CARE HOME ADULTS 18-65
Annitsford Drive, 15 15 Annitsford Drive Fordley Cramlington Northumberland NE23 7AP Lead Inspector
Jim Lamb Key Unannounced Inspection 8th May 2007 09:30 Annitsford Drive, 15 DS0000033093.V338082.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 Annitsford Drive, 15 DS0000033093.V338082.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. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Annitsford Drive, 15 Address 15 Annitsford Drive Fordley Cramlington Northumberland NE23 7AP 0191 200 8001 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) North Tyneside Council Mrs Jacqueline Thompson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th November 2005 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. Fees for the home cost £83.60 per week. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives and staff. The Visit: An unannounced visit was made on 8.4.07 During the visit we: • • • • • • Talked with people who use the service, relatives, staff, and the manager. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last inspection visit. We told the manager what we found. What the service does well:
Staff were friendly and relaxed and showed a good understanding of service users needs. Arrangements for service users to maintain contact with their family and friends are good. A variety of social activities were available providing Service users with varied activities and visiting places of interest
Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 6 Meals are varied and well balanced offering a good choice and nutritious food at all meals. One service user present said she was pleased with the quality and choice available. Meals are seen as a relaxed and social occasion. Hygiene practices were good protecting the health of service users and staff. The home is well staffed with a skilled, consistent and trained staff team giving security to residents. Staff recruitment and training records were clear and concise and contained all relevant information. The vetting process helps protect service users. The staff have a good understanding of individual needs. More than eighty percent of staff is qualified to National Vocational Qualification in Care level 2 (NVQ) or above providing service users with a trained, skilled staff team. People who move into the home for short breaks have a thorough assessment of their needs. The information is used to plan the care they require in recorded care plans. These plans are detailed and show what the person can do independently and the help they need from staff. Ten service users feedback cards were received. Service users speak very highly of the standard of care provided. Comments include “I’m very happy with the care I receive”, “I am always well cared for here”, “Fordley is spot on ”. Service users feel they are treated with respect and that staff observe their privacy and dignity. Arrangements are in place to access a range of health care professionals. All receive prompt medical attention to meet their health care needs. Trained staff deal with medication appropriately, and service users can manage their own medication if they wish, and have the capacity to do so. All are consulted about the social activities, events and outings that are provided. Many make good use of local community facilities. Individuals are encouraged to be as independent and active as possible regardless of age. They make informed choices and decisions about their lives and lead the lifestyle they prefer during their short breaks. Any complaints received about the service are dealt with professionally and in a timely manner. Service users and relatives know how to make a complaint and feel confident any concerns will be acted upon. There are procedures in place to protect vulnerable adults from harm. Staff are trained in preventing abuse to keep service users safe. The home is clean and comfortable and kept to a high standard. There is an attractive garden that residents enjoy using. Suitable staffing levels are provided to meet service users needs. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 7 New staff are carefully recruited to make sure service users are protected. Staff receive regular training in topics that are relevant to caring for younger adults, including LADAF and equality and diversity training. There are good systems to get the views of service users, professionals and relatives to develop the quality of the service. Service users have their personal finances safeguarded. The health safety and welfare of residents is promoted. What has improved since the last inspection? What they could do better:
The manager has agreed to purchase a food temperature probe, and keep a record of the temperature of cooked meats. Please contact the provider for advice of actions taken in response to this
Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 9 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 Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with enough information about the service to enable them to make a choice about where they want spend their short breaks. All service users are appropriately assessed prior to admission into the home. All are provided with a written contract explaining their terms and conditions with the home. 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 homes Statement of Purpose and the Service Users Guide both contained the full range of information required. Information is available in picture formats and on DVD. Two service users’ files were checked and each included a full needs assessment.
Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 11 They contained a range of appropriate information. The service users are involved in drawing up both these initial assessments and the home’s subsequent service user plans. The 2 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. The service users feedback cards all showed their needs were met and they were happy with the care offered to them. Two care plans were checked and staff interviewed, which confirmed that a range of specialist services was provided to service users. The staff member spoken to had excellent knowledge of the service users holistic needs. Staff interviewed had had a range of relevant training and experience. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 12 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. 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 using available evidence including a visit to this service. The care planning system is clear enough to ensure that staff have the information they need to meet the assessed needs of the service users. Service users are supported to make decisions about their lives, and take risks to promote their independence. EVIDENCE: There are comprehensive assessments in the service users’ care records. There is also a comprehensive risk assessment of service users. These have been agreed and signed by service users and their representatives. There are advocacy arrangements, as well as family input, to represent service users. Each service user has an allocated key worker.
Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 13 Care plans are drawn up with service users. Plans are amended and reviewed on a regular basis. There are systems in place that will ensure that the placement and the service users plans are reviewed annually. These involve the care managers and the service users representatives. Service users can use a range of external agencies that promote independence. Any rights that are restricted are linked to risk assessments. During there stay, each service user receives support from staff to manage their finances. Service users’ feedback cards all showed that they are able to make decisions for themselves, and that they are happy with all aspects of the care that they receive. Annitsford Drive, 15 DS0000033093.V338082.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The meals in the home are good, offering both choice and variety. The service users have opportunities for personal development and leisure activities. They are supported to maintain very good links with the community and their relatives and friends. EVIDENCE: Each service user has a practical life skills assessment carried out. This is reviewed and updated on a regular basis. All service users participate in this process. During their stay, service users use a range of community-based services, which promotes and provides opportunities to learn and use life skills. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 15 Service users are supported to live a normal life in the community. They are supported and encouraged to be in control of their own lives, to enjoy their own interests and hobbies. One service user recently expressed a wish to meet the players of Newcastle United Football Team. His key worker arranged for him and several other service users to meet the team at St James Park. The staff team continue to liaise closely with external agencies in order to monitor each service user’s progress. During their short breaks at the home, all service users are supported to maintain close links with their families and friends. They can choose who they want to see and when. Two service users are facilitated to attend church services. Daily routines promote independence, choice and freedom of movement. Service users are encouraged to be involved in light housekeeping tasks, and one enjoys helping in the garden during his time there. The Home’s menus are based on the known likes and dislikes of the service users. At least two hot meals are provided each day. The service users help to plan the menus and are involved in the food shopping. Service users have access to the kitchen and can prepare snacks for themselves if they wish. It is recommended that hot food temperatures are monitored and recorded, this is particularly important for any cooked meat, and to avoid the risk of salmonella. Annitsford Drive, 15 DS0000033093.V338082.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health care of the service users is met and there is good multi disciplinary working taking place. The promotion of health care needs is taken seriously. Medication systems are well managed. Personal support is always provided in the way that service users prefer. EVIDENCE: Service users moving and handling needs are assessed, and staff receives moving and handling training. Occupational Therapists assessments are carried out on request, and appropriate aids and adaptations are provided. Privacy and dignity are respected at all times. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 17 Service users care records showed that they have access to external health care services. G.Ps visit when necessary. Service users are referred for specialist health care if appropriate. The medication systems were examined for ordering, receiving, administering and disposal. These are well managed. Medication records contain a photograph of the service users. All staff has had accredited medication training. Controlled drugs are not currently prescribed. Should this change; appropriate systems and procedures will be put in place. The dispensing pharmacist continues offers good support and advice and carries out medication audits Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good, clear, user-friendly complaints system and service user’s views are listened to and acted upon. Procedures are in place to protect service users from harm, and these are followed. EVIDENCE: There is a complaints procedure. It contains details of how to contact the CSCI to make a complaint, if complainants are not happy with the homes investigation and response. The procedure is written in a way that ensures service users fully understand its contents. In earlier inspections, service users said that they had been given copies of the procedure and that staff listened to their complaints and dealt with them fairly. The service users feedback cards, all indicated that they would know how to make a complaint. The home keeps a record of complaints. Since the last inspection visit, there have been no complaints received. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 19 The home has a Whistle Blowing policy and the Local Authorities Vulnerable Adults procedures. There is also has a copy of the Department of Health’s document, “NO SECRETS”. The service keeps detailed financial records on behalf of the service users, during their time there. Receipts of personal spending are kept, and audits of cash held are carried out daily. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment for those living there. The standard and decoration within the home is generally very good. Some areas still need to be improved. Communal areas and bedrooms are large, and meet the service users needs. All areas within the home are well maintained, clean, tidy and free from offensive odours. EVIDENCE: The home was clean, well decorated and well maintained. The home is in an attractive residential location, close to local amenities. The grounds were tidy, safe, attractive and accessible. During the last twelve months, the fire service and the environmental health department had made visits to the home. No requirements were identified.
Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 21 The home has an appropriate amount of sitting, recreational and dining space. There are enough rooms for a variety of activities to take place. Service users can see visitors in private in their own rooms. Furnishings and fittings were domestic in design and in very good condition. Lighting throughout the home was bright and domestic in design. All doors have privacy locks, and service users are given a key to their bedrooms. Room sizes meet the minimum required. There is space on either side of beds when necessary, to enable access for carers and specialist equipment. There are two ground floor bedrooms and these are used for service users with physical disabilities. Service users’ bedrooms have opening windows. The rooms are centrally heated and the heating level could be controlled within each bedroom. Radiators are low surface temperature, safeguarding against burns. There was emergency lighting throughout the home. Water is stored at over 60°C. Valves at water outlets ensure water is provided close to 43°C to prevent scalding. The laundry facilities are well organised and the washing machine has the specified programme to meet disinfection standards. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is a good match of well-qualified staff offering consistency of care within the home. There are robust procedures in place for the recruitment and selection of new staff, which helps to protect service users. The staff receive supervision and this provides them with a good understanding of the service users support needs. EVIDENCE: Staff levels on the day of the inspection continue to meet the agreed level. There is a very stable and esablished staff team. All the staff were over 18 years of age and those left in charge were at least 21. Training needs of staff are identified in supervision and appraisal sessions. There is a good staff training and development programme in place. And this includes specialist training such as, equality and diversity, mental health capacity, POVA, and aggression limitation management.
Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 23 The training programme has been reviewed to ensure it meets The National Training Organisation requirements for the first six months. The staff files confirm that the Authority has a rigorous staff recruitment and selection process to ensure that all appropriate checks and references are in place prior to employment. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager is supported by the organisation in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The systems for service users’ consultation are very good, and service user’s views are both sought and acted upon. The health and safety of the service users is promoted. The service is aware of equality and diversity and its implications. EVIDENCE: Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 25 She has many years experience in senior management, and has recently completed Registered Managers Award. The service promotes the equality and diversity agenda, and staff training has commenced, this included race, age, disability, religion, sexuality etc. Staff spoken to were clear about their responsibilities, and the service users care needs, emphasis is concentrated on outcomes for service users. Service users are told when inspections take place and they are shown inspection reports. These are also summarised and discussed in service user meetings. Copies are available for relatives and others to see. The organisation has continued to develop a range of new policies and procedures which are in-line with the National Minimum Standards. Service users are consulted about new procedures, and some are members of the policy and development working group. The service continues to operate an excellent quality assurance system, this is based on gaining feedback from service users, relatives and professionals. The system consists of sub sections based on the NMS and each section has an agreed action plan for improvement. As part of the QA system, all staff in the home take responsibility for certain areas, this system works extemely well. The records inspected were found to be appropriately completed. These included the homes fire risk assessment, fire log book, accident book, personal allowance records and Health and Safey manual. There are appropriate maintenance contracts for the home in place.. Water storage tanks, gas and electrics are checked annually. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 26 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 4 2 X 3 4 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 3 27 3 28 3 29 3 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 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 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 4 X Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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 YA17 Good Practice Recommendations Keep a record of all cooked meat prepared in the home. Annitsford Drive, 15 DS0000033093.V338082.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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