Inspection on 13/01/06 for Bailiffgate, 16

This inspection was carried out on 13th January 2006.

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

The inspector 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

Bailiffgate, 16 29/06/07

Bailiffgate, 16 04/05/05

Bailiffgate, 16 10/11/04

Bailiffgate, 16 03/06/04

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 Bailiffgate, 16 16 Bailiffgate Alnwick Northumberland NE66 1LX Lead Inspector Anne Urwin Brown Announced Inspection 09:30 13 January 2006 th Bailiffgate, 16 DS0000000669.V263547.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 Bailiffgate, 16 DS0000000669.V263547.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. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bailiffgate, 16 Address 16 Bailiffgate Alnwick Northumberland NE66 1LX 01665 605669 01665 605669 bailiffgate@stcuthbertscare.org.uk 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) St Cuthberts Care Mrs S McEwan Care Home 11 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (1) of places Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: Bailiffgate is registered to accommodate eleven people with learning disabilities. It is situated a short walk from the centre of Alnwick near to shops and leisure facilities. There is access to public transport in the town. The accommodation is provided in a stone built terrace house on three floors. There is a large garden to the rear of the building. There is a lift installed for access to the first and second floor. The house is comfortably furnished. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day. It included discussion with the manager, six residents, four staff, inspection of four residents’ records, other associated records and a tour of the building. Questionnaires were made available before the inspection and all responses were very positive. What the service does well: What has improved since the last inspection? What they could do better: Work is going on to improve the care planning system and to have all care plans in the new format. This work is making plans more focussed and user friendly. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 6 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. Bailiffgate, 16 DS0000000669.V263547.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 Bailiffgate, 16 DS0000000669.V263547.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): 3, 4 Prospective residents know that their needs and aspirations will be met at Baillifgate. Before coming to live permanently at the home prospective residents are able to visit for short periods or full days and make short stays that are suited to their needs. Their relatives are encouraged to visit. EVIDENCE: Records showed that services are identified and provided to suit individual residents’ needs. Evidence was available that an assessment has been undertaken for one person suffering from dementia and arrangements put in place for her support. Staff are experienced and qualified to provide support to the residents. The manager described how specialist training for staff has been provided to ensure residents’ needs are effectively met. Respite care is not provided at Bailiffgate. The manager said that prospective residents are encouraged to visit the home before making a decision to move in. She described different arrangements including half day and/or full day visits and short stays that are arranged to suit individual needs. Records show all residents have a trial period before they make up their minds to stay permanently. Family/friends are encouraged to visit prior to admission. Bailiffgate, 16 DS0000000669.V263547.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): 6, 9, 10 Residents know their assessed and changing needs are identified within their individual plan. Residents are supported to take risks as part of an independent lifestyle. Information kept about residents is handled appropriately and confidentiality is maintained. EVIDENCE: Records show that appropriate assessments are carried out when residents are admitted and that they are consulted about their plans. Each resident has an individual plan that is developed from the Care Management assessment. The plans cover all areas of residents’ lives. Any restrictions on choice or freedom are recorded and records show that residents/or their relatives have been involved in making decisions about this. Each resident has a key worker who discusses the plan with them and identifies their preferences. Evidence was available of regular review of residents’ plans from records. All records seen were in good order. Detailed risk assessments are in place and these are regularly updated. Prior to admission risk assessments are drawn up. Evidence was available that residents and/or their relatives if appropriate are involved in drawing up the Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 10 risk assessments. Written guidance is in place for dealing with unexplained absences. Staff reported that no resident has gone missing. Policies and procedures on confidentiality are in place. Staff were aware of this guidance and showed a good understanding about issues relating to confidentiality. The manager confirmed that new staff receive appropriate information about maintaining confidentiality during their induction training. Records confirmed this. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 15, 16 Residents are able to take part in age, peer and culturally appropriate activities. Residents have opportunities to take an active part in events within the local community. Appropriate relationships are fostered and supported by staff at the home. Residents’ rights are respected and responsibilities are recognised within their daily lives. EVIDENCE: Residents’ individual preferences are met with activities of their choice. Individual records show that choice is given about how residents spend their time. All activities are recorded individually and evidence was available to confirm that staff support residents to find out about opportunities in the local area. There is a wide range of activities enjoyed by residents including education/training, gardening, literacy, numeracy, developing life skills, photography, art and riding. Staff are aware of services and activities available within Alnwick and the surrounding area. Residents’ records showed that they have regular opportunities to take part in local events and use local services including the cinema, theatre, churches and leisure centre. Staff confirmed that good Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 12 relationships are fostered with the neighbours and others in the community. Staff are made aware of taking account of cultural and racial issues through training and policies. Evidence was available from talking to residents and staff that appropriate links are kept with family and friends. Staff reported that all residents have contact with members of their family. Records show there are regular visits to the house by family and friends of residents and that staff support residents to visit relatives. An open visiting policy is in place. Evidence was available to show that staff support residents with keeping in touch by telephone and by providing transport. Relatives confirmed in questionnaires that they feel satisfied with the arrangements for keeping in touch with the residents. Records show that residents’ routines are organised to suit their individual needs and wishes. Each resident has her own room. Some residents have chosen to have a key to their rooms. Residents said that they are consulted about what activities and outings they would like. They also said they could choose not to take part, and during the inspection it was evident that residents were free to make choices about what they do during the day. Residents are encouraged to take part in household tasks suited to their capabilities and records confirmed this. None of the residents smoke and staff smoke outside the home. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 Residents receive sensitive and flexible support to meet their personal care needs. The support takes account of the need to respect their privacy, dignity and independence. Each person has an appropriate assessment of their health care needs and appropriate arrangements are in place to meet their needs. EVIDENCE: Evidence was available from records and discussion with residents and staff to confirm that residents are consulted about how their personal care needs are met. Individual care plans show evidence of involving residents in making choices about their routines, clothing and appearance. Residents said that staff knew what they needed help with and were relaxed with staff. Support from physiotherapists and occupational therapists has been provided where appropriate the manager confirmed, however there have been difficulties in accessing a speech therapy service for one resident. Each resident has a key worker and those residents with high support needs have two key workers. Residents’ records identify their particular routines, likes and dislikes. Each resident has her health care needs clearly identified. Residents are registered with local general practitioners and have regular health, dental, optical, chiropody checks. Records show that particular problems are identified and prompt action taken to refer residents for specialist support. Staff were Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 14 knowledgeable about residents’ health care needs and any treatment being given. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Residents are satisfied that their views are listened to and acted upon. EVIDENCE: Written guidance is available on dealing with complaints. Staff were aware of how to help a resident make a complaint. The manager said that there are regular discussions at staff meetings about how to help a resident make a complaint. Records are kept of all complaints and no complaints have been made since the last inspection. Residents said during the inspection that they felt able to speak to staff about any concerns they have. Staff said that during key worker sessions they regularly talk to residents about how to make a complaint. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 16 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, 25, 26, 27 Residents live in a homely, comfortable and safe environment that meets their individual and collective needs. Each resident has a single bedroom that suits her needs. Bedrooms are well equipped and furnished. Bathrooms are well equipped to meet residents’ needs and provide sufficient personal privacy. EVIDENCE: 16 Bailiffgate is a terraced stone built house situated a short walk from the centre of Alnwick where a good bus service is available. The accommodation is arranged on three floors and a shaft lift is fitted. There is a private walled garden to the rear of the property. The premises are well furnished and comfortable. Residents are encouraged to choose furnishings and the décor. The premises meet the requirements of the local fire service and environmental health department. There is a planned maintenance and renewal programme in place for the premises. Each resident has her own bedroom. Inspection of the premises confirmed that appropriate furnishings are provided and rooms are personalised by residents to suit their taste and interest. As part of the ongoing maintenance programme three bedrooms have been decorated and new furniture and carpet has been provided in one bedroom. Each resident has her own personal lockable space. Residents are able to have a key to their room if they wish. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 17 Records are kept if a resident is unable to manage to have a key for their room. Bathrooms and toilets have appropriate aids and adaptations to suit the residents’ needs. There are enough toilets and bathrooms for the number of residents living at Bailiffgate. Toilets and bathrooms have lockable doors. One bathroom has been retiled. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 18 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): 31, 32, 34, 35 Staff have clearly defined roles appropriate to their job descriptions. Staff have a clear understanding of their responsibilities. Residents are supported by staff who are competent and appropriately qualified. Residents are protected by the home’s recruitment policy and procedures. EVIDENCE: Staff confirmed that they are aware of the aims and objectives of the home. From records and discussion with staff it was evident that staff know residents’ needs. During the inspection it was apparent from observation that a good relationship exists between residents and staff. A copy of the General Social Care Council code of practice is made available for staff. All staff apart from two people have completed qualifications in care. These two staff are expected to complete this training this year. The staff group are experienced in caring for people with learning disabilities and records show they have the appropriate skills to meet residents’ needs. None of the staff are under eighteen years of age. Appropriate policies and procedures are in place for the recruitment of staff. Staff files contained copies of appropriate reference and Criminal Records Bureau checks. The manager was aware of the recruitment procedure and could describe the process for appointing new staff. There is a six-month probationary period for all new staff and this can be extended if the manager Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 19 has concerns. Staff are supplied with a copy of the code of practice for the General Social Care Council. A staff training and development plan is in place. The manager confirmed there is an appropriate budget available for staff training. Staff said there is a wide range of training opportunities and that they receive five days paid training. Training provided in the last year includes Handling Medication, Health and Safety, Outcomes into Practice, Moving and Handling, Safer Moving and Handling, Administration of Insulin, Non-Violent Crisis Intervention, Supervising Health and Safety and Dementia. Individual training profiles are in place and records confirm that staff have had appropriate training. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Residents benefit from a well run home. Residents’ views underpin all selfmonitoring, review and development by the home. The health, safety and welfare of residents are promoted and protected. EVIDENCE: The manager has completed registered manager training. She has fourteen years experience of working with people with learning disabilities. There is a written job description in place for the manager. There is evidence from records that the manager undertakes regular updating training. Residents’ surveys are carried out and copies were available to confirm this. Family and professionals are also asked for their views using the surveys. The manager is working on preparing a development plan using the information from resident, relative and professionals’ questionnaires. Evidence was available from records of self-monitoring. Regular residents’ meetings, care planning meetings and reviews give residents opportunities to feed back their views about the service and records confirm that this is happening. Aims and Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 21 objectives for the home were available and records show that these are drawn up each year. Staff have regular training in moving and handling, first aid, fire safety, food hygiene and infection control and records confirm this. Written guidance is in place for Health and Safety and Infection Control. Appropriate records are kept of regular testing and servicing of the fire alarm and fire equipment. Records are kept of fire training and of fire drills and these show appropriate arrangements are in place. Accident records are maintained satisfactorily. Staff confirmed that they receive appropriate induction training that includes information about safe working practices. Records confirm this. Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 22 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 3 4 X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bailiffgate, 16 Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 4 X 3 X X 3 X DS0000000669.V263547.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No 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. Refer to Standard Good Practice Recommendations Bailiffgate, 16 DS0000000669.V263547.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Cramlington Area Office 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. 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