Inspection on 04/05/05 for Bailiffgate, 16

This inspection was carried out on 4th 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

Bailiffgate, 16 29/06/07

Bailiffgate, 16 13/01/06

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 16 Bailiffgate Alnwick Northumberland NE66 1LX Lead Inspector Anne Urwin Brown Unannounced 4 May 2005 09:30 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. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service 16 Bailiffgate Address Alnwick Northumberland NE66 1LX 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) 01665 605669 01665 605669 bailiffgate@stcuthbertscare.org.uk St Cuthberts Care Mrs S McEwan CRH 11 Category(ies) of LD LEarning Disability (10) registration, with number LD(E) Learning Disability - over 65 (1) of places 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration. Date of last inspection 10 November 2004 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. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted four hours and involved talking to residents and the staff; inspection of records and a tour of the building. The Manager was at a training event and was not present during the inspection, however the staff on duty provided the information needed to complete the inspection. Some of the residents present during the inspection had limited ability to communicate their views about the service. It was possible to observe residents’ communications with staff. What the service does well: The service provides individual care and support to suit the needs of each resident. Staff recognise the importance of identifying changing needs of older residents. There is a very homely environment. Individual residents’ likes and dislikes are well known to staff. Individual programmes are in place for each person. A good level and range of training is provided for staff. Staff are committed to training and recognise the importance of developing their skills. There is a clear complaints procedure and this is regularly discussed with residents. A good rapport existed between residents and staff. One resident confirmed that she was satisfied with the support provided by staff. She also said that the food was good. Communications with staff showed a good relationship existed and that residents were relaxed and comfortable in their home. Records seen during the inspection contained appropriate information about care needs and the support required. The Home is well furnished and each resident has her own bedroom. Bailiffgate was clean and hygienic. Staffing numbers are maintained at an appropriate level. Staff confirmed that they feel well supported by the Manager. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 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 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 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) 2 Service users’ needs are assessed prior to their admission to the Home. EVIDENCE: Four service users’ records were seen at the time of the inspection. These showed that an assessment is carried out before admission and records were available to confirm this. Staff described how information is collected from the person, their relatives and Care Managers before they are admitted to the Home. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 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 standard(s) 6, 7 Residents’ needs are known and are reflected with an individual plan. Residents are encouraged to make decisions about their lives and are assisted with this as needed. EVIDENCE: Records of four residents were inspected. Each resident has a profile and daily plan in place. Staff described how residents are involved in developing and agreeing their individual plans. They said that each resident is encouraged to take part in this. Inspection of care plans showed that monthly summaries are completed to identify changing needs. Records of formal reviews were also available. Written risk assessments are in place. Staff reported that the format for these has been changed recently and work is going on to complete risk assessments using the new format. The residents present during the inspection were unable to give their views about their involvement in the care planning process. However it was possible to observe staff asking their views and consulting them during the inspection. Staff were able to give examples of how residents are consulted and records were available to confirm this. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Residents are able to take part in appropriate leisure activities. A healthy diet is offered to residents and they enjoy their meals. EVIDENCE: Daytime activities are provided including attendance at day services, college and a gardening group. Records and discussion with staff confirmed that in addition there are regular opportunities to go shopping, swimming, keep fit class, horse riding, discos and pub outings. During the inspection one resident went out shopping with a relative and another with a member of staff. The Home is near to the shops and leisure facilities in Alnwick and from discussion it is evident that residents are able to make use of these. Residents’ likes and dislikes are recorded and staff demonstrated that they know these well. Residents enjoyed the food served at lunchtime during the inspection. Menus were available to show a good variety of food is available. Staff confirmed that the budget for food is sufficient. Staff described the arrangements in place to promote a healthy diet. Records showed that staff have completed Food Hygiene training. Two residents stated that they like the food. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 11 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) 20 Residents are supported to take their medication and written procedures are in place relating to administration of medicines. EVIDENCE: None of the residents administers their own medication. Appropriate records are in place for recording administration, ordering and disposal of medication. Storage of medication is satisfactory. Written procedures are in place for Handling of Medication. Training for staff on the administration of medication has been provided and records confirmed this. During the inspection it was noted that cream/ointments are not dated on opening. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 12 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 Residents feel that their views are listened to and acted on. Residents are protected from abuse, neglect and self-harm. EVIDENCE: Staff stated that there is discussion about making a complaint at residents’ meetings and records were available to confirm this. A copy of the complaints procedure is available in each resident’s file. Key workers regularly discuss how to make a complaint with residents. Records are kept of all complaints. No complaints have been made within the past year. A separate record of any complaint is kept in each resident’s file. Procedures are in place for adult protection. Staff were able to describe the process for reporting any allegations and were aware of the procedures. Protection of Vulnerable Adults training was last provided in October 2003 and staff stated that this is to be updated shortly. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 13 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) 28, 30 Shared space complements and supplements residents own rooms. The Home is clean and hygienic. EVIDENCE: The sitting room on the first floor is well furnished and spacious. There is a kitchen/dining room on the ground floor that is large enough to accommodate all the residents. This room is well fitted with kitchen units and appliances. Comfortable dining furniture is provided for residents and staff. The Home is clean and there are fifteen hours of domestic support provided. Cleaning materials and sharp knives are locked away. A separate laundry room is provided and the washing machine has appropriate wash cycles. Staff were aware that there is written guidance on infection control. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 14 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, 36 Competent and qualified staff support the residents. Staff have regular supervision and support from the Manager. EVIDENCE: Six staff have completed training qualifications in care. Discussion with staff, and records, show training has been provided in: • Moving and Handling, • First Aid, • Infection Control, • Fire Training, • Dementia • other specialist training appropriate to the needs of the residents. From observation during the inspection staff demonstrated good communication skills and a relaxed atmosphere was evident. Residents felt able to approach them with issues and a good rapport was evident. There are at least two staff on duty during the day, and the staff rota showed that there are often more. The rota showed sufficient staff hours to meet the needs of the residents. Staff reported that the turnover of staff is low and that there is a low level of sickness leave. Since the last inspection there has been an increase in staffing 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 15 numbers by one full time and one part time posts. Staff stated that they feel well supported by the Manager and confirmed that they receive regular supervision six times per year. Staff confirmed that there are sessions at each change of shift for transfer of information. Regular staff meetings are held and minutes were available to confirm this. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 16 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) 42 The health, safety and welfare of service users are promoted and protected. EVIDENCE: There are appropriate systems in place for testing and servicing the fire alarm system and equipment. During the visit records were seen that confirm this. Staff stated that Moving and Handling, First Aid, Infection Control and Fire Training have been provided. Records were available to confirm this. Written policies and procedures are available for Health and Safety and Infection Control. Health and safety checks are carried out and records are kept. There was evidence available that the Home complies with relevant legislation relating to Health and Safety. 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x 3 x 3 Standard No 11 12 13 14 15 16 Bailiffgate x x x 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 x x 3 Version 1.20 Page 18 B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc 16 17 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 13 Requirement Creams/ointments must be dated on opening. Timescale for action 01.06.05 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 Good Practice Recommendations 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 20 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 16 Bailiffgate B53-B03 S669 Bailiffgate V221005 040505 Stage 4.doc Version 1.20 Page 21 - 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. 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