Inspection on 15/01/07 for 14 Coronation Road

This inspection was carried out on 15th January 2007.

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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

14 Coronation Road 05/09/07

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

CARE HOME ADULTS 18-65 14 Coronation Road Sunniside Gateshead Tyne and Wear NE16 5NR Lead Inspector Miss Nic Shaw Unannounced Inspection 15 &17 January 2007 09:00 th th 14 Coronation Road DS0000067740.V329048.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 14 Coronation Road DS0000067740.V329048.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. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 14 Coronation Road Address Sunniside Gateshead Tyne and Wear NE16 5NR 0191 4886521 0191 4889743 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) www.c-i-c.co.uk. Community Integrated Care Ms Nicola Mould (not yet registered). Care Home 2 Category(ies) of Learning disability (2), Physical disability (1) registration, with number of places 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: Coronation Road is a care home owned and run by Community Integrated Care, a registered charity that provides care services for people with learning disabilities. Coronation Road is registered to provide 24 hour care for 2 people who have a learning disability, one of whom has a physical disability. Coronation Road is pleasantly situated in a quiet part of Sunniside within close proximity to health care facilities, local shops, pubs and surrounding countryside. There are frequent bus services to Gateshead and Newcastle and the Metro Centre. Service users are able to use of their choice within the community with support from a trained staff team. The service users also have use of a car. Coronation Road is one of several bungalows in the area. It has been adapted to divide the bungalow into 2 separate living environments both consisting of a lounge, dining room, bathroom, toilet, kitchen and bedroom offering each of the service users their own home in which to live. The building is surrounded by extensive well kept gardens. The weekly charge to the service user is £62.35 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days in January 2007 and was an unannounced key inspection. Time was spent talking to the manager and staff. Care plans and other records were looked at as part of the assessment of the service. In order that the views of service users were sought time was spent talking with them, looking at what it is like from their point of view living at Coronation road. Time was also spent watching the staff’s care practices with the service users and checking that information obtained from discussion with staff and observation was recorded in the care plans. One of the service users let the inspector look at their bedroom and the inspector looked at other areas of the homes such as the lounges, kitchens and bathrooms. A questionnaire was also sent out to relatives in order to find out what they thought of the service provided at Coronation Road. One completed form was returned. What the service does well: There’s lots of information in the “Statement of Purpose” and “Service User Guide”, (the home’s brochures), to tell the service users about what to expect from living at Coronation Road. The service users needs were assessed before they moved into their new home to make sure that this was the right place for them to live. There was also plenty of time for the service users to get to know the care staff before they moved into their new home, which helped them alot with the move. The service users are fully involved in everything that is going on and staff make sure that they are supported to make choices and decisions for themselves. There’s plenty for the service users to do and because staffing levels are so good, each day service users can choose exactly what they want to do. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 6 Service users are supported by staff to do their own shopping and make their own meals and this helps them to develop independent living skills. Staff also make sure that any help the service users need with their personal care is given in a sensitive way. Service users get to see their doctor quickly if they are ill. They also see other people such as occupational therapists so that if they need any special equipment this is sorted out for them. There is a nice atmosphere in the home and staff listen to what the service users tell them. If this involves something about poor care practise staff do not hesitate in reporting this to the manager. Each service user lives in their own home supported by their own team of staff which is excellent. Both houses are homely and well maintained and have lovely spacious gardens. There are good recruitment procedures so that only the right people are employed to work at Coronation Road. Staff are given lots of training to help them do their job well. There are also lots of policies and procedures so that staff know what they should do in many different situations. The manager has lots of experience and gets on well with the service users as well as the staff. Service users said: “the staff are alright” “I like it here, its my home” What has improved since the last inspection? What they could do better: The service users need to be provided with a copy of the contract so they know what their rights are. The care plans and risk assessments need looking at so that they provide upto-date information on the service users needs. This should include things like the support people need with their healthy eating plan as this is important to make sure that all of the staff give support in the right way. Medication needs looking at to make sure that service users get only what they have been prescribed. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 7 It would be good practise to make sure the service users relatives are given a copy of the complaints procedure so that they know what to do if they have any concerns. The manager must make sure that all of the staff are given training on the local authorities “safeguarding adults” procedure. This is so that staff will know who to report any suspicion of abuse to quickly. The wall separating the two houses should be sound proofed so that the two service users can have more privacy. All of the staff should get a regular private meeting with their manager, (known as a supervision), to make sure they continue to do their job well. The manager should carry out more checks to make sure the service users are getting a good service. Staff should be given more regular fire instruction so they know what they should do if there is a fire. Records, such as staff files and the accident book, need to be kept up-to-date as this will help protect the service users. 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. 14 Coronation Road DS0000067740.V329048.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 14 Coronation Road DS0000067740.V329048.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): 1,2,3,4&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with sufficient information on which to make informed decisions about whether the home will meet their needs. The care needs of the service users were fully assessed before moving to Coronation Road and they were also able to visit the home prior to this to ensure that the care offered is appropriate to meeting their needs. There was no evidence that service users or their representatives had been given a copy of the contract and therefore they may not be aware of their rights and conditions of residency. EVIDENCE: There is a Statement of Purpose and a Service user Guide which provides the service users with information including the aims and objectives of the home, the type of services which are provided and specific information on key policies and procedures. Both documents are available in an accessible format with large print and pictures, in order to meet the diverse communication needs of the service users. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 10 The manager confirmed that the needs of both service users were fully assessed before they moved into Coronation Road, however, a copy of the social work care plan could only be found for one service user. It was apparent from observation and discussion with staff that they knew how to meet the service users needs. Throughout the inspection they demonstrated that they knew how to communicate with the service users and practiced “person centred care”, that is making sure that they involved the service users in all aspects of the decision making process, treating each individual as a valued person. Examples of this included asking the service users permission before making themselves a cup of coffee. The staff said that they had supported one service user to visit their new home prior to them moving in. As part of the introductory period the staff team were also able to work with the service users for approximately three months before they moved into Coronation Road. This meant that the staff and the service users had plenty of time to get to know one another. The manager said that she was certain that service users representatives had been provided with a copy of the contract or statement of terms and conditions of residency, however, copies of this document were not available in the home to confirm this. 14 Coronation Road DS0000067740.V329048.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): 6,7,8,9&10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care needs recorded in the care plans need to more fully reflect the service users physical, emotional and social care needs, to ensure that the service users welfare is fully promoted. Whilst service users are supported to take risks and make decisions and can enjoy a range of activities as part of living an independent lifestyle, risk assessments need to be reviewed to ensure that the autonomy and independence of the service user’s is maintained. Information about service users is handled appropriately so that their confidences are kept. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 12 EVIDENCE: Information was available in care plans to advise staff of the interventions needed of them to meet the service users personal care needs. Some of the guidance in the care plans was put into practise by staff during the inspection, as evidence that they had read, understood and recognised the importance of these. Information was written in a “person centred” way, that is it focused upon the individual and their strengths and aspirations with the “lifestyles plan” document called “Who I am and what people think of me”. However, in one file this information related to the service user’s previous accommodation and did not reflect the positive changes to the person’s well-being and subsequent changes to support needed of staff since moving to Coronation Road. Some information had not been dated or signed and therefore it was not possible to establish whether or not it was current. Staff spoken to were clear of how best to support those people who may become agitated and what might act as a trigger to this. However, this was not fully recorded in the care plan. One service user had signed their care plan as evidence that they had been involved with this. Staff and one service user said that the staff always wrote the daily notes with the service users, fully involving them in this process. Staff respect the service user’s right to make decisions. For example, staff involved the service users in everything they did, opening the front door, making a cup of tea, cooking and preparing meals. Staff described a situation where they had been able to support a service user to go shopping to choose their own clothes, an activity which they had never been able to take part in before moving to Coronation Road. A service user’s decision to own and care for their own cat had been supported by staff and was clearly a major part of their life. An advocate is involved with both service users, and records showed that they had visited over Christmas. Detailed risk assessments with supporting risk management plans had been developed to provide guidance for staff on how to support the service users with their move to Coronation Road as well as the best way of supporting service users who may become agitated. These, however, had not been reviewed to reflect the increased range of activities the service users are supported to take part in or the changes in the service users behaviour since moving to Coronation Road. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 13 Discussion with the manager confirmed that staff training in relation to confidentiality is provided during their induction. The service users records are stored in a secure location within the home. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 14 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): 11,12,13,14,15,16&17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by the staff to lead active fulfilled lifestyles with their rights as individuals being respected. This means that their personal development and role as valued members of the community is promoted. Service users are offered a varied menu with wholesome food, which promotes their health and well being, although care plans do not always reflect the service users dietary needs. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 15 EVIDENCE: Service users are supported to maintain their independent living skills. Staff spoken to clearly saw their role as being that of “enablers” and observations confirmed that the service users were encouraged to take part in all aspects of daily living. For one service user this has meant learning how to cook. The manager confirmed that she is in the process of identifying the service users religious needs as part of the care plan review process. Positive steps have been taken by the staff to support the service users to become part of the local community. The staff and service users talked of the good relationships they have developed with their neighbours since moving into Coronation Road. Staff also spoke of how they support the service users to use their local shops and as a result of this described how they felt that the local community had developed a greater understanding of the needs of people with a disability. The staff have started to develop what is called a “circle of friendship” plan. By increasing opportunities for service users to be part of the local community the aim is to increase the number social contacts each service user has and therefore their “circle of friendship”. The excellent staffing levels means that every day service users are able to take part in a range of leisure activities. Service users do not attend day services and each day activities are offered based upon the individuals likes and interests. The service has its own transport, which is shared between the two service users. Some of the staff are able to drive and this has enabled the service users to enjoy activities further away. On the day of the inspection one service user was preparing for a trip out for lunch. Staff spoke enthusiastically of how they have supported service users to take part in activities which they had been told by hospital staff would, due to the service users complex needs, never be possible. For one person this has meant the experience of the Metro Centre and trips out to the coast. Service users maintain contact with their relatives and friends. One service user said that they often visit their friend who lives in another care home and that their sister had recently visited them over Christmas. Feedback received from relatives in the questionnaire confirmed that they were always made to feel welcome in the home and that they are kept informed of important matters affecting their family member. The manager confirmed that it is her intention to fully involve relatives in the development of the care plans. Meals are based upon the service users likes and service users are encouraged to shop for their own food and prepare their own meals. A dietician has been involved with the service users and healthy eating is encouraged. However, where it had been identified in the service user’s assessment that they required support with their diet, the aim being to loose weight, a care or goal 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 16 plan had not been developed in enough detail to guide staff on how best to support the person to achieve this. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,&20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users are assisted by staff to maintain good quality health and receive personal support in a way that they prefer. The health of the service users is not fully protected by the medication procedures. EVIDENCE: Staff provide service users with support in relation to their intimate personal care in a sensitive, discreet manner, carrying out care tasks in the privacy of the person’s bedroom. The staff group is balanced to enable choice of male or female staff, according to the service users needs. The staff said that the age of the staff is also very important to one service user and the manager confirmed that she is in the process of reviewing the rotas to accommodate this. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 18 Service users regularly see a number of health care professionals including, speech therapists, GP’s, chiropodists and community nurses. Aids and equipment are provided to encourage maximum independence and are regularly reviewed, involving the occupational therapist in order meet the changing needs of the service users. One service user spoke of how they were waiting for grab rails to be fitted so that they could enjoy a bath safely. Staff are very aware of healthcare triggers, particularly in relation to epilepsy, and knew what to do to meet the service users needs. There is a medication policy available to staff in the office. Medication records examined confirmed that generally medication is administered to the service users appropriately. However, on one occasion staff on duty had not given a service user their prescribed medication. Some of the instruction on the medication containers differed from that recorded on the Medication Administration Record. A service user had been prescribed both Co-codamol , which contains Paracetamol, as well as a separate supply of paracetamol, which could potentially lead to an overdose of Paracetamol. (An immediate requirement notification was issued to the manager at the time of the inspection asking that she sort this out straight away). Clear written guidelines are in place, which had involved the GP, advising staff of what to do should a service user refuse to take their medication. Information contained within the pre-inspection questionnaire confirmed that Community Integrated Care have policies and procedures in place in relation to caring and supporting the service users through illness and death. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The views of service users and their supporters are taken seriously and procedures are in place to take appropriate action to resolve concerns and complaints. However, not everyone is aware of the complaints procedure which may mean that they do not know what to do if they have a concern or what to be expected if a complaint has been made. Appropriate policies and procedures are in place to ensure service users are protected from abuse, although further staff training is needed to fully safeguard the service users. EVIDENCE: Staff promote an open culture where service users feel safe and are encouraged and supported to share any concerns. Staff were able to demonstrate that they listened to what the service users told them and where necessary they reported concerns to the manager to address. A good example of this was a service user who mentioned that a member of staff had been using their personal mobile phone when on duty. Staff said that they had reported this to the manager. Service users said that they would talk to staff if they were unhappy 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 20 There is a complaints procedure. This is provided in pictures and symbols to assist those people who have verbal communication difficulties. A copy of the complaints procedure is available in the Service User Guide. However, one relative commented in the pre-inspection questionnaire that they were not aware of the home’s complaints procedure. The complaints record confirmed that there have been no complaints since the home opened. The home has its own policy and procedure documents relating to abuse which are available to staff to guide them if they have any concerns in this area. None of the staff have as yet received training in to the local authority safeguarding adults procedures, (formally known as Protection of Vulnerable Adults (POVA)), however, the manager confirmed that plans are in place to address this issue within the near future. Service users are protected from financial abuse. Money is stored securely and detailed records of expenditure incurred maintained. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 21 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): 24,25,26,27,28,29&30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users are provided with a homely, clean, comfortable environment, which promotes their independence, however, the thin wall separating the two living environments, may compromise the privacy of either service user. EVIDENCE: It was evident from staff practices that the service users are encouraged to see Coronation Road as their own home. For example, staff continually reminded service users that it was their home and asked permission before using their facilities, such as their kitchen or toilet. The homes were designed to promote individual living accommodation, which is excellent practise, where the service users can benefit from maximum independence living in an ordinary house as part of the local community. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 22 Each half of the bungalow has its own lounge/dining area, bedroom, bathroom and toilet. Prior to registration the bungalow was fully adapted to meet the needs of each of the service users. This process involved the help and support of other professionals such as the occupational therapist. Each service user has their own private entry to their home and refurbishment and re-decoration throughout is to a high standard. Both parts of the bungalow were found to be clean and warm at the time of the visit. A particular strength of the environment is the spacious gardens where the staff said the service users enjoy sitting in the warmer weather, socialising with their neighbours. There is a small office for staff to use located off one of the kitchen areas. When sitting in the lounge of one service user’s home staff commented that everything could be heard through the wall which had been built to separate the two living environments. This was evident during the inspection visit. All staff have received training in relation to infection control. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 23 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): 31,32,33,34,35&26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty is excellent which means that the service users needs are fully addressed. The service users benefit from an effective well trained staff team who are knowledgeable of their needs, however, the staff need more regular supervisions to ensure that they continue to carry out their jobs well. Service users are protected by the home’s recruitment procedures. EVIDENCE: Each service user has a staff team recruited especially to meet their needs. One service user has 2:1 support during the day whilst the other service user benefits from 3:1 support. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 24 At the time of the inspection there were 3 staff vacancies. Discussion with staff and the manager confirmed that this has meant they have at times had to rely on agency staff. The manager said that she always tried to ensure that agency staff do not work on their own with the service users and that, in order to promote continuity of care, she always used the same staff. However, staff said that on one occasion, this had not been the case with a new member of agency staff working on their own during the night. The benefits of developing a policy in relation to the use of agency staff to avoid this happening again was discussed with the manager. Staff said that they had been provided with induction training and confirmed that they had to complete a probationary period prior to being given a permanent contract. All staff are provided with a job description as well as a copy of the General Social Care Council code of practise. The majority of care staff have either attained and NVQ qualification in care or are working towards one. There is always a Registered General Nurse (RGN) on duty. There are regular team meetings and minutes are kept of these. Staff confirmed that they had completed a range of training, for example in crisis prevention intervention and challenging behaviour, however, staff files did not always reflect this. In one staff file there were no copies of any training certificates to confirm the training they had had. Staff recruitment files examined contained 2 written references. The manager confirmed that a satisfactory Enhanced Criminal Records Bureau check is obtained as well as checking the Protection of Vulnerable Adults before new staff are able to work with service users. The manager confirmed that she needs to ensure that all staff receive a supervision at least every other month. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 25 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): 37,38,39,40,41,42&43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While the manager provides good leadership and runs a service that is financially competent and focussed on the best interests of the service users, monitoring systems need to be put in place to measure the success of the home in achieving its aims. Policies and procedures are regularly reviewed, however, in order to fully safeguard the service users’ rights and best interests’ health and safety recording needs to improve. Although the health and safety of service users is generally promoted this may be compromised, as staff have not been provided with regular fire instruction and drill. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 26 EVIDENCE: The manager has approximately 6 years management experience in a wide range of different settings and is a RGN. Although not yet registered she has recently submitted her registered manager’s application to the Commission. She is supported by a number of RGN’s who are responsible for the supervision of the care staff. In order to help fulfil her role as the manager she has 15 hours dedicated management time. The remainder of her time is spent working alongside staff and service users which she commented assists her to monitor the quality of care provided. Effective relationships have developed between service users, staff and the manager. Service users and staff were observed interacting with the manager with confidence and respect. There are clear lines of accountability within Community Integrated Care, and the locality manager carries out a monthly visit to check on the operations of the home. Although service users are encouraged and supported by staff to maximise their decision-making skills in their everyday life, the views of service users and their families have not been formally sought. There was no evidence of internal quality audits taking place, other than the monthly locality manager check and some health and safety checks being carried out by staff, such as checking bathwater temperatures and testing the fire alarms, and the manager agreed that this was an area for future development. There are many policies and procedures produced by Community Integrated care and these are available to staff in the office. There is a rolling programme of training for staff in health & safety matters, however, record keeping is poor and as previously mentioned there was little in the way of documentary evidence by way of certificates to confirm this. The accident records had also not been kept up-to-date. Staff talked of an accident involving a service user slipping in the bath, however, this has not been recorded in the accident book. Fire log records showed that fire instructions have not been carried out at the required intervals. ( An immediate requirement was given to the manager in relation to this issue during the inspection). The financial viability of the service was assessed during the registration process in May 2006 and found to be satisfactory. The manager has control of a budget and appropriate employment liability insurance is in place. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 4 4 3 5 1 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 4 25 4 26 4 27 4 28 3 29 4 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 4 2 3 LIFESTYLES Standard No Score 11 4 12 3 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 2 3 2 2 3 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 28 First inspection 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 YA5 Regulation 5(1)( c ) Requirement Service users must be provided with a copy of the contract for the provision of services and facilities provided by the home. Care plans must be developed to provide staff with detailed up-todate guidance on how best to support the service users. Risk assessments must be reviewed and up-dated. Service users must receive medication as prescribed by their GP and in accordance with their care plan. A review of the service users medication must be carried out. All staff should receive training in relation to the local authorities safeguarding adults procedure. All staff must receive regular supervision. The quality assurance processes must be developed to include internal audits to ensure the service is meeting its stated aims and objectives. The views of service users and their representatives should also be formally sought. Timescale for action 31/05/07 2. YA6 15(1) 31/07/07 3. 4. YA9 YA20 15(2)(b) 13(2) 31/07/07 17/01/07 5. 6. 7. 8. YA20 YA23 YA36 YA39 13(2) 18(1)( c )(i) 18(2) 24 17/01/07 31/07/07 31/07/07 31/10/07 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 29 9. YA41 17(3) 10. YA42 23(4)(e) All records required by regulation 31/07/07 for the protection of service users must be maintained and kept up-to-date. All staff must receive fire 17/01/07 instruction and drill at the required intervals. 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. 2. 3. 4. Refer to Standard YA22 YA24 YA33 YA41 Good Practice Recommendations The service users relatives should be provided with a copy of the complaints procedure. The wall dividing the two living environments should be further sound proofed to ensure the privacy of both service users. A policy should be developed on the use of agency staff. All written information should be dated and signed. 14 Coronation Road DS0000067740.V329048.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South Shields Area Office 4th Floor 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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