CARE HOME ADULTS 18-65
All Saints Vicarage Church Road Eppleton Hetton-le-hole Tyne And Wear DH5 9AJ Lead Inspector
Mrs Elsie Allnutt Unannounced Inspection 10:00 18 November 2005
th All Saints Vicarage DS0000015776.V268917.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 All Saints Vicarage DS0000015776.V268917.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. All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service All Saints Vicarage Address Church Road Eppleton Hetton-le-hole Tyne And Wear DH5 9AJ 0191 526 6326 0191 526 6326 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) Autism North Limited Miss Sandra Douthwaite Care Home 6 Category(ies) of Learning disability (6) registration, with number of places All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th August 2005 Brief Description of the Service: As the name suggests the house was previously a vicarage. It is a big old building in its own grounds with an extensive grassed area and mature trees. The home has recently been extended to the back of the building but a large garden area still remains. The building is next door to the church it used to belong to. On the other side is a childrens play area. Church Road is a quiet street that runs parallel to the main road through Hetton. The interior of the house retains many of its original features such as wooden shutters on the windows and care has been taken during the extension work to maintain such features. The décor is bright and the furniture uncluttered, allowing freedom of movement. All of the service users have single bedrooms that are individually decorated. The extensive grounds are kept tidy by a gardener and the general repairs are addressed by a handyperson. The home is currently registered to provide care for five service users under 65 years all of whom have a learning disability and who have autism, however an application is currently being addressed so that the home can accommodate one service user who is 17years old. All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 4 hours over one day in November 2005. The views of five service users and four members of staff were sought. Due to the needs of the service users their satisfaction of the service provided did not rely on verbal communication but it was interpreted through observations of body language, interaction with staff, discussions with staff and the examination of records. This process demonstrated that all were satisfied with the service and the care and support given by staff. As part of the inspection process a tour of the building took place and a sample of service users’ care files and the homes records were examined. So that the needs of a prospective service user are met appropriately and that the changes to the building are registered, an application for a major variation is currently being addressed by the CSCI. What the service does well: What has improved since the last inspection?
There have been substantial changes to the environment since the last inspection. All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 6 The work carried out to extend the building was carefully planned and accomplished in a safe manner, with as little disturbance as possible to the service users. Larger areas to the lounge and dining rooms have been provided and the use of good quality materials has resulted in the original features of the building being maintained. Two further rooms with en-suite facilities have been developed on the first floor. This will provide separate accommodation for an identified prospective service user. In addition to this the whole of the building has now been refurbished, offering bright but calming colours throughout that pleasantly coordinate with the small furnishings and new furniture. These alterations have not only provided added space for another service user but have provided more areas for the existing service users to use and to accommodate their different activities. The service users contracts now include the full cost of the service delivered at the home and respecting confidentiality these are kept in a locked facility. 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. All Saints Vicarage DS0000015776.V268917.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 All Saints Vicarage DS0000015776.V268917.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): 1,2,5 Service users needs are assessed prior to admission in order to determine that their needs can be met by the home and they are issued with a contract that confirms that the home can meet their needs, clearly stating the terms and condition of their care, and the full cost of the fees to be paid. . EVIDENCE: The manager and records confirmed that service users are admitted to the home only after a full preadmission assessment and the home is confident that it can meet their needs. Records confirmed that multi disciplinary assessments have been made, as well as the home carrying out their own preadmission assessment, prior to the decision being made that the home can meet a prospective service user’s needs. Having now put the necessary facilities, consisting of two separate rooms on the first floor, and resources, an identified team of staff, into place to accommodate their needs, the home is confident that the needs of the prospective service user can be met. The manager has now ensured that the service users’ contracts, that record the terms and conditions of their stay, include the full fees that each person pays. The records, that were examined, are kept in a locked drawer to maintain confidentiality. All Saints Vicarage DS0000015776.V268917.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): No standards assessed on this occasion. EVIDENCE: All Saints Vicarage DS0000015776.V268917.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): 16,17 Although the people who live at this home have complex needs their right to choice and to live a normal life as possible is successfully promoted. To also maintain a balanced and healthy lifestyle, varied and wholesome food is provided by the home. EVIDENCE: Although it was evident when reading a sample of the care plans, that the likes and dislikes of individual service users are clearly recorded, it is acknowledged that due to their complex needs offering choices can cause anxiety. Staff explained that to avoid this choice is often limited, and often the choice of two options is given, or in some cases the choice is made for the person by staff. It was explained that this is achieved by using the knowledge recorded about the service user both in the care plans and the homes Choice and Consultation file. Records confirmed that service users are assisted to take part in various activities that include taking responsibility for the domestic chores around the house. Information in the care plans demonstrate that service users are supported to take part in as normal a life as possible and the risks that may be involved in
All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 11 doing this are addressed and risk management plans put in place. These are an integral part of the care plan. The manager explained that the risk assessment provides useful information as to whether a service user would be safe taking part in a particular activity that they enjoy, for example whether swimming should take place in a public pool or whether a specialist pool is needed. Depending on their needs records proved that service users enjoy the activity in both environments and guidelines were in place for staff to follow to ensure the relevant support was given. All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 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 the following standard(s): No standards assessed on this occasion. EVIDENCE: All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 13 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 There are satisfactory procedures in place which protect the current service users, as adults, from abuse, however the staff are not aware of the local Area Child Protection Committee procedures, therefore the service user who plans to move into the home within the next two weeks and who is 17 years, could be at risk. EVIDENCE: Staff confirmed that they have received awareness training regarding abuse and adult protection, as well as training in relation to handling verbal and aggressive behaviour. In discussion staff were able to appropriately describe what action to take in a situation where they witnessed abuse. However the manager and staff were not aware of the local Area Child Protection Committee procedures (ACPC). The manager was advised to address this issue and to ensure that all staff who work with, or who come into contact with service users who are 16 or 17 years old, should attend training in ACPC procedures and a copy of the procedures should be kept in the home for reference and guidance. All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 14 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 The home has successfully and tastefully extended the building to provide separate accommodation to address the needs of a prospective service user, while at the same time providing extra space and renewed décor and furnishings of a high standard, for the current service users. EVIDENCE: The home has completed work on an extension to the building that partly has been built to meet the particular needs of a prospective service user. Two additional rooms upstairs have en-suite facilities and it is planned that the prospective service user will solely use these. Building Control and the Fire Service inspected the building work prior to this inspection and have now issued certificates approving the work carried out. The extra rooms will provide the appropriate space required to meet the assessed needs of the prospective service user without impinging on the needs of the present service users. The décor throughout the building is now almost complete and at the time of the inspection the final touches were being made.
All Saints Vicarage DS0000015776.V268917.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): 34,35 Robust recruitment & selection procedures and regular training opportunities ensure that service users are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: Records and staff confirmed that the home has a comprehensive induction programme that new staff work through. The manager confirmed that new staff would also be working through the Learning Disabilities Framework Award (LDAF) as part of their induction process. This will improve their knowledge in relation to issues surrounding learning disabilities. Records also proved that, a service-training plan and individual staff training plans are in place. Staff confirmed that all staff either have NVQ or are working towards it and enthusiastically discussed their progress. The manager confirmed that the team of staff that will be working with the prospective service user who is under 18 years old are currently working towards Level 3 NVQ Caring for Children and Young People. The manager was advised that any new staff employed to work with service users 16 or 17 must register on this course. The sample of staff files examined included staff recently employed by the home. All of the files demonstrated that robust recruitment procedures had
All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 16 taken place and included in the records, two references, one of which was from a previous employer, and the original CRB certificate. All Saints Vicarage DS0000015776.V268917.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, who is well supported by her staff team, provides good leadership and runs a service that has effective monitoring systems that are focussed on the best interests of the service users. EVIDENCE: The manager is well experienced in this line of work and has recently successfully completed the Registered Manager’s Award (RMA). She confirmed that she has only 2 units to complete before she is awarded NVQ 4 in Care. This home was awarded the Investors in People Award in March 2003 and will be reassessed in 2006 to make sure that they continue to meet the relevant standards. It is clear that the home continues to follow clear quality assurance and monitoring methods, checklists completed by staff and audits carried out confirmed this. The results of the service users surveys are recorded every two years, a copy of which is forwarded to the CSCI. All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 18 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 2 3 X X 3 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 4 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
All Saints Vicarage Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 3 X DS0000015776.V268917.R01.S.doc Version 5.0 Page 19 no 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 YA1 Regulation 6 Requirement Timescale for action 31/12/05 2. YA23 13(6) The Statement of Purpose and Service User Guide must be reviewed and revised to address the changes made to the service. All staff working with service 31/01/06 users 16 or 17 years old or come into contact with them must receive training in relation to the local Area Child Protection Committee (ACPC) procedures. A copy of the procedures must be kept in the home for guidance. Any new unqualified members of 31/01/06 staff employed to work with people 16 or 17 years must enrol for NVQ 3 Caring for Children and young People. 3. YA35 33(c) 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 All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 20 1 YA24 The refurbishment to the building should be completed as soon as possible and the flooring at the entrance to the office made safe. All Saints Vicarage DS0000015776.V268917.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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