Inspection on 29/06/07 for Bailiffgate, 16

This inspection was carried out on 29th June 2007.

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 13/01/06

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 Aileen Beatty Key Unannounced Inspection 29th June 2007 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 Bailiffgate, 16 DS0000000669.V330145.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. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 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.V330145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 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 are spacious bedrooms with shared toilet and bathing facilities. There is a kitchen diner and a communal lounge situated on the first floor. There is a large garden to the rear of the building. A lift is installed for access to the first and second floor. Information about the home is available in the statement of purpose and service user guide. The last inspection report is made available. Fees range from £370.45 and £729.18 Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day and involved discussions with residents, staff and visitors, reading records and a tour of the premises. The home provides a very high standard of care. Visitors and residents are very happy with the care provided. The manager provided information to CSCI before the inspection took place. What the service does well: What has improved since the last inspection? Staff have received further training which means that they are continuously developing new skills. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 6 Some new equipment has been provided including a new microwave and cooker. A computer has also been provided in the residents lounge. Some training is going to be given to help residents learn to use this. 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. The summary of this inspection report can be made available in other formats on request. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 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.V330145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive assessments are carried out before and after admission to ensure that people’s needs are known, and plans in place for them to be 0properly met. Detailed information is available to help people make choices about the service before moving in. Introductory visits to the home are sensitively planned. EVIDENCE: A pre-admission assessment is carried out before any resident is admitted to the home. Each care file read contained such an assessment and they are detailed and very specific. The information is very useful for care staff to help them to get to know the resident and make initial plans for their care. They are written in a person centred style, which means that the needs and wishes of the resident are emphasised. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 9 Information is provided to the home by the care manager. This is read carefully and on the day of the inspection, the home manager had noticed some conflicting information in an assessment and contacted the care manager for clarification. All new residents are offered the chance to have visits to the home before deciding to stay permanently. These may be very short visits to start with and building up to longer stays. For example they may come for a cup of tea, or for lunch then overnight. Relatives and friends may accompany residents to provide support. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Effective care planning and involvement of residents ensures that their needs and wishes are reflected in care plans. Residents are well supported and encouraged to make decisions and choices by fully trained and experienced staff. Good risk assessment tools and appropriately trained staff help residents to take calculated risks as part of an independent lifestyle. EVIDENCE: The care plans of three residents were read. All contain detailed care plans and evidence that residents have been involved in formulating and reviewing these. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 11 Care plans are detailed and written in a way that is easy to understand. Where a resident has a physical illness, supplementary information is made available beside the plan for staff to read. Where necessary the district Nurse will be involved in care planning. A detailed assessment is carried out and the information is used to develop individual plans of care. All of the records read contain assessments and care plans. The areas assessed include communication, comprehension, self care, domestic skills, personal relationships and social skills. Both strengths and needs are assessed. Any restrictions placed upon a resident or agreements about acceptable behaviour are recorded and signed by the resident and staff. Care plans and agreements are reviewed regularly and residents are involved in this. A key worker system is in place. Key workers help residents to make choices regarding long term goals, for example residents may wish to go to college. On a day to day basis, staff were observed encouraging residents to make choices and responding to requests. There are individual risk assessments in place and these are detailed and agreed with residents or family if appropriate. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16, and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is a broad range of activities for people to be involved in taking into account their individual needs and preferences. Residents are given good support from staff to remain involved within the local community. Staff understand the importance of helping residents to maintain appropriate personal relationships and do this very well. Residents are encouraged to make their own decisions and well trained staff promote and respect these rights. A varied menu is provided and residents enjoy their meals. Mealtimes are an enjoyable part of the day. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 13 EVIDENCE: A broad range of activities is provided. On the day of the inspection, only four residents were at home. The remaining residents were involved in activities such as attending the adult training centre nearby. Those remaining at home were involved in activities they enjoyed in the home, such as drawing and writing and helping to clear up after lunch. One resident went out with visitors for lunch. There was evidence that activities such as horse riding, attending college, arts and crafts, gardening, swimming and drama are available. It was noted that one resident raised at their review that they no longer wished to go swimming so an alternative activity was offered. Staff are continuously looking for new ideas, and drama is a new activity being tried this year. Residents have good links with the local community. They are able to attend events locally such as shows at the Alnwick Playhouse and trips to the shops and leisure centre. Neighbours call on a regular basis, and visitors are always made to feel welcome. Personal relationships are fostered and supported. The relatives of one resident were interviewed by the inspector. They were extremely complimentary about the home and said that their relative had improved immensely since moving into the home. In addition to this they were most impressed by the way that the home strive to help residents remember to send birthday and Xmas cards and presents. They had been extremely touched when they received flowers from their relative and staff at the home following a hospital stay. They describe this as being over and above what would be expected. Having been to many homes, they feel that Bailiffgate is the best home they have ever been to and said that no matter what time of day they visit they are made welcome. Each resident has their own room and they are nicely decorated and personalised. Some hold their own key and rooms are decorated in a variety of ways reflecting individual taste and styles. There is clear evidence that the routines in the home fit around the needs of the residents and not the opposite way round. The inspector ate lunch with residents. Meals are made by staff and residents choose what they would like to eat. Staff were observed helping residents to make choices. Four desserts were put in front of one resident to point to which one they would like. The kitchen is well equipped and residents are able to help if they wish to do so. Residents also help with shopping at the local supermarket. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff provide a good level of personal support to residents in line with their own needs and preferences. The physical and emotional needs of residents are clearly identified with clear plans in place to meet these needs. Good procedures are in place that protect residents receiving medication in the home. EVIDENCE: An assessment is carries out and regularly reviewed regarding the level of support required by residents. Records show that the level of support required varies and that residents are consulted about their routines, clothing and appearance. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 15 Physical and psychological care plans are in place for all residents. These are detailed and well written and reviewed regularly, except perhaps when resident have been away on holiday with staff which is acceptable. All residents have access to a good range of healthcare professionals and access these in the same way as most people; by visiting their local service such as dentist and GP. Staff are trained in basic podiatry and certificates are held in their training file. People with diabetes always have their feet attended to by the chiropodist. Where physical problems are identified very prompt action is taken by staff. The manager stated that she felt this was one of the strengths in the home and records confirm this. There is evidence that residents are encouraged to attend health screening such as breast screening. Where they have been offered this but refused, this is recorded. Due to the risk of memory problems associated with the genetic link between some learning disabilities and dementia, a baseline assessment is carried out to compare at a later date if necessary. There are satisfactory arrangements in place for the administration of medicines in the home. Medicines are provided by the local pharmacy in Alnwick. Some residents are supported to manage their own medication. Documentation is satisfactory. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems in place for ensuring that the views of residents are listened to and acted upon. Appropriate procedures are in place to make sure that residents are protected from abuse neglect and self harm. EVIDENCE: A good complaints procedure is in place and residents are made aware of how to express concerns. There was one complaint recorded but this was by a resident regarding having her hours cut at the local adult training centre which was not a decision made by the home. The complaint was recorded as the home supported the lady in complaining to the appropriate people. This demonstrates that complaints are taken seriously and acted upon. There have been no adult protection issues in the home. Staff receive safeguarding adults training and the manager has completed a two day course. Evidence is available in staff training portfolios. Individual risk assessments protect residents from potential self harm. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is clean and well maintained. EVIDENCE: The home is a large terraced house in Alnwick, close to the town centre. There are three floors and the home is domestic in style. Bedrooms are nicely personalised and very homely. The communal lounge is upstairs and is very nicely decorated and very clean and tidy. A small desk has been provided in the lounge for the new computer. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 18 The kitchen is the heart of the home and where residents and staff tend to congregate over a cup of tea. There is a very homely and relaxed atmosphere in the home. New kitchen benches have been provided since the last inspection. There is a large garden area that has been tastefully decorated with hanging baskets and planters. The home is clean and hygienic. There are no offensive odours and there is evidence of regular infection control measures such as sterilisation of shower heads taking place. There is one domestic employed and staff also take part in domestic routines in the home. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 19 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 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are well trained to enable them to be competent and adequately qualified to support residents. Recruitment procedures are robust and protect residents from the risk of abuse or neglect. EVIDENCE: Staff demonstrate a very good rapport with residents. The culture in the home is very positive and staff say they enjoy working there. Staff have to “sleep in” as part of their duties and describe Bailiffgate as a “home from home”. There is a nice atmosphere in the home and residents appear well cared for with their individual needs met. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 20 Staff records were checked and contained all of the required information. This included two references and criminal records checks. A comprehensive induction takes place for all new staff. There are currently no volunteers working in the home but criminal records checks would be sought for regular volunteers. Other visitors from the community are supervised in the presence of residents although they may obviously meet with their own visitors in private. A good range of policies and procedures are available to guide staff. These are regularly reviewed and updated. Statutory training is up to date. All staff have their own training portfolio containing certificates from training attended. Training has been provided in infection control, health and safety, first aid, moving and handling, protection of vulnerable adults, foot care, and medication administration. Training about specific physical ailments is provided relevant to the residents living in the home. These include insulin administration, understanding type 1 diabetes, epilepsy awareness, causes of hypo and hyperglycaemia and palliative care (care of the dying). There is evidence that the home keeps up with changes in legislation and provides training accordingly, such as mental capacity act awareness. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 21 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 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well run in the interests of residents. There are good systems in place to ensure that the views of residents underpin all self monitoring in the home. There are good health and safety procedures in the home that are followed by staff. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 22 EVIDENCE: During the first part of the inspection, the manager was not present. The staff member on duty was very knowledgeable and it is clear that the home operates well in the absence of the manager. The manager is very experienced and committed to providing the highest standard of care possible. Her attitude towards providing the best for the residents is also extended to staff who she endeavours to support to develop new skills and to share their views. Residents surveys are carried out regularly and residents meetings are used to gain the views of residents and to remind them of the existence of some policies and procedures such as complaints and privacy. Staff are well trained and supervised and aware of limitations to their role. The manager plans ahead and puts contingency arrangements in place. For example, staff do not have access to staff files but a key has been made available in a sealed envelope which is signed and dated by the manager, which can be given to the inspector if the manager is not available. This is only one example of the attention to detail evident in this home. There are also long term objectives for the home identified. There are good safety procedures in place. In addition to a general risk assessment for the home, each resident has a personal evacuation plan which describes how they should be helped out of the building in an emergency and what specific help they may need. There are regular safety checks carried out such as water temperatures, and a safety tour of the premises identifies any hazards. There is an uneven step in the garden, which has already been identified by the manager. The most recent fire and environmental health reports are positive with no concerns identified. Risk assessments have been carried out regarding lone working and staff are provided with a mobile phone. Due to widely reported incidents regarding carbon monoxide poisoning in the media, the home now has a detector fitted which is checked regularly. A spare phone is available for use in the event of a cut to the power supply. A monthly report is submitted monthly to head office detailing any untoward incidents such as fires, restraint, violence, accidents and near misses or security beaches. These reports can be made available for inspection. Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 23 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 X 2 3 3 X 4 3 5 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 3 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 X 3 X X 3 X Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 24 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. Refer to Standard Good Practice Recommendations Bailiffgate, 16 DS0000000669.V330145.R01.S.doc Version 5.2 Page 25 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 © 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 - 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. 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