Inspection on 09/08/06 for 17 Jervaulx Road

This inspection was carried out on 9th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 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 08/11/05

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 Joanna D White Key Unannounced Inspection 9th August 2006 12:00 17 Jervaulx Road DS0000031330.V305158.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 17 Jervaulx Road DS0000031330.V305158.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. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 17 Jervaulx Road Address New Skelton Saltburn by the Sea Cleveland TS12 2NL 01287 653814 01287 653817 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 Care Home 18 Category(ies) of Learning disability (18) registration, with number of places 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 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, two units provide respite care 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.V305158.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and was unannounced on the first inspection day. There were two visits to the home by one inspector on 9th August 2006 from 12 pm until 4.55pm, and 1st September 2006 from 08.30 am until 4.55 pm. Two inspectors undertook a final visit to the home on 7th September 2006 from 1pm until 2.55pm. Three visits were made to the one stop shop in Eston to look at staff recruitment and selection files and staff training records on 13th September 2006 from 2.20 pm until 4 45 pm, 19th September 8.30 am until 10 .45 am and the 20th October from 1pm until 2.30 pm. All of the key standards were examined during the inspection. In total six residents files were examined three belonging to those residents receiving long term care and three for those residents who were provided with respite provision. Four staff files were examined including recruitment and selection and personal training and development plans. In addition the medication records, health and safety records and policies and procedures, were examined during the inspection. A tour of the home also took place. A pre-inspection Questionnaire, which the manager had completed, was also provided. Seven ‘ Have your say about ‘ were completed by the residents including two relatives / visitors comment card. The inspector spent time with two of the residents finding out what it was like for them to live in Jervalux Road. Two relatives also spoke to the inspector about what day to day life was like for their relatives in Jervalux Road. The manager, staff, and residents welcomed the inspector to the home. There was much discussion throughout the inspection with the Manager. The Service Manager informed the inspector weekly charges for residents’ accommodation were £90.40 for residents aged 18 years to 24 years, £62. 35 for residents aged 25 years to 59 years and £94.45 for residents aged 60 years and over. What the service does well: One Relatives/Visitors Card said, “ My family and I are very happy with the care and attention all of the carers give …at the present and over the years” and another wrote, “ I am very happy with the care. …gets.” A parent wrote down in ‘Have your say about ‘ “ ….as parents with regular contact we know… is happy and content where … is and with what. …does and as such we are more than satisfied”. Another parent wrote “ …is happy and satisfied with everything because…. appears to be happy”. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 6 The residents are provided with opportunities to completely re-furbish their rooms and choose the decoration and furnishings. The staff team are committed to meeting the needs of the residents. The residents were observed to be relaxed and happy in the presence of staff with whom they were able to communicate their wishes views and feelings. The home ensures it provides activities, which meet the needs of all of the residents. Parents and carers involvement is encouraged by the home. What has improved since the last inspection? What they could do better: The homes policies, procedures, and auditing processes for the receipt, recording, handling, storage, safe administration and disposal of all medicines including controlled drugs should be reviewed and updated. The complaints procedure should be reviewed and updated to include information that residents can make a complaint to the commissioning authority. The bath surround in the bathroom on unit three (17c) should be replaced and the tiles surrounding the bath must be appropriately secured. The toilet on unit three (17c) should be painted and the leak repaired. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 7 New flooring should be fitted in the toilet on the first floor of unit three (17 C). The ceiling in the shower room on unit three (17c), and the shower room on the respite unit should be painted. The recruitment and selection procedures should be updated and robust. The new manager has to register with the Commission for Social Care Inspection to ensure she has the correct qualifications to be the manager at Jervalux Road. 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.V305158.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 17 Jervaulx Road DS0000031330.V305158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during a visit to this service. Resident’s individual needs and aspirations were assessed and recorded. EVIDENCE: The current residents had lived in the long-term unit at Jervalux Road in excess of twenty-two years. Discussion with the manager confirmed that any new residents would receive a comprehensive needs assessment, completed by their social workers and health professionals. A copy would always be shared with the home prior to the admission of the resident to afford an opportunity for the needs assessment for each prospective person to be considered as well as the capacity of the home to meet those needs. Potential residents would also be given an opportunity to spend time in the home via tea visits and overnight stays during which the staff would have a chance to confirm their needs and identify any additional support, which was necessary. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 10 The respite unit co-ordinator shared with the inspector copies of ‘ Information on short breaks and respite care for people who want to access the service ‘, which included information about privacy, dignity, independence, and choice terms and conditions of residency, etc. and ‘Induction and Guide for new guests staying at Jervalux Road ‘ which detailed the admission procedure for short term care. She confirmed prior to the admission of each perspective resident she liaised with their families and social workers to ensure a full needs assessment had been undertaken and that the service was able to meet the perspective residents needs. 17 Jervaulx Road DS0000031330.V305158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made from evidence gathered before and during a visit to this service. Residents assessed and changing needs and personal goals are reflected in their care plans. Residents make decisions about their lives. The staff when necessary provide support. EVIDENCE: The manager confirmed each residents file was in the process of being reviewed and updated and contained a ‘Life Plan’ a ‘Care Plan’ and a ‘Health Plan which were presented in an accessible pictorial format and contained evidence the residents had been consulted and given an opportunity to access and understand the information. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 12 In total six residents files were examined three belonging to those residents receiving long-term care and three for those residents who were provided with short term/respite care. The ‘Care Plans’ provided information ‘about me’ which included major events medical sheet, medical notes, finance, reviews, etc and a wallet for personal documents such as birth certificate medical card passport etc. The ‘Life Plans’ detailed evidence of staff consultation with the residents and included information about“ Who am I personal profile” “ How I interact with others” How I look after personal care including eating, drinking, behaving and coping and emotions etc. “My goal action plan, Advocacy and a personal risk assessment and review sheet were also included. One member of staff informed the inspector “ Putting together Life Plans…. liaise with families. ………Completing as the residents are admitted”. The ‘Health Plans’ gave details of the residents’ general health, medical history, current medication etc. Photographs of each resident were also available. In addition the respite unit co-ordinator confirmed a daily recording sheet for each resident receiving short term care was also completed which provided information about personal care, behaviour, meals, communication, activities etc. The manager, staff and the respite unit co-ordinator informed the inspector that the residents participated in activities to promote their independence. One resident was observed in the respite unit making a cup of coffee. He/she said “ I like making cups of coffee and tea” Staff told the inspector another resident “ Attended college once per week and was helped to manage his/her own money. The resident also liked to cook and shop and was involved in domestic activities in the home such as making his/her own bed, washing dishes and making his/her own drinks and snacks”. Another member of staff said, “Some of the residents do their own washing in their units and are assisted to do the ironing” One of the residents had returned from playing football and said, “ I really like playing football, our team won I am a great football player” The manager said appropriate risk assessments for these activities were available in the care plans. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 13 The records also evidenced that the residents were seen by the home as individuals in their own right who were able to make decisions about areas of their life, which were important to them such as, relationships, personal finances, community participation, leisure, work, education, and support. One residents care plan, which was examined, stated “ He/she made decision if she/he is in danger rather than staff directly telling her/him what to do” Another residents file said “ I am happy with my key worker” The manager also confirmed the residents were empowered to make decisions about every day things such as choosing their own room decoration, menu planning, where to go on holiday and trips and outings. The staff said they respected the privacy, dignity, and rights of the residents and explained they always knocked on residents’ doors and bathroom doors before they entered. The Statement of Purpose confirmed, “ The staff ensure doors are shut when personal tasks taking place… ensure positive images are promoted …. Not talking down to people and using appropriate language…making sure the service users consulted about visitors and introduced to people who enter the home…providing service users with information and empowering them to make informed choices and have an awareness of their rights”. 17 Jervaulx Road DS0000031330.V305158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made from evidence gathered before and during a visit to this service. Staff assist the residents to take part in valued and fulfilling activities and support them in continuing their education or training. Staff in accordance with the residents assessed needs and Individual Plans encourage them to become part of and participate in the local community. Relatives and friends are encouraged to maintain contact with the residents. The residents’ individual choice and freedom of movement is ensured by daily routines and house rules, which promote independence. The residents’ nutritional requirements are promoted by a varied diet. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 15 EVIDENCE: The Statement of Purpose was examined and stated “ Positively valued leisure and activities aid social inclusion and individuals sense of self worth and increase independence for individuals”. The manager confirmed that collective activities for the residents were actively promoted and said an activity week 24th –28th July 2006 had taken place and had included visiting a local pub to play pool, going on a picnic, visiting the cinema, and playing nine hole golf, crazy golf and putting. Activities to meet the individual needs of the residents were also promoted and a member of staff told the inspector one of the residents “ Liked to go out for meals, or to play bowls and was particularly interested in photography. Other residents liked to go swimming, to the cinema, the theatre, visiting cafes and restaurants and doing needlecrafts and art. One resident said, “ I like dancing and music”. Opportunities were also available for the residents to attend Redcar and Cleveland Disability Day Services where they had access to additional social activities including sport, leisure, drama groups, Further Education College courses, the walking club, conservation work, woodwork, and model making. One resident told the inspector “ The food here is great tonight we are having a take away I am going with a member of staff to get it later. I like take aways” A member of staff confirmed that food was prepared for the residents in each unit and catered for their dietary needs and likes and dislikes. Everyone was involved in the decision about what they were going to eat. Fresh ingredients were available in the fridges for food preparation and fresh fruit was also observed to be present. On the day of the inspection a family had given the staff some fresh plums for the residents to enjoy. The manager provided weekly menus. One resident had regular weekly contact with their brother and another resident’s family “ made sure that they were included in family events”. During the inspection three residents families were observed to be visiting. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 16 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): 18, 19, 20. Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during a visit to this service. In accordance with the wishes of the individual resident staff meet the residents healthcare and personal needs in a sensitive and flexible manner. The residents’ physical and emotional needs are generally met. The homes medication policies and procedures are not as robust as required and need further review and development to ensure safe and effective systems are in place. EVIDENCE: The inspector observed that staff responded appropriately and sensitively in all situations involving personal care by ensuring that it was conducted in private and by a person of the same gender. Staff who were spoken to confirmed that they respected the privacy, dignity, independence, choice, rights and fulfilment of the residents. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 17 The inspector observed that aids and equipment were provided to encourage the maximum independence of the residents. One resident was observed using a walking frame during a visit by their relative. Times for going to bed were flexible. One resident in their care plan had agreed, “Going to bed early”. The staff said they knew the residents very well and consequently would share any concerns about their emotional health within the staff team to ensure that there was consistency of care and that their health needs were met. Residents’ records confirmed that they had contact with the GP, Consultant Psychiatrist, Community Psychiatric Nurse, Optician, Chiropodist, Dentist, Nurses, Occupational Therapist, The Outreach Team and Social Workers. The manager stated that none of the residents administered their own medication. The homes medication policies and procedures were examined by two inspectors and did not provide sufficient detail in terms of receipt, storage, handling, administration, and disposal of medication. Staff confirmed that no current residents were prescribed controlled drugs. The system in place to record the receipt, administration and disposal of controlled drugs was discussed with the manager. She confirmed these records were not kept in a bound book or register with numbered pages. There was also no provision for detailed information to be recorded about the balance remaining for each product with a separate page being maintained for each resident. There was also no evidence that there was a system in place to check the balance of controlled drugs at each administration and also on a regular basis e.g. monthly. The manager stated the current system would be reviewed as a matter of urgency. The medication administration records for three long-term residents and three short stay residents were examined. The signature of the member of staff administering the medication was not always present and no explanation was recorded when medication was not administered. Detailed information was also not available about the amount of medication returned when a short stay resident left Jervalux Road. There was also no evidence that the medication records were audited. The manager confirmed she had discussed these matters at a staff meeting and changes had been introduced immediately to ensure safe and effective systems were in place. She also confirmed the homes medication Policies and Procedures would be reviewed and updated. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 18 Discussions with the staff and an audit of four staff files revealed that they had all undertaken medication training. 17 Jervaulx Road DS0000031330.V305158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made from evidence gathered before and during a visit to this service. The manager and staff listen to the views of the residents and are fully aware of how a complaint investigation is conducted. Written procedures are in place to promote the welfare of the residents. EVIDENCE: The complaints procedure was examined and contained the required information in terms of how to make a complaint, but it did not specify that residents could make a complaint to the commissioning authority. The Terms and Conditions of residence within Jervalux Road were examined and contained information for residents about the complaints procedure. A discussion with a relative confirmed she would know what to do if she wanted to make a complaint. Two complaints had been received within the last twelve months both of which had been responded to within twenty-eight days. It was confirmed through discussion with staff and the manager and an examination of four staff files and Personal Training and Development plans including a discussion with the Training manager that all staff had received training in Protection of Vulnerable Adults and No Secrets Training. In addition staff that were spoken to gave clear examples of how they would respond in particular situations. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 20 There had been two vulnerable adult referrals, which had been dealt with appropriately. The home had received a number of compliments since the last inspection, which included the following from relatives and visitors “ My family and I are very happy with the care and attention all the carers give my relative at the present and over the years. Thank you” and “ I am very happy with the care” and “ I am very grateful to all staff at Jervalux Road for the care they take when looking after my relative. Without their support with respite periods there is no way I could continue to care for.. at home. Thanks for a job well done”. 17 Jervaulx Road DS0000031330.V305158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during a visit to this service. Residents are predominantly provided with a homely, and comfortable environment but some maintenance issues remain outstanding. The residents live in a clean and hygienic environment. EVIDENCE: The home provided the residents with a welcoming and comfortable environment that was bright, cheerful airy, and clean. Furnishings, fittings, adaptations and equipment were of an acceptable quality. However since the last inspection the bath surround in the bathroom on unit three (17c) had not been replaced and the tiles surrounding the bath had had to be secured as a temporary measure. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 22 Staff informed the inspector as a result appropriate risk assessments were in place for the residents. The toilet on unit three (17c) had not been painted and in addition a leak was observed from the toilet on the day of the inspection. New flooring had not been fitted in the toilet on the first floor of unit three (17 C). The ceiling in the shower room on unit three (17c), and the shower room on the respite unit had not been painted. The situation was discussed with the manager who sought immediate agreement for the necessary repairs to be undertaken. She later informed the inspector appropriate authorisation had been given and the outstanding maintenance work would be completed as a matter of urgency. Discussion with a relative and staff confirmed that residents were able to refurbish their own bedrooms by choosing “ the colours for their rooms, coordinated bedding and curtains and new furniture and carpets. One relative added “ My son/daughter likes spending time in their room listening to their CD collection and watching television”. There was also evidence of personal items, magazines, photographs, videos, televisions and items of personal interest. One resident said “I really like being in my room”. Access was provided both inside and outside of the home for all residents. The outside of the property was well kept. The manager shared with the inspector a copy of the Corporate Guidance for the Control of Infectious Diseases within the workplace, which had been, reviewed on 28th February 2005. 17 Jervaulx Road DS0000031330.V305158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during a visit to this service. The resident’s benefit from a competent, knowledgeable, qualified and welltrained staff team. The recruitment records do not consistently contain sufficient information to ensure that service users are fully supported and protected. EVIDENCE: The manager confirmed that the staff had the necessary skills, experience and training to meet the needs of the residents. Four staff files and four Personal Training and Development plans were examined. Discussion also took place with the manager and the Councils Training manager who confirmed that staff had completed all of the required mandatory training including fire, first aid, health and safety and food hygiene. Information was also available that the staff had attended manual handling and first aid refresher courses and an advanced fire awareness course. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 24 The training manager shared with the inspector a copy of Redcar and Cleveland Borough Council Training Newsletter Social Care dated May 2006 which contained information about qualifications which were available to develop relevant posts and a training schedule listing some of the courses available, “ which is not exhaustive; if you have identified any training needs not listed please contact a member of the team” Information was also available for all new care workers who were required to complete induction training within twelve weeks of commencing work. Social Care specific training was also recorded examples of which included Deaf and Disability Awareness, Visual Impairment Awareness, Epilepsy Awareness, etc. The training manager also discussed with the inspector The Personal Development Portfolio for Adult Social Care Staff, which had recently been developed, the Staff Supervision and Performance Review and Personal Development Social Care Document revised in September 2006 and the Competency Framework for staff that had been introduced in March 2005. The pre inspection questionnaire completed by the manager confirmed details of future planned training which included induction training for new staff, mandatory training as required and a staff development day. The pre inspection questionnaire also stated that currently 94 of the staff were trained to NVQ Level 2 or above. The recruitment and selection records of four members of staff were examined at the Councils One Stop Shop. Some really good practice was evidenced in respect of recruitment, such as the carrying out and receipt of appropriate POVA/Criminal Record Bureau checks for all staff prior to commencement of employment and the carrying out of appropriate Criminal Record Bureau checks for all staff that had been employed since July 2004 where the Council had a accepted a copy of a Criminal Record Bureau Check that had been carried out by a previous employer. Appropriate references, job descriptions and job specifications and the start date of employment were also available on each file. In a number of files examined, there were some gaps in the records such as no photographs, and no clear evidence of staff members’ identification, such as passport or birth certificate. Copies of relevant qualifications were also not present although the senior manager confirmed that the interview panel always saw these. There was also no evidence available relating to how any gaps in the employment record were explored. The senior manager stated a system had been introduced and copies would be placed on future staff records. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 25 Discussion with senior management confirmed an urgent review was taking place of the recruitment and selection records to ensure all of the necessary information was available. The staffing rota was examined and confirmed that there were enough staff on duty to provide quality time for each resident to pursue their own interests. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 26 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, 42 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during a visit to this service. The residents’ benefit from a well run home. The views of the residents are actively sought to underpin all self- monitoring, review and development by the home. As far as reasonably practicable the health, safety and welfare of residents and staff are promoted. EVIDENCE: Throughout the inspection the manager displayed knowledge in the day-to-day running of the home. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 27 She confirmed she had completed The National Vocational Qualification Level 4 Management and The National Vocational Qualification Level 4 Care and was in the process of completing the Registered Manager application with CSCI. The manager stated there were arrangements in place for consultation to take place with social workers about the operation of the home. In addition residents had individual meetings with their key workers on a monthly basis to address any problems concerns or complaints. The residents and their families following periods of short-term care also completed exit questionnaires. The results of a ‘service user questionnaires’ were also available which had included questions about ‘do the staff treat the residents well, food, clothing, activities, and how the building looked etc. The manager added the Council also completed an internal audit. Parent carers and staff group meetings were held on a weekly basis at Jervalux Road where everyone had an opportunity to share any concerns and discuss positive aspects about the service they were receiving or share any ideas for future development. The manager confirmed the homes self –reviewing process was being constantly reviewed and developed. Health and Safety records were examined. Maintenance matters such as boilers, fire alarm and equipment, and PAT (Portable Electrical Appliances) testing were noted to be up to date. The manager confirmed that all portable appliance equipment brought into the home by those residents receiving respite /short stay was checked on a yearly basis. 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? YES 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 YA20 Regulation 13(2) Requirement The registered person must ensure the homes policies, procedures and auditing processes for the receipt, recording, handling, storage, safe administration and disposal of all medicines including controlled drugs are reviewed and updated. The registered person must ensure the complaints procedure is reviewed and updated to include information that residents can make a complaint to the commissioning authority The registered person must ensure the bath surround in the bathroom on unit three (17c) is replaced (Previous timescale of 30/04/06 identified at the last inspection not met.) The registered person must ensure the tiles surrounding the bath are appropriately secured. The registered person must ensure the toilet on unit three 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 30 Timescale for action 10/01/07 2. YA22 22 30/12/06 3. YA24 23 10/12/06 (17c) is painted. (Previous timescale of 30/04/06 identified at the last inspection not met.) The registered person must ensure the toilet leak on unit three (17c) is repaired. The registered person must ensure new flooring is fitted in the toilet on the first floor of unit three (17 C). (Previous timescale of 30/04/06 identified at the last inspection not met.) The registered person must ensure the ceiling in the shower room on unit three (17c), and the shower room on the respite unit are painted. (Previous timescale of 30/04/06 identified at the last inspection not met.) 4. YA34 17 and 19 The registered person must ensure that the recruitment and selection procedures/practices are reviewed, updated and robust. Every staff file must include all of the information as stated in Schedules 2 & 4 of The Care Homes Regulations 2001. The registered person must ensure the Council provides documentary evidence in staff records of the exploration of any gaps in employment for staff prior to the commencement of employment. (Previous timescale of 08/11/05 identified at the last inspection not met.) 30/12/06 5. YA34 13, 17 30/12/06 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 31 6. YA34 17 The registered person must ensure staff records contain a recent photograph including proof of identification. (Previous timescale of 30/12/05 identified at the last inspection not met.) 30/12/06 7. YA37 9 The proposed manager must satisfy the requirements of the registered manager and complete the necessary process with CSCI. 30/11/06 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 17 Jervaulx Road DS0000031330.V305158.R01.S.doc Version 5.2 Page 32 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.V305158.R01.S.doc Version 5.2 Page 33 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!