Inspection on 31/05/05 for Annitsford Drive, 15

This inspection was carried out on 31st May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Annitsford Drive, 15 08/05/07

Annitsford Drive, 15 07/11/05

Annitsford Drive, 15 06/02/05

Annitsford Drive, 15 15/07/04

Annitsford Drive, 15 08/02/04

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 15 Annitsford Drive Fordley Cramlington Northumberland NE23 7AP Lead Inspector Jim Lamb Unannounced 31 May 2005 10:30 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. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 15 Annitsford Drive Address Fordley Cramlington Northumberland NE23 7AP 0191 200 8001 N/A sheilalee/adultservices@northtynesidecouncil.go v.uk North Tyneside Council 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) Vacant CRH 6 Category(ies) of LD Learning disability (6) registration, with number of places 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 6.2.05. Brief Description of the Service: The home provides short-term personal care and accommodation for 6 service users. The home is located in a residential area of Dudley close to shops, pubs, the post office and other local amenities. The home is a converted house, all bedrooms are single. the two bedrooms on the ground floor can accommodate people with physical disabilities. The home does not have a lift. The service users have access to an attractive rear landscaped garden. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first annual unannounced inspection visit. Time was spent in the office talking to the homes new manager and examining service users records and the homes policies and procedures. The manager provided the inspector with a very detailed action plan of how she will address the requirements and recommendations from the homes previous inspection visit, some of these have already been addressed. Time was spent talking to staff and service users. What the service does well: What has improved since the last inspection? After being without a permanent manager for over a year there is now a new manager who has been in post for 4 weeks. The new manager has many years’ experience of working with people with physical and learning disabilities. She has some very good ideas about how she intends to improve the delivery of care and services within the home. The manager was able to demonstrate how she will meet the requirements and recommendations identified from the previous inspection visit carried out on 6. 2 05. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 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 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 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) 1 2 3 4 5 EVIDENCE: Details of the extra charges and what these are for, are in the contract given to service users and are agreed prior to their admission. The service users contracts are currently being up-dated. The homes Statement of Purpose and the Service Users Guide both contained the full range of information required, these are available in a range of formats eg on DVD, and Pictorial. The homes statement of purpose needs to be revised to include YA 4.2 4.4 and 4.5. The standard contract used contains the range of information required by the standards. These have recently been reviewed and up-dated. Three service users’ files were checked and on each were a copy of a full needs assessment. These were carried out by appropriately trained people eg - the referring social worker and for those self-funding by the registered manager. They did contain a range of appropriate information and service users are involved in drawing up both these initial assessments and the home’s subsequent service user plans. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 9 However it is acknowledged that the majority of the service users assessments and plans of care are out-dated, currently the CLDT are in the process of reviewing and up-dating the service users records. The 3 service user plans checked by the inspector were comprehensive, and listed details of service user’s needs and actions taken by the staff to meet these needs. Two residents interviewed said their needs were met and they were happy with the care offered to them. Three care plans were checked and one staff member interviewed. These confirmed that a range of specialist services was provided to service users. Staff interviewed had had a range of relevant training and experience. All service users are invited to visit the home prior to using the service to meet other service users and staff. Overnight stays can also be arranged. On discharge from the home, a summary of the service users stay is given to their representative. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 7 9 10 The Community learning disability team are currently reviewing and up-dating the service users plans of care and assessments, without these there is no assurance that service users care needs will be fully met. The homes statement of purpose also needs to be revised. Service users are supported to take risks and are aware that information is handled appropriately. EVIDENCE: There is evidence of a comprehensive assessment in the service users’ care plans. There is also a comprehensive risk assessment of service users. There was evidence of advocacy arrangements, as well as family input. Each service user has an allocated key worker. Care plans are drawn up with service users. There is evidence that the homes plans are amended and reviewed on a regular basis. The community care assessments are currently being evaluated and up-dated by the Community Learning Disability Team. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 11 Self-advocacy is promoted, service users can access a range of external agencies that promote independence, and any rights that are restricted are linked to risk assessments. If necessary each service user receives support from staff to manage their finances. Two service users’ said that they are able to make decisions for themselves. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 12 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) 11 12 14 16 17 Service users are supported to maintain and enjoy community-based activities and engage in leisure activities. Service users rights are acknowledged. The home meets the nutritional needs of individual service users. EVIDENCE: Each service user has a practical life skills assessment carried out and this is reviewed and updated every six months, all service users participate in this process, and their relatives are invited to attend. Validated intervention treatment programmes are accessed if a need does arise. During their stay the service users have access to a range of community-based services, which promote and provide opportunities to learn and use life skills. There was evidence that each service user has the opportunity to continue to participate in community-based activities, including supported work programmes, education and training. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 13 The staff team liaise closely with external agencies in order to monitor each service user progress. There was evidence that daily routines promote independence, choice and freedom of movement. I was informed that some service users are involved in housekeeping tasks. The Home’s menus are based on the known likes and dislikes of the service users. At least two hot meals are provided on a daily basis. Service users who are able have access to the kitchen to prepare snacks for themselves if they wish. The service users that I spoke with said that the food was very good. I was informed that the service users are involved with the food shopping. A range of special diets can be catered for. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 14 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) 19 20 Promotion of service users health care needs is taken seriously. The service users welfare is closely monitored. The homes medication systems are well managed. EVIDENCE: I was informed that privacy and dignity are respected at all times. Many service users require technical aids or equipment staff have been trained to use equipment safely. The service users all indicated that they felt their privacy is respected. There was evidence within the service users care records that they have access to external health care services. If necessary service users are able to register with a local GP practice during their stay at the home. I examined the records and the procedures for the administration of medication; these appeared to be appropriately detailed. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 15 The medication systems were examined for receiving and administering and disposal. All were found to be appropriately documented. The manager has arranged to have a controlled drugs cabinet fitted. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 23 The homes arrangements for complaints, bullying and behaviour management are well managed, the service users concerns are listened to and protected. EVIDENCE: The home does keep a record of complaints. The home has a Whistle Blowing policy procedure as well as, the Local Authorities Vulnerable Adults procedures. The home also has a copy of the D.H. “NO SECRETS” for further information. Staff has undertaken POVA training. The Home maintains detailed financial records on behalf of the service users. There was evidence of personal spending and receipts are kept. The home maintains a daily audit of service users cash. The Authority are currently drawing up a policy and procedure for restrictive physical interventions, this will be inline with Department of Health Guidance 2002. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 17 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 25 26 27 28 29 30 The home provides a safe, clean and comfortable environment. There are several areas within the home that need to be improved; new bedroom furniture and re decoration will improve these areas greatly. Specialist equipment in the ground floor bathroom will maximise the service users independence. EVIDENCE: On the day of the inspection the home was clean, generally well decorated and well maintained. The home is in a residential location. The grounds were tidy, safe and attractive. A new ramp has been installed to allow easy access to the rear garden that has recently been landscaped. The fire service have recently visited the home, they have provided the manager with information about door opening devices. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 18 The home does have an appropriate amount of sitting, recreational and dining space. There are sufficient rooms for a variety of activities to take place. Service users can see visitors in private in their own rooms. The dining area is large enough to cater for all service users. There is a smoke-free sitting room. Outdoor space and all areas of the home are accessible to people in wheelchairs. Furnishings and fittings in the communal areas were domestic in design and in good condition. Lighting was sufficiently bright and also domestic in design. The home does have a sufficient number of baths, showers and toilets. The bathroom on the ground floor is no longer suitable for use, however following advice from a qualified occupational therapist, funding is in place to revamp the bathroom to provide assisted bathing for those who require high dependency bathing. Doors were labelled and had privacy locks. There were appropriate aids and adaptations – eg seat raisers, grip rails, bath hoists and tracking systems. Several communal areas have recently been decorated and protective wall surfaces have been fitted to prevent further damage. Room sizes did meet the minimum required. Room dimensions were such there was space on either side of the bed when necessary to enable access for carers and specialist equipment. Service users’ bedrooms checked all had opening windows. The rooms were centrally heated. All the homes bedrooms require new furniture, the manager has ordered new beds, and is in the process of obtaining quotes for additional furniture. Some bedrooms require new carpets and decoration. Radiators were low surface temperature and pipes were guarded. Lighting levels were sufficient and there was emergency lighting throughout the home. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 19 Valves are in situ at water outlets to ensure water is provided close to 43°C to prevent scalding. The home was clean and free from offensive odours. The laundry facilities appeared to be well organised, COSHH information was displayed. The washing machine has a specified programme to meet disinfection standards. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 20 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) 32 33 34 36 The home provides adequate staffing levels to meet the needs of the service users. A good system has recently been introduced to ensure that extra staff is on duty if a need does arise. The home has detailed procedures in place for the recruitment of staff. The staffs training needs are identified during supervision. EVIDENCE: Staff levels on the day of the inspection did meet the agreed level. Samples of’ rotas were checked and these stated the required numbers of staff were on duty. Staff spoken to and service users interviewed said that staffing levels were appropriate and that there were additional staff on duty at peak times of the day. The manager has introduced an excellent system that identifies well in advance when additional staff are required to be on duty, this system identifies when high dependent service users are pre- booked into the home. The manager said that the home receives very good support from the primary health care trust who can provide one to one support for some service users with high depenency needs. All the staff were over 18 years of age and those left in charge were at least 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 21 21. The inspector was informed that all of the home’s staff is expected to qualify to NVQ level 2/3 by December 2005. The inspector was informed that Authority has a thorough recruitment process which includes obtaining two written references, obtaining full employment histories and checking gaps in these, a criminal records check, medical checks, obtaining proof of ID and of any qualifications. The Authority is making arrangements for each home to retain staff files on site. Training needs of staff are identified via supervision and appraisal sessions. It was confirmed that staff receive more than three days paid training. Staffing Levels; 7.30am – 10pm 3 staff. Between 10pm – 7.30am one staff sleep-in, if a need does arise additional waking staff during the night can be arranged. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 22 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 40 41 42 The service will benefit greatly by having a permanent manager. The new manager is very experienced and has some excellent ideas about the future management of the home. The Authority involves service users in drawing-up new policies and procedures. Service users welfare is promoted and protected. EVIDENCE: The registered manager has many years experience in senior management and she has HNC qualification. The Authority will need to make arrangements for her to commence a level 4 National Vocational Qualification in management and care Staff interviewed were clear about the their responsibilities. Staff interviewed spoke positively about the manager saying she had encouraged both staff and service users to contribute to the development of the service. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 23 The home does have a quality assurance system, which seeks the views of service users, via meetings and questionnaires this system will be examined more closely during the next inspection visit. Service users are informed when inspections take place and have access to inspection reports. Copies are on display for relatives/others to see The Authority have established a working party that includes service users, they have developed a range of new policies and procedures that are service user friendly and have to some degree been linked to the National Minimum Standards. The records that I inspected were found to be appropriately completed, these included the fire log book, accident book, personal allowance records, and I was provided with information which verified that appropriate maintenance contracts for the home are in place. Finance records have previously been forwarded to the CSCI to verify that the home is viable. 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 24 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 2 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 2 3 x 2 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 15 Annitsford Drive Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x 3 3 3 x B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 25 on-going Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. Standard 37 24 4and5 13(4) (5) 14 13 (2) Regulation ya 9 ya 23 ya5 ya 6 ya 20 Requirement The manager is required to commence level 4 NVQ training in both management and care To safegaurd service users and staff,the homes front and rear doors should be alarmed re-new and up-date the service users contract (on-going) continue to up-date the service users plans of care and assessments (CLDT) (on-going) Lockable cabinet to be installed in all service users bedrooms. A controlled drugs cupboard to be installed. (on-going) Provide a policy and procedure for restrictive physical intervention. (on-going) Staff employment files to be held on site. (on-going) Timescale for action 31 12 05 1 8 05 28.7.05. 28.7.05. 28.7.05. 6. 7. 13(6) (7) schedule 4 17,(2) (3) ya 23 ya 34 28 7 05 28.7.05. 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 ya1and 4 Good Practice Recommendations Statement of purpose to be revised to include YA4.2 4.4 B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 26 15 Annitsford Drive 4.5 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 15 Annitsford Drive B53-B03 S33093 Annitsford Drive,15 V224543 300505 Stage 4.doc Version 1.30 Page 28 - 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!