Inspection on 08/11/05 for 17 Jervaulx Road

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 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 18/07/05

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 the Sea Cleveland TS12 2NL Lead Inspector Katherine Acheson Unannounced Inspection 8th November 2005 11:00 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 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 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 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. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 17 Jervaulx Road Address New Skelton Saltburn by the Sea Cleveland TS12 2NL 01287 653814 01287 653814 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) Redcar and Cleveland Borough Council Mrs Jacqueline Nixon Care Home 18 Category(ies) of Learning disability (18) registration, with number of places 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2005 Brief Description of the Service: Jervaulx Road is a modern, purpose built, two storey building, comprising of four separate units interlinked by internal corridors housing staff sleep in rooms, office and laundry facilities. Each unit provides a distinct service. One unit is for those residents requiring long term care, another for respite, another provides short term rehabilitation and preparation for living within the community and the fourth unit offers accommodation to one resident who may require admission to the home in the event of an emergency/crisis. 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 and the emergency/crisis unit has a small lounge/dining room. 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 DS0000031330.V250986.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 11:00am and lasted for five hours. A number of residents were out of the home on the day of the inspection and Communication with those residents in the home was limited, however, a short discussion did take place with one resident. A lengthy discussion took place with three staff during the inspection; a discussion also took place with the Manager. Numerous records were examined including care plans, menus, quality assurance, policies and procedures. A tour of the premises was carried out. Requirements identified at the last inspection were re-visited. An additional visit was made to Redcar & Cleveland Borough Council offices on 20th September 2005 to look at staff recruitment, selection and training records for all of the adult services, this additional visit lasted for four hours. What the service does well: What has improved since the last inspection? Requirements highlighted at the last inspection with the exception of one, in which it was highlighted that the corporate policy/procedure for infection control required to be reviewed and updated have been addressed. The Manager is working hard to improve the care planning system for those residents receiving respite care. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: The above standards were not inspected. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: The above standards were not inspected in full, however, a requirement identified at the last inspection in July 2005 in which it was highlighted that all residents must have a plan of care was re-visited. Two plans of care were examined at random during this inspection. Both were plans of care for residents receiving regular respite care. Plans of care were observed to be basic, however did contain relevant information. The Manager said that she is in the process of meeting with Care Managers to develop a system in which to ensure that the home is kept informed and updated on all residents who come to Jervaulx Road for respite/short term care. The Manager said that all care plans for those residents receiving respite/short term care are to be reviewed and updated, and that this process of review will occur for each visit/stay at the home. One resident spoken to during the inspection said, “I do like it here, I like the staff”. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 17 Residents are involved in the meal planning at Jervaulx Road. Residents are supported and offered guidance to ensure that meals are nutritious and well balanced, and as such promotes health and wellbeing. EVIDENCE: The Manager said that all residents are involved in the menu planning of the home. She said that residents on each unit sit with staff to complete a meal plan for the week ahead. Records were available to confirm that this is the case. Menus examined were wholesome and varied. All units had a different meal plan for the week ahead. Those residents that are able go food shopping with staff and also assist with food preparation. Residents are encouraged and supported to make drinks and snacks independently. Records were available to confirm that appropriate temperature checks are carried out on fridge, freezers and food. Records of food provided were available for inspection. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 11 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 the following standard(s): EVIDENCE: The above standards were not inspected, however a recommendation highlighted at the last inspection in which it was highlighted that medication that is to be returned to pharmacy should be recorded in a page numbered bound book had been addressed. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 23 The home’s adult protection policy and staff knowledge helps protect residents from abuse. EVIDENCE: The home has an adult protection policy/procedure in place that includes action that staff must follow if abuse is suspected. The Manager said that all staff receive adult protection training on induction, and that she is now in the process of working through an adult protection workbook with all staff. Records were available to confirm that this is the case. Three staff were interviewed during the inspection, all were able to give a clear account of action they would take if abuse were suspected. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 24, 25, 26, 27, 28, 29, 30 The standard of the environment within this home is good providing the people who live there with and attractive, homely and comfortable place to live; refurbishment of bathroom areas would further enhance this. Not all portable appliances are checked on a yearly basis and as such does not ensure a safe environment for all. EVIDENCE: A tour of the premises showed that the home is generally well maintained internally and externally. The home was clean and odour free. Suitable communal space is provided for residents and these areas are decorated in a homely and comfortable manner. The unit designated for those residents requiring long-term care has recently benefited from re-decoration and new curtains. Resident’s bedrooms are homely and personalised with personal possessions being evident, particularly those bedrooms of residents residing on the long stay unit. Residents bedrooms visited were well decorated and furnished. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 14 The tiling surround on the bath on the long stay unit was observed to be in a poor state of repair and must be replaced, one toilet required painting, another required new flooring and the shower room ceiling was observed to have flaking paint. The shower room on the respite unit also required painting. Two light switches in the toilet/bathroom areas on the long stay unit were observed to be faulty and required repair. Following discussion with the Manager it became evident that the home has a system in place in which electrical items in the home are tested on a yearly basis, however, portable electrical equipment brought into the home by those residents receiving respite care is not. The Manager said that she would take immediate action to address the situation. The Manager said that all residents are mobile and as such the home do not require any hoists. Specialist baths are available and money is available in the home’s budget to buy any other specialist equipment that may be required. The Manager said that all baths, showers and sinks in bedroom areas are temperature regulated, however kitchen sink water temperatures in resident areas are not. The Manager said that a risk assessment would be carried out on any residents that staff at the home think may come to harm as a result of the higher kitchen sink water temperatures. It has been highlighted at previous inspections that Corporate Policies/procedures in respect of control of infection must be reviewed and updated. The Council have informed the Commission for social Care Inspection that a draft copy of the policy will be available within the next couple of weeks. It was also highlighted at the last inspection that the laundry floor finishing must be impermeable and the walls readily cleanable. The Council has taken action to address this. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Staff receive appropriate training to ensure that care needs of residents are met. The Council’s procedures in respect of recruitment of staff are not robust and as such do not provide safeguards to offer protection to people living at the home. EVIDENCE: 94 of care staff at Jervaulx Road are trained to NVQ level 2 and above (or equivalent). Duty rotas examined during the inspection confirmed that the home is working with the appropriate number of staff on duty. The Manager said that staffing levels fluctuate depending on dependency and resident numbers. An additional visit was made to Redcar & Cleveland Borough Council offices on 20th September 2005 to look at staff recruitment, selection and training records. The Council keep a record of each staff member working at the home, qualifications and relevant experience gained. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 16 At the start of the visit the Inspector intended to view eighteen staff records, however following a thorough examination of six it was felt that information required had been obtained. Of six staff files sampled none were found to have a photograph of the staff member. Three were found to have a full employment history on the application form three did not, and the Council had not explored these gaps. Four files were observed to have proof of identification, two did not. Following discussion with staff and examination of records it became evident that the Council are not carrying out appropriate Criminal Record Bureau Checks on all staff prior to the commencement of employment. The Council have been accepting Criminal Record Bureau Checks that have been undertaken by previous employment. An immediate requirement was left in respect of this and as such the Council must cease to carry out this practice immediately. This will be followed up as a separate issue. It was observed that the Councils employment reference does not ask the referee to confirm dates of employment. The Council offer a rolling programme of all mandatory and other training relevant to the job that staff are employed to do. Induction training is provided on commencement of employment. Discussion with the Training Manager of the Council during the additional visited highlighted that each staff member has a personal training and development plan, and that the department monitor staff employed and ensure that all training is undertaken. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 The Manager works extremely hard to ensure that Jervaulx Road is managed efficiently and effectively. Appropriate quality assurance monitoring is in place to ensure that the home is run in the best interests of the residents EVIDENCE: The Manager, Jacqueline Nixon, has worked in social care for many years. Jacqueline holds a Diploma in Social Work (DipSW) and a NVQ level 4 in Management. It is evident following the inspection that Jervaulx Road is well managed. Staff spoken to during the inspection spoke of strong leadership and guidance. One staff member said, “The Manager is supportive and approachable. I can quite happily go and knock on her door at any time.” Appropriate quality assurance monitoring is in place to ensure that the home is run in the best interests of the residents. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 18 It was highlighted at the last inspection that the Council must provide a suitable program of fire training to all staff working at the home. The Council have taken action to address this. 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 17 Jervaulx Road Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 3 DS0000031330.V250986.R01.S.doc Version 5.0 Page 20 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 YA30 Regulation 13 Requirement Timescale for action 30/12/05 2 YA27 16, 23 3 4 YA27 YA34 13, 23 13 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 and 30th October 2005 not met) 30/04/06 • The bath surround in the bathroom on unit 17c must be replaced • The toilet on unit 17c must be painted • The ceiling in the shower room on unit 17c must be painted • The toilet on the first floor of unit 17c must have new flooring • The shower room on the respite unit must be painted The faulty light switches in the 08/11/05 bathroom/toilet areas on unit 17c must be repaired • The Council must carry out 08/11/05 and be in receipt of appropriate POVA/Criminal Record Bureau Checks for all staff prior to the commencement of DS0000031330.V250986.R01.S.doc Version 5.0 17 Jervaulx Road Page 21 5 YA34 13, 17 6 YA34 17 7 YA42 13 employment • The Council must carry out appropriate Criminal Record Bureau Checks for all staff that have been employed since July 2004 where the Council have accepted a copy of a Criminal Record Bureau Check that has been carried out by a previous employer. Supervision of such staff must be put in place until a satisfactory check has been received The Council must explore any gaps in employment for staff prior to the commencement of employment • Staff records must contain a recent photograph • Staff files must contain proof of identification Portable appliance equipment brought into the home by those residents receiving respite/short stay must be checked on a yearly basis. 08/11/05 30/12/05 08/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations The Councils reference request should be developed further to seek confirmation of dates of employment 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Tees Valley Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI 17 Jervaulx Road DS0000031330.V250986.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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