclosure and two written references obtained and all files contained the ID required by schedule 2. 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 and since the previous inspection all staff are now up to date with their mandatory training and have completed the medication training, however they still need to complete the POVA training. The staff team have not yet received an annual appraisal and the manager did not have a training plan for the home. Supervision had not been provided to staff however they have been having regular staff meetings. These were held in May, June and November of this year and given the size of the home the records did indicate that discussions about meeting the service users needs and the running of the home had been addressed with all staff. However staff must still have the opportunity to receive personal, private time with their manager. DS0000056742.V322278.R01.S.doc Version 5.2 Page 22 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): 37,39,40,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides effective leadership; guidance and direction to staff to ensure that the service user receives consistent quality care promoting and safeguarding their health, safety and welfare. EVIDENCE: The manager is not yet registered with the CSCI for 134 Newtondale however the management of the home is robust. The home is safe and comfortable for the person living there and provides a clean, comfortable and homely environment. DS0000056742.V322278.R01.S.doc Version 5.2 Page 23 A requirement had been made at the previous inspection asking that the manager look into the purchase of the service users new car and ensure that it had been made in consultation with the service user. The manager stated that she had looked into this and confirmed that previous staff employed had not given the service user the opportunity to choose however it was now too late to rectify this. The inspector was satisfied that the new manager and staff team would now ensure that the service user is offered choice regarding items to be purchased. Avocet have developed a quality assurance system however this has not yet been fully implemented within the home, this means that the service user and their advocates views are not yet utilised to help shape the way the service is provided in the future. As part of the inspection all of the maintenance records were examined and those seen were in order. The fire officer had recently visited the home following a request by the manager and required that Intumescent fire and cold smoke seals be fitted to the fire doors, the manager stated that is being dealt with. All of Avocets policies and procedures have been reviewed and amended to ensure that staff are aware of their responsibilities and are able to protect service users from harm. DS0000056742.V322278.R01.S.doc Version 5.2 Page 24 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 x 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 2 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 2 33 x 34 3 35 2 36 2 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 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 3 x 3 x DS0000056742.V322278.R01.S.doc Version 5.2 Page 25 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 YA23 Regulation 13 (6) Requirement The registered person must ensure that all staff have received training in the Protection of Vulnerable Adults (Timescale of 30/09/05 and 31/01/06 not met) Timescale for action 31/03/07 2. YA32 18 The registered person must 30/09/07 ensure that at least 50 of staff are qualified to NVQ level 2. (Timescale of 30/09/05 and 30/06/06 not met) The registered person must ensure that all staff have an individual training profile and the home has a training plan. (Timescale of 30/09/05 and 31/01/06 not met) The registered person must ensure that all staff receive supervision a minimum of six times per year. The registered person must ensure that the manager of the home is registered with the CSCI (Timescale of 31/01/06 not met) 31/03/07 3. YA35 18 4. YA36 18 (2) 30/06/07 5. YA37 8 31/03/07 DS0000056742.V322278.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000056742.V322278.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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