Inspection on 23/09/05 for 6 Queensview Crescent

This inspection was carried out on 23rd September 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 but made no statutory requirements on the home.

Other inspections for this house

6 Queensview Crescent 14/07/08

6 Queensview Crescent 18/03/08

6 Queensview Crescent 04/01/07

6 Queensview Crescent 30/01/06

6 Queensview Crescent 29/03/05

6 Queensview Crescent 22/09/04

6 Queensview Crescent 12/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 6 Queensview Warley Road Scunthorpe North Lincs DN16 1QN Lead Inspector Matun Wawryk Unannounced 23 September 2005 rd 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. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 6 Queensview Address Warley Road Scunthorpe North Lincs DN16 1QN 01724 270407 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) New Era Housing Association Ltd Undergoing Registration Care Home 6 Category(ies) of LD(6), PD(3) registration, with number of places 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 6 Queensview Crecsent is a care home providing personal care and accommodation for six adults aged 18-65 years with learning difficulties. The care home is owned by New Era Housing and Support and is situated close to two other homes owned by that company. The home is located in a residential area close to the centre of Scunthorpe. It is close to local shops, amenities and public transport. The home is a purpose built bungalow. All the bedrooms are single, bedrooms are fitted with a wash hand basins. Bedrooms are decorated and furnished to meet individual service users requirements and preferences. Communal areas of the home are decorated and furnished in a domestic style. Aids and adaptations had been provided as required to meet service users needs. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced took place on the 23rd of September 2005 and lasted for 3 hours, forty-five minutes. A tour of the home took place and a number of service user care records were examined. In addition the inspector also looked at a sample of medication administration records and some procedures. The inspector spoke to three members of staff who were working in the home at the time of the inspection. Four service users were at home on the day of the inspection. The service users had some communication therefore inspector spent time observing activities instead of conducting formal interviews. What the service does well: At the time of the inspection the home was clean and tidy. Staff spoken to reported that they enjoyed working in the home. Staff stated that they felt the home was well managed and commented on the approachability of the manager. The inspector found the staff to be very friendly and they knew about the care the service users who lived in the home needed Staff reported that relatives are made to feel welcome when visiting the home, and records seen confirmed this, thereby helping service users to maintain family contacts. Service users are encouraged and supported to access local facilities and amenities in the area. This means service users have opportunities for getting out and about. Individual care programmes for service users are detailed and reflect all areas of identified needs. These means staff have necessary guidance to enable them to meet the needs of the service users. The meals in the home are good offering both choice and variety. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 6 What has improved since the last inspection? 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. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.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 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.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) There had been no new admissions to the home in the last few years and no admissions are planned. Therefore none of these standards were assessed on this occasion. EVIDENCE: 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.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 & 9 Individual care programmes are detailed and reflect all the service users identified needs. Care programmes must be produced in a different format to improve the accessibility of these for service users. EVIDENCE: Case tracking of two service users was completed. This included talking to staff and examination of individual care records. Care records were detailed and reflected all areas of need. This means staff have all the information they need to care for service users properly. Completed risk assessments were in evidence in both files examined. Care programmes are currently produced in standard written format. These must to be produced in a more accessible format for service users. In discussion with the inspector the manager reported that person centred plans were shortly to be introduced for all of the service users. The need to produce care programmes in a more accessible format remains an outstanding requirement from previous inspections. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 10 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.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) 13, 15, & 17 Service users are encouraged to maintain family links and friendships. The meals in the home are good offering both choice and variety. EVIDENCE: Staff stated relatives and visitors are made welcome at any reasonable time and records seen confirmed this. Key workers helped service users to maintain family contact by sending cards at significant occasions such as birthdays and Christmas. Staff reported that service users are encouraged and supported to go out into the local community to use local facilities and amenities and records seen confirmed this. This means service users are enabled to get out and about. Records of food provided showed service users were offered a variety of food. Food likes and dislikes were recorded. Staff reported that service users were shown meals to assist them making a choice of what to have to eat. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 12 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 Personal support is offered in such a way as to promote and protect the service users privacy and dignity. Staff need to be provided with formal medication training. This is needed to ensure staff develop necessary skills and competencies. EVIDENCE: All the bedrooms are single occupation this means treatments and examinations can be carried out in private. Care programmes detailed how personal care should be provided. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 13 Care workers administer medication. The home uses the Nomad system for drug administration. Medication administration records checked were satisfactory. There were no controlled drugs in the home at the time of the Inspection. Staff reported that in-house training had been provided and records seen confirmed this. Staff had not been provided with accredited medication training. This matter was discussed with the manager. The manager stated that New Era believed the training provided met the requirements of NMS 20. The manager was advised to forward a copy of the training programme onto the Commission for Social Care Inspection for consideration. This had not been received at the time of completing this report. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 14 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) 20 The arrangements for handling complaints are satisfactory. Complainants can be assured their complaints will be listened to and acted upon. EVIDENCE: A detailed complaints procedure was in place. The complaint procedure had been rewritten in a more suitable format for service users. The majority of service users had some communication difficulties therefore the inspector was not able to confirm service users were fully aware of the complaints process. There had been no complaints made since the last inspection. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 15 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) 24 & 30 The home was clean and tidy. The standard of furnishings within some parts of the home do not provide service users with an attractive place to live in. EVIDENCE: The inspector carried out a partial tour of the home. The home was clean and tidy. No mal odours were noted. Two bedrooms carpets were in need of cleaning or replacing. The sitting room carpet was marked and stained in places. Although this does not pose a health and safety risk to service users, it does not create a pleasing and welcoming environment for service users. The layout of the home means service users and their visitors do not have access to a quiet space away from other service users. The rear garden is on a slope which means it is not readily accessible to service users. The need to improve the accessibility of the garden remains an outstanding requirement from previous inspections. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 16 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) 33, 34, 35 & 36 The home operates sound recruitment and selection practice. Proper checks are carried out on staff before they commence working in the home. This means service users and their carers can be assured that staff have been properly vetted. The arrangements for staff training are generally satisfactory, however further improvement is needed with regards to the provision of service user specific training EVIDENCE: 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 17 The majority of service users have resided in the home for several years. From records examined and discussions held with the manager and staff it was evident that the dependency levels of some service users have changed. In addition staff reported there had been a reduction in the amount of day centre time allocated to some service users. This means service users are spending more time in the home. However this has not resulted in a review of staffing levels. The home did not have a tool for assessing dependency levels of service users, which could be used to inform decisions concerning number of care hours required. This is needed to ensure staffing levels are appropriately matched to the needs of service users. Staff spoken too were very clear about their roles and responsibilities and understood the management and reporting structures for the home. The home had recruited one new staff member since the last inspection. Examination of this individual’s personnel records showed all required checks had been completed and necessary records were in place. Staff recruitment practice is robust and consistent. The home had a good mandatory training programme. Training records examined showed staff had received a good level of training, including NVQ training. However as indicated there was limited evidence to show staff had received more specialist service user specific training. This is needed to ensure staff develop necessary skills and competencies to meet the changing needs of the service users. The majority of staff had not yet been provided with equal opportunities training, including disability training; race equality and anti-racism training as set out in NMS 35. This remains an outstanding requirement from previous inspections. This matter was discussed with the manager who reported that the newly revised induction programme covered these areas. A programme of formal supervision was in place. Staff confirmed supervision was provided on a regular basis, records examined confirmed this. This means service users can be assured that staff are properly supervised and that there is proper management oversight of the home. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.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) 37 & 42 There is currently no registered manager for the home. The manager must submit an application to register with the Commission for Social Care Inspection. The arrangements for the management of health and safety are satisfactory. This means staff and service users can be assured their health and safety is promoted as far as practicable. EVIDENCE: Staff reported that the manager was efficient and approachable. Systems were in place for the manager to brief staff and to receive feedback from staff for example staff meetings and handovers. The manager must make an application to register with the Commission for Social Care Inspection. This is needed to meet legal requirements. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 19 There were comprehensive health and safety policies in place. Safe working practices were maintained by the provision of training to staff in the form of moving and handling, basic food hygiene, first aid and fire safety. Systems were in place to ensure that all the homes equipment was maintained. Environmental and fire risk assessments were in place. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.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 x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 2 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x 3 x 3 3 x Standard No 31 32 33 34 35 36 Score 3 2 2 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 6 Queensview Score x x x x Standard No 37 38 39 40 41 42 43 Score 1 x 1 x x 3 x J54 6 Queensview 2872 V242556 UI 23 Sep 05.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. Standard 20 Regulation 18(1) Requirement The registered person must provide all staff dealing with service users medication with accredited training. Timescale of 16.10.03 not met. The registered person must ensure that the gardens are safe, well maintained and accessible to all service users. Timescale of 16.10.03 not met. The registered person must provide all staff with equal opportunities training, including disability training; race equality and anti-racism. Timescale of 16.10.03 not met. The responsible person must develop support plans in a more accessible format for service users. Daily records should relate to the support plans. Timescale of 31.3.05 not met. The registered person must develop a quality assurance and monitoring system that meets the requirements of this standard and produce an annual development plan based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users. Timescale for action 31.9.05 2. 28 23(2)(o) 31.8.05 3. 35 18© 12(4)(b) 31.9.05 4. 12(3) 6 31.12.05 5. 39 24(1)(a)( b)(2)(3) 31.12.05 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 22 Timescale of 19.2.04 not met. 6. 32 18 The registered person should ensure that training is ongoing so that 50 of care staff in the home hold NVQ 2 or above by 2005. The registered person must ensure the manager submits an application to register with the Commssion for Social Careb Inspection. The registered person must have the sitting room carpet cleaned or replaced. The sitting room must be redecorated The registered person must ensure stained and marked bedroom carpets cleaned and oir replaced The registered person must develop a tool for assessing dependency levels. This should then be used to assess whether care hours provided in the home are appropriate to enable staff to meet the care and support needs of service users currently living in the home. 31.12.05 7. 37 8 31.11.05 8. 24 16 31.11.05 9. 24 16 31.12.05 10. 33 18(1)(a) 31.12.05 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 14 Good Practice Recommendations The registered person should provide service users in longterm placements with the option of a minimum seven-day holiday outside the home as part of the basic contract price. 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit 3, Hesslewood ountry Office Park, Ferriby Road Hessle HU13 0QF 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 6 Queensview J54 6 Queensview 2872 V242556 UI 23 Sep 05.doc Version 1.40 Page 24 - 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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