Inspection on 18/07/05 for 17 Jervaulx Road

This inspection was carried out on 18th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

17 Jervaulx Road 27/09/07

17 Jervaulx Road 09/08/06

17 Jervaulx Road 08/11/05

17 Jervaulx Road 25/01/05

17 Jervaulx Road 24/08/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 17 Jervaulx Road New Skelton Saltburn-by-Sea TS12 2NL Lead Inspector Katherine Acheson Unannounced 18 July 2005 12:25 pm 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. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 17 Jervaulx Road Address New Skelton Saltburn-by-Sea TS12 2NL 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) 01287 653814 01287 653814 Redcar & Cleveland Borough Council Mrs Jacqueline Nixon Care Home 18 Category(ies) of LD - Learning Disability (18) registration, with number of places 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/01/2005 Brief Description of the Service: Jervaulx Road is a modern, purpose built, two storey building, comprising of three separate units interlinked by internal corridors housing staff sleep in rooms, office and laundry facilities. Each unit provides comfortable living accommodation for six residents with a learning disability. Each unit provides a distinct service, one unit is for those residents requiring long term care, another for respite, and the third provides short term rehabilitation and preparation for living within the community. Accommodation is provided in eighteen single rooms, all of which meet with spacial requirements of National Minimum Standards. Bedrooms do not contain ensuite facilities. Communal space in two of the units consists of a kitchen/dining room and a lounge. The third unit consists of a dining kitchen and two lounges. Kitchens are domestic in nature and accessible to residents. Externally there is a lawned garden with shrubs, rockery seating and patio area. The home is located near to the centre of Skelton and is close to local amenities and bus routes. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 12.25pm and lasted for four and a half hours. A discussion took place with four residents and the person in charge of the home during the inspection; no relatives were present during the inspection. Discussions with residents were limited due to the nature of their disability. Numerous records including care plans, policies/procedures maintenance and staff records were examined. A brief tour of the premises was carried out. The Manager was not present at the home during the inspection, however, staff should be complimented on their efficiency throughout the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Policies and procedures as highlighted at previous inspections are required to be reviewed and updated in order to meet with National Minimum standards and Care Home Regulations 2001. Although a number of policies have been reviewed a number remain outstanding and must be addressed as a matter of urgency. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 6 Of two residents files examined at this inspection, one was not adequate and did not contain a plan of care. Immediate action must be taken to ensure that all residents have an appropriate plan of care. The laundry wall finishes and flooring requires addressing. 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. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 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 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 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) 2 Appropriate assessments of prospective residents are carried out to ensure that the home can meet their needs. EVIDENCE: Residents are admitted to the home following an assessment that is carried out by a Social Worker or Health Care Professional. The home do not carry out their own formal pre-admission assessment, however, prospective residents do visit the home prior to admission and during this time staff at the home will indirectly assess their needs, capabilities and assistance required. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 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, 9 The home is good at meeting the needs of the residents, however, not all residents have an individual plan of care, which clearly sets out how the assessed needs will be met. Residents are supported to take responsible risks to ensure that independence is promoted. EVIDENCE: Two plans of care were examined during this inspection, both of which were observed to contain a photograph of the resident. One plan of care was that of a resident receiving long-term care. This plan of care found to be informative, included a detailed assessment of needs and evidence of resident involvement and choice. The second plan of care was that of a resident who had been in the home for a number of months and is preparing for independent living. Examination of records found that there was only limited information on file for this resident, no plans of care or any information in respect of preparation for independent living. This was pointed out to the person in charge of the home during the inspection who agreed to take immediate action to rectify this. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 10 Files examined contained a record of visits carried out by chiropodists, G.P’s, opticians and other health care professionals. It was evident following speaking to residents that they are encouraged to make decisions and exercise freedom of choice. One residents spoken to during the weekend said, “I like to have a sleep in on a weekend. When I get up I go and get a paper from Bells Stores”. Residents are enabled to take responsible risks. The person in charge of the home during the inspection spoke of a number of residents who are able to go out independently and how they were supported by the home to do this. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 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) 12, 13, 15, 16 Resident’s daily lives are enhanced by the social activities provided by the home and the welcome it extends to residents visitors. EVIDENCE: The person in charge of the home during the inspection said that the majority of residents staying at the home attended day services Monday to Friday. She also stated that one resident is currently doing a computer course and that a computer is available within the home environment for use by residents. The home has their own car to transport residents; recent trips have included Whitby, the cinema and tea out at a restaurant or pub. Residents staying on the long stay unit do have an annual holiday, this year the residents have chosen a trip to Blackpool. Although residents are staying in the same hotel they have each planned different activities and things to do. Residents spoken to during the inspection said that they were looking forward to the planned trip. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 12 One resident spoken to during the inspection said, “I’m going to see the new Batman movie and I’ve just been to see Cliff Richard”. One resident had recently taken part in the bowling event at the Special Olympics. One resident staying on the respite care unit, said “I like it here” Residents spoken to said that contact with family and friends is encouraged and that visitors are made to feel welcome at any time. Independence is encouraged for those residents who are able. Some residents are able to assist with tea preparation, washing up and ironing. The person in charge of the home during the inspection said that staff at the home have not been able to take the residents out as much lately due to increased dependency of residents. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 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, 20 The home is good at meeting the physical and emotional health needs of residents by ensuring that residents receive their care in the way that they choose to. Arrangements for dealing with medication are appropriate for the needs of the residents and are managed in a safe manner; minor improvements to record keeping would further enhance this. EVIDENCE: Residents spoken to during the inspection said that staff at the home respected their privacy and dignity whilst assisting with care needs. Staff interaction with residents on the day of inspection was observed to be relaxed, respectful, understanding and enabling. It was evident from the inspection that residents are able to exercise choice and that there is flexibility in routine. One care plan examined during this inspection contained detailed information about the resident, care requirements and how the resident wanted their care to be delivered. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 14 The person in charge of the home during the inspection said that currently there are not any residents who are able to self medicate, however, if there was to be in the future, a risk assessment would be carried out to determine if self medicating was possible and safe. The home has a policy/procedure in respect of medication systems that are in place at the home. Since last inspection the home has worked extremely hard to improve medication systems that are in place in the home, appropriate systems are now in place. Records were examined to confirm that appropriate records were kept of medication coming into the home and that staff were keeping a record of medication returned to pharmacy, however records of returned medication was on loose leaf paper. Medication returned to pharmacy or going out of the home should be recorded in page numbered bound book. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 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 The home has an effective complaints procedure, which enables residents to make any complaints they feel necessary. EVIDENCE: The home has a clear complaints procedure, details of which are also available in the statement of purpose and service user guide. Residents spoken to during the inspection said that the Manager and staff at the home are approachable and if they felt the need to complain then they would do so. Examination of the home’s complaints records showed that complaints were recorded and dealt with appropriately. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 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) EVIDENCE: The above standards were not inspected, however, requirements highlighted at the last inspection in January 2005 were re-visited. Exposed hot water pipes in residents bedrooms had been boxed in to ensure safety of residents, the toilet on the respite unit had been re-decorated, however corporate policies and procedures in respect of control of infection had not been updated. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 17 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) EVIDENCE: The above standards were not inspected, however a requirement highlighted at previous inspections in respect of staff records being stored in the care home has been addressed. It has been agreed by the Commission for Social Care Inspection that staff records can be held centrally at Redcar & Cleveland Borough Council Offices, and that the CSCI will view records on an annual basis at the Council offices. Since last inspection the home made a number of changes to the home environment in order to accommodate a crisis unit. This change has resulted in a move of the home’s laundry area. The new laundry area of the home does not have flooring that is impermeable or walls that are readily cleanable, this must be addressed. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 18 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) 40, 42 Staff receive training relevant to the job that they do, however, fire training is not adequate to ensure safety and protection of staff and residents. Not all policies and procedures have been reviewed and updated to ensure resident’s rights and best interests are safeguarded. EVIDENCE: The home operates a rolling programme of servicing appliances and equipment. Records examined at random confirmed that the home’s central heating, boilers, fire extinguishers and fire alarm system are serviced on a regular basis. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 19 Records were available to confirm that staff receive regular training in respect of moving and handling, first aid and other training relevant to the working environment. Records were available to confirm that staff receive fire training, however, this training is provided to staff by them watching a video and then answering questions. A discussion took place regarding the suitability and effectiveness of the video. Records were available of regular fire drills in which both staff and residents participate. Redcar & Cleveland Borough Council also carries out health and safety audits at the home at regular intervals. It has been highlighted at previous inspections that policies and procedures in the home environment must be reviewed and updated to meet with National Minimum Standards and Care home Regulations 2001, although a number of policies have been updated, there are still a number outstanding. 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 20 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 17 Jervaulx Road Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x x x 2 x 2 x B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 21 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. 2. Standard YA6 YA30 Regulation 14, 15 13 Requirement Each resident must have a plan of care Corporate Policy/procedures in respect of control of infection must be reviewed and updated by a suitably qualified person (Previous timescale for action 1st April 2004 not met) Policies and procedures must be reviewed and updated to meet with National Minimum Standards and Care Home Regulations 2001 (Previous timescale for action 1st April 2004 not met ) A suitable program of fire training must be provided to all staff working at the home The laundry floor fininshing must be impermeable and the wall finishes readily cleanable Timescale for action Immediate 30th October 2005 3. YA40 13 30th October 2005 4. 5. YA42 YA30 13, 23 23 Immediate 30th August 2005 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 B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 22 17 Jervaulx Road 1. YA20 Medication returned to pharmacy should be recorded in a page numbered bound book 17 Jervaulx Road B51 B01 S31330 17 Jervaulx Rd V239411 180705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit B - Advance St Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. 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