Inspection on 11/09/06 for Bamburgh Crescent, 10

This inspection was carried out on 11th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bamburgh Crescent, 10 20/12/05

Bamburgh Crescent, 10 26/05/05

Bamburgh Crescent, 10 21/12/04

Bamburgh Crescent, 10 21/06/04

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 Bamburgh Crescent, 10 10 Bamburgh Crescent Shiremoor Newcastle upon Tyne Tyne & Wear NE27 0NX Lead Inspector Glynis Gaffney Key Unannounced Inspection 11 and 12 September 2006 14:00 th th Bamburgh Crescent, 10 DS0000033083.V295628.R02.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 Bamburgh Crescent, 10 DS0000033083.V295628.R02.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. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bamburgh Crescent, 10 Address 10 Bamburgh Crescent Shiremoor Newcastle upon Tyne Tyne & Wear NE27 0NX 0191 200 8625 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) christine.browell@northtyneside.gov.uk North Tyneside Council Mrs Christine Browell Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. It is recognised that a percentage of the service users may also display physical disabilities 20th December 2005 Date of last inspection Brief Description of the Service: Bamburgh Crescent is set in a residential street in the Shiremoor area of North Tyneside. It is a single storey building, which has been designed to meet the needs of adults with learning and physical disabilities. The Home provides short stay residential care breaks. Nursing care can be provided on an individual basis. A bus route, pub and local shops are within easy walking distance. Service users are able to access all parts of the premises. The Home consists of two units, one of which is used to care for one adult who requires extra care and support. The other unit provides three places for adults with a range of care needs. There are two kitchens, a laundry, two lounges, two dining areas, a sit-down shower/toilet and an assisted bath/toilet and four single bedrooms. There are two ramps to the rear of the Home and a small garden to the front. Street parking is available. The current charge for a place at Bamburgh Crescent is £73.50. There are no additional charges. A copy of the Commission’s most recent inspection report was available to visitors, staff and service users. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, took place over 8 hours and involved one Inspector. A range of evidence has been used to support the judgements reached in this report, including interviews conducted with a senior Manager, staff team members and a small number of service users. At the time of the inspection, there were only three service users accommodated, two of whom were interviewed. The premises were also inspected, as were a sample of records. What the service does well: The Home had a warm, welcoming and relaxed atmosphere. Staff appeared to have developed warm and caring relationships with the people in their care. Service users were satisfied with the care and support provided at the Home. The staff team demonstrated enthusiasm and commitment in their attitude and approach towards meeting service users’ care needs. Staff were committed to providing a high quality service and worked well together as a team. The majority of staff had obtained a care-based qualification. Service users’ care records were easy to understand and written in plain English. The building was a well-maintained and provided service user with a clean, homely and comfortable place to stay. A range of risk assessments had been completed ensuring that the Home was maintained in a safe and hazard free condition. Staff had been provided with access to a wide range of training. The staff team had recently issued all service users and their families with quality questionnaires. A detailed and comprehensive report summarising the findings had been prepared and made available to the Commission. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Relevant Care Management Assessment and Care Plan information must be obtained before a new service user is admitted into the Home. This will help ensure that staff have access to all of the information they need to safely care for service users staying at the Home. Further improvement to the external grounds is required to ensure that service users are able to safely use the Home’s garden areas. The Learning Disability Service must prepare a Maintenance and Refurbishment Plan to ensure that the Home is maintained to its current high standard. Support plans and risk assessments must be updated to take account of information provided by other key professionals. Service users’ support plans Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 7 must be reviewed at least annually. This will help ensure that the Home provides service users, and their families, with the best possible care. Moving and handling risk assessments must be reviewed on a regular basis and be relevant to the facilities at Bamburgh Crescent. This will help ensure that staff transfer service users in a safe manner, which takes account of their current assessed needs. The training provided to staff to enable them to administer emergency epilepsy medication must be updated to ensure continued competence in this area. Service/maintenance reports must be kept at the Home. This will provide evidence that suitable arrangements have been put in place to keep the Home’s equipment in good working order. Staff must be provided with fire training delivered by a ‘Competent Person’ at least once a year. This will ensure that staff are clear about what action they should take in the event of a fire. A more comprehensive risk assessment must be put in place where bedside rails are used for the protection of service users. This will help ensure that service users are properly protected from unnecessary falls or entrapment. All hoisting equipment must be serviced at least six monthly and a written report kept at the Home. This will ensure that equipment used by service users is safe and in good working condition. 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. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 8 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 Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 9 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): 2. Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Satisfactory arrangements were not in place to ensure that staff had access to the information they needed to provide new service users with adequate care and support. EVIDENCE: A selection of service users’ care records was examined and it was found that: • • Care record A: a copy of the service user’s Care Management Assessment and Care Plan had been obtained; Care record B: there was no Care Management information available. The inspector was advised that this information was located at the service user’s previous placement because the service user had moved into the Home in an emergency; Care record C: the service user had been admitted into the Home on an emergency basis before their Care Manager had forwarded his assessment and care plan to Bamburgh Crescent. The Home did not receive the above information until the following day. • Bamburgh Crescent, 10 DS0000033083.V295628.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. A good system of care planning was in place and when support plans were satisfactorily completed and reviewed, they provided staff with the information they needed to meet residents’ needs. Staff supported service users to make everyday decisions. Service users were supported to take risks as part of an independent lifestyle. EVIDENCE: Individual support plans were in place for each service user and generally covered all aspects of health, physical and social care. Staff interviewed spoke knowledgeably about service users’ needs and how the team had established effective ways of working with people using the service. In some of the care records examined, staff had completed useful summaries of service users’ Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 11 stays. Generally, the support plans and risk assessments examined had been signed by either the service user or their carer. The plans of care examined were not in a format and language, which could be easily understood by service users. But, following a detailed audit of one service user’s support plan, a number of concerns were identified as follows: • • • • Not all of the advice provided to the Home regarding the service user’s nutritional care needs had been added to their support plan; An assessment to minimise the risks posed by choking and coughing fits whilst eating had not been updated to reflect the latest advice provided by the Speech Therapy Service; There was no evidence that a Care Management review had been held during the last 12 months; Although a Moving and Handling risk assessment was in place, it had not been updated since 1998. The assessment also referred to a previous care provider. It was also noted that some support plans had not been reviewed during the last 12 months. One service user said that ‘I decide what I do and when I do it. Staff help me by listening. They help me by doing what I want.’ This person also said that she decided: • • • What she ate; What she wore; What to do with her own time. Another service user said that he had arrived at the Home following an emergency in his previous placement. He said ‘staff have listened to my concerns and are giving me good advice so I can decide what I do. I think I will be able to make choices here the staff are good.’ A small number of individuals cared for at Bamburgh Crescent required 1 to 1 support to meet their complex care needs. Some of these service users also displayed behaviours, which required staff to plan strategies for working with them. On occasions, the 1 to 1 unit is secured by way of a keypad to enable staff to safely care for the person staying there. A member of staff was unsure if there were guidelines in place regarding the use of the keypad. Care Management information obtained by the Home included details of the potential risks faced by service users in their daily lives and how these risks were being managed. There was evidence that the Home had prepared risk assessments in response to the information they received from Care Management. Bamburgh Crescent, 10 DS0000033083.V295628.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Standard 12 is not applicable given the purpose of the Home. Service users were provided with opportunities to join in everyday community activities. Service users were offered a good diet, which took account of their personal likes, dislikes, and special dietary needs. Service users enjoyed the meals served at the Home. Service users were encouraged to form relationships with staff and other people staying at the Home. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 13 EVIDENCE: Service users were able to choose whether to attend their day care placement when visiting the Home. As service users attend the Home on a respite care basis only, Bamburgh Crescent staff are not usually involved in decisions about employment and educational opportunities. Service users were supported to make use of local facilities such as parks, the cinema, the Metro Centre and local pubs. The Home has access to a small wheelchair accessible bus, which a number of staff are licensed to drive. One service user said that she was very satisfied with activities offered by staff when she stayed at the Home. Service users’ social care needs were addressed in their support plans. Service users were supported and encouraged to build relationships with other people visiting the Home. Service users’ stays had been planned in advance taking into account individual needs, preferences and wishes wherever it had been possible to do so. Opportunities were available for service users to help with everyday household tasks such as tidying their bedrooms and helping out at meal times. Staff were observed knocking on service users’ bedroom doors before entering. Bedrooms doors were closed whilst staff provided personal care to service users. A service user told the inspector that staff always called her by her name. Throughout the inspection, staff were seen to engage service users in conversation and to involve them in what ever they were doing. Service users had access to all parts of the building with the exception of the 1 to 1 unit where a decision had been made to use a keypad lock. Staff worked flexible shifts built around the needs and interests of service users staying the Home. Staff interviewed said that this usually worked well. But, they also said that at times there might not be enough staff on duty to support service users who wanted to go on social activities outside of the Home. They said that this was because of the care required by some service users with complex care needs. There were no service users visiting the Home who had a different cultural or ethnic background. A Diet and Nutrition Policy was in place. Staff demonstrated a good understanding of service users’ nutritional needs. Before receiving a service at the Home, service users had been visited by a member of staff to find out about assistance required with eating and drinking, and about food likes and dislikes. Service users confirmed that staff had asked them what they wanted Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 14 to eat at the beginning of their stay. The menu viewed on the day of the inspection had taken into account service users’ individual dietary needs and preferences, as well as information obtained from their carers. A list of service users’ dietary preferences, and information about allergies, was available in both kitchens. Although the weekly menu set out the main meal choice for each day, there was no record of the food and beverages served at the breakfast, tea and suppertime meals. Support plans contained useful guidance on meeting service users’ dietary needs and assistance required at meal times. Both kitchens were visited and found to be clean, tidy and hygienic. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 15 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 and 20. Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff provided personal support in such a way as to promote and protect service users’ privacy, dignity and independence. The systems in place to support the safe administration, storage and disposal of medication were considered satisfactory and promoted residents’ good health. Satisfactory arrangements were in place to promote service users’ health and well being enabling them to lead healthy lives when staying at the Home. EVIDENCE: When delivering personal care and support, staff were observed to be gentle, kind and considerate. Support plans addressed service users’ needs for support with personal care. Support plans also contained information on service users’ preferred personal routines. A member of staff said that when the rotas were prepared, the Manager always took into account which staff Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 16 would need to be rostered on duty to meet service users’ intimate personal care needs. A range of aids and adaptations were available within the Home and staff felt that they had access to the equipment they needed to meet service users’ needs. It was identified that bedside rails were being used in some of the bedrooms to ensure service users’ safety whilst in bed. Although a risk assessment had been drawn up regarding the use of bedside rails, it did not cover all of the recommended areas. Given the purpose of the Home, staff are not usually involved in arranging how service users’ health care needs will be met. Where service users have identified health care needs, the Home liaises with the appropriate health care professionals and ensures that staff have clear guidance and training on how to meet such needs. For example, in one service user’s care records, there was detailed written guidance setting out how staff were to manage the individual’s epilepsy and continence care needs. Staff interviewed said that support with attending hospital or GP appointments would be provided if requested. A Medication Policy was available. Individual guidelines were in place to ensure that service users’ emergency epilepsy medication was properly administered. But, it was noted that the specialist training provided to staff about how to administer such medication, was out of date. A selection of Medication Administration Records (MARs) was examined and no problems were noted. Identification photos had not been placed on service users’ MARs. Lockable medication cabinets were available. There were no service users administering their own medication or taking controlled drugs at the time of the inspection. With one exception, all staff had received accredited training in the handling of medicines. Hand wash facilities were available. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 17 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 and 23. Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. The Home had a satisfactory complaints procedure and there was evidence that service users felt their views and opinions were listened to. A satisfactory Adult Protection Policy was in place ensuring an appropriate response to any suspicion or allegation of abuse received by the Home. EVIDENCE: The Home had a detailed complaints procedure and a helpful complaints leaflet. A service user said that they would be happy to raise concerns with any member of staff. The Commission and the Home had received one complaint during the last 12 months. The complaint received was being investigated under the Council’s internal complaints procedure. The Home’s Adult Protection Policy complied with the relevant guidance and legislation. There had been no adult protection concerns raised with the Commission or the Home since the last inspection. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. The standard of the internal environment within this Home was good providing service users with an attractive and homely place to stay. The overall quality of the furnishings and fittings was good. The necessary aids and adaptations had been provided enabling service users to be safely cared for. But, adequate arrangements were not in place to ensure that the garden areas were maintained in an acceptable condition. EVIDENCE: On the day of the inspection, bedrooms, the communal rooms, bathing and kitchen areas were clean, tidy, homely and well maintained. The Home was bright, cheerful, airy and free from offensive odours. The Home was located in a residential area and local transport links were close by. The outward appearance of the Home was in keeping with the local area and it did not have any signs publicising its status as a care home. The standard of decoration Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 19 and fixtures and fittings provided was good. But, a Maintenance and Refurbishment Plan was not in place. There was a large garden to the front of the building and a separate rear garden for each unit. The rear gardens were lawned and pathways had been provided. But, there were trailing overgrown bushes and weeds that made the garden areas look unkempt. Service users said that they were very happy with their bedrooms. Service users and staff had access to a range of specialist aids to promote independence. For example, grab rails and hoisting equipment had been fitted in the bathing areas and in some of the bedrooms. Staff felt that the Home had been fitted with the aids and adaptations required to enable staff to safely care for residents. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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 and 35. Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Staff were clear about their own and each others’ roles and responsibilities. Staff had the skills, competencies and qualities needed to meet service users’ needs. But, satisfactory arrangements were not in place to provide staff with refresher training in some areas. The Home had sufficient numbers of staff on duty to meet service users’ assessed needs. Service users are supported and protected by the Council’s recruitment policy and practices, although some of the required information was not available in the Home. EVIDENCE: Staff interviewed were clear about the purpose of the Home. They were able to clearly describe how they put the Home’s aims and objectives into practice on a day-to-day basis through their work supporting service users. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 21 Staff rotas included the required information. The following minimum staffing levels had been agreed with the Commission and were in place at the time of the inspection: 7am to 11am Two staff 11am to 2pm Two staff 2pm to 11pm Two staff 11pm to 7am 1/2 staff sleeping over/or on waking night duty in the Home Extra staff are sometimes rostered on duty to enable service users to take part in leisure pursuits and to provide care and support to those individuals with complex care needs who require 1 to 1 staffing. Staff interviewed said that there were usually two staff on duty throughout the working day, although this level could be reduced, or increased, depending on the needs of the service users accommodated. Also, where service users are absent from the Home during the daytime period, staffing may be reduced to one carer. A review was underway to ensure that rota arrangements made the best use of the available staff hours. Staff felt that satisfactory staffing levels were in place. There was on-call support available to staff and managers out of business hours. All staff had, with the exception of one member of staff, obtained a relevant care based qualification. Some of the staff files examined did not contain certificates confirming that staff had received training in all of the required areas. Also, some staff needed to update their training in fire safety. A temporary member of staff needed to complete all of the required mandatory training. Some staff personnel records did not contain all of the required information such as copies of references. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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 and 42. Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. The Home was run and managed by a person who was fit to be in charge, was of good character and able to discharge her responsibilities fully. Arrangements had been made to review the Home’s performance through a programme of self-review, which included seeking the views of service users and their families. EVIDENCE: A Registered Manager was in post. Mrs Browell is a qualified social worker and has a relevant management qualification. She has worked with children and adults who have learning disabilities for at least ten years and has considerable Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 23 experience working with individuals with complex care needs. Mrs Browell has worked as the Manager of the Home for over five years. A quality assurance system was in place. Service users and their families had recently been consulted about the quality of care and support provided at the Home. A report had been prepared summarising the results of the consultation exercise. Following on from this, the Home had identified areas, which it performed well in, as well as those areas in which improvements were required. A Best Value Review of the services provided by the Council was underway at the time of the inspection. A review of the Home’s health and safety arrangements was undertaken. It was confirmed that: • • • • • • • • • • The Manager had completed a range of premise and individual service user risk assessments; An asbestos assessment was completed in March 2004; A Gas Safety Certificate had been awarded in March 2006; Action had been taken to comply with requirements set by the local environmental health officer; The Home’s fire risk assessment had been updated in June 2006 and the Home had received a recent visit from the local Fire Service; The Home’s fire alarms had been tested on a weekly basis and were serviced in August 2006; Emergency lighting had been checked on a monthly basis and had last been serviced in May 2006; Fire equipment had also been checked on a monthly basis; There had been two fire drills during the last 12 months; Some staff had not received fire instruction at the frequency recommended by the Fire Service. But, it was also noted that: • The names of staff receiving fire instruction, and participating in fire drills, had not been recorded in the Home’s Fire Log Book; • Not all hoisting equipment had been serviced on a six monthly basis; • Service certificates covering the following items of equipment were not available – the fire alarm system; emergency lighting and fire equipment; • Premise related risk assessments had not been dated or signed. Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 X 3 X x 2 X Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA2 Regulation 14 Requirement The Registered Manager must ensure that copies of the Care Manager’s Assessment and Care Plan are obtained prior to the admission of a new service user. Timescale for action 01/11/06 2. YA6 15 The Registered Manager must 01/11/06 ensure that: • Service users’ support plans and risk assessments are updated to reflect advice provided by other key professionals; Service users’ needs are reviewed at least once every year; Service users’ moving and handling risk assessments are reviewed on a regular basis and are relevant to Bamburgh Crescent. 01/11/06 • • 3. YA17 17(2) Schedule 4 The Registered Manager must ensure that the records of food provided to service users contain sufficient detail to DS0000033083.V295628.R02.S.doc Bamburgh Crescent, 10 Version 5.2 Page 26 enable the Home’s Inspector to judge whether a satisfactory diet is being provided. 4. YA18 13(2) The Registered Manager must ensure that bedside rails risk assessments cover those areas recommended by the Medicines and Healthcare products Regulatory Agency. Please refer below for details of how to contact this Agency. info@mhra.gsi.gov.uk 5. YA19 18 The Registered Manager must ensure that the administration of emergency epilepsy medication training provided to staff is updated every 12 months. The Registered Manager must ensure that identification photos are placed on each service user’s medication administration record. The Registered Manager must ensure that arrangements are made for a temporary member of staff to complete training in the required mandatory areas. The Registered Manager must ensure that documentary evidence of any relevant qualifications held by staff is available within the Home. (Previous timescale of 01/11/05 not met.) 9. YA42 23(2)(b) The Registered Manager must 01/01/07 ensure that: 01/12/06 01/12/06 6. YA20 13(2) 01/12/06 7. YA32 18 01/01/07 8. YA34 7, 9 and 19 01/01/07 Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 27 • Day staff receive refresher training in fire prevention every six months and night staff on a three monthly basis. A ‘Competent Person’ must deliver at least of one of these sessions; (Previous timescale of 01/02/06 not met.) • Service certificates covering the following items of equipment are available for inspection purposes – the fire alarm system; emergency lighting and fire equipment; The names of staff receiving in-house fire instruction, and participating in fire drills, are recorded in the Home’s Fire Log Book. • 10. YA42 23(4) (Previous timescale of 31/03/06 not met) The Registered Manager must ensure that: • All hoisting equipment is serviced at least six monthly and certificates of maintenance made available within the Home for inspection purposes All risk assessments are both signed and dated. 01/11/06 • Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 28 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 YA6 Good Practice Recommendations The Registered Manager should ensure that: • • Service users’ support plans are made available in a format which can be easily understood by service users; Where relevant, service users’ support plans and risk assessments contain guidance on when the 1 to 1 unit should be secured by way of the keypad lock. 2. YA34 The Registered Manager should ensure that a copy of each staff member’s most recent Personal Development Review is held within the Home. 3. YA10 The Registered Manager should review the practice of recording confidential information about service users in the Staff Handover Book Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 29 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. Extracts may not be used or reproduced without the express permission of CSCI Bamburgh Crescent, 10 DS0000033083.V295628.R02.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!