Inspection on 11/01/06 for Basra

This inspection was carried out on 11th January 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Basra 06/10/06

Basra 06/09/05

Basra 13/01/05

Basra 23/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 Basra Station Road Rowlands Gill Gateshead Tyne & Wear NE39 1JP Lead Inspector Mrs Eileen Hulse Announced Inspection 11th January 2006 09:15 Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Basra Address Station Road Rowlands Gill Gateshead Tyne & Wear NE39 1JP 01207 545879 01207 545879 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) Northgate & Prudhoe NHS Trust Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (2), Physical disability (4), of places Physical disability over 65 years of age (2) Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Basra is a home run by Northgate and Prudhoe Trust, which provides residential care for four people who have learning and physical disabilities. The home is a large bungalow situated in Rowlands Gill in a quiet setting yet close to local shops and a variety of amenities. There are gardens to all sides of the bungalow that are accessible to all service users. Within one section of the garden is a gazebo, a sensory footpath and two solar water features that have recently been developed. The bungalow has been adapted to meet the needs of the people living there. There is an overhead tracking system, a raised bath and other relevant aids that enable and encourage comfort, safety, and independence. The home is staffed by home support workers, who support service users with their personal care and activities, and enablers, who solely enable service users to access activities outside the home. The activities available are varied and include short breaks away from the home. The home does not provide nursing care. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 11th January 2006 by one inspector (Eileen Hulse), the date and time of the inspection was announced to people who use the service including the Manager and staff and was carried out as part of the annual inspection programme. Prior to the inspection, questionnaires were sent out to all of the service users, however, because service users living in the home have complex needs and are not able to verbally express how they feel about the service, no completed questionnaires were returned. The inspection took 7hrs to complete that included 2hrs to prepare for the inspection. The focus of the inspection was to gain insight into the quality of life and services received by people who live in the home. Time was spent chatting with service users, observing the practice of staff throughout the inspection and talking with the Manager and staff who were on duty. Some records were inspected that included service user contracts, care plans, medication, POVA and complaints records and staff training records. A tour was made of the communal areas of the premises accompanied by a staff member. What the service does well: What has improved since the last inspection? The home has worked hard to address some of the requirements in the last report, one of the service users bedrooms has been adapted to suit the needs of the service user. Some of the records that were not seen at the last inspection are now available. The staff work well as a team and they have worked hard to individually gain an NVQ qualification and a lot more training opportunities have been made available to the staff. The change of some staff in the home has brought in fresh ideas that the acting Manager is currently implementing. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 6 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. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 All service users living in the home have individual contracts of their terms and conditions. This ensures service users or their representatives are aware of the services they are entitled to receive. EVIDENCE: Contracts were checked and showed that all service users living in the home have contracts on their personal files that details good information. Some areas included within the contract are: • • • • The care and support service users can expect to receive that is recorded within the personal care plans. A period of notice to be given if the service user moves out of the home. The scale of charges that service users are required to pay Service users personal costs that are not included. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 The care plans evidenced they are up to date and well maintained and include comprehensive, detailed information about service users as individuals and staff have found ways in which to communicate with service users and this helps staff to provide a good quality of care. EVIDENCE: The care plans follow a ‘Person Centred Planning Approach’ and they include information to ensure the needs of the service users are identified in detail in both personal and social care. Guidance for staff is informative and easy for them to follow to ensure a complete programme of care to service users. Staff are knowledgeable about the service users and observation showed there is a good rapport between staff and service users. The service users have complex needs including no speech, and the communication links that have been developed helps to effectively communicate their needs and choices to staff through facial expression and body gestures, such as pointing to what they want. One service user has the services of a speech therapist and progress is being made using picture card formats and plans are in place to have a more intense interaction, which will Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 10 involve working with the service user and the staff team. Through these individual ways of communication, staff explained they are able to communicate with service users effectively to know what service users want or don’t want. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 16 and 17 The home has an open door policy on visiting and service users have become more involved within the local community that enables service users to lead full lives. It was clear from observations that some people who live in the home have limited freedom of movement within the bungalow and have difficulty in choosing what they would like for their meals due to complex needs and disabilities. However, during the mealtime it was observed that service users and staff have formed good relationships and this results in a good quality of care being received by people living in the home. EVIDENCE: One service user has contact with the community links scheme in Blaydon Youth Centre and on the day of the inspection, another service user was helping a member of staff to shop in the village. Due to the complex needs of service users, records showed they are supported and guided by staff in choosing what they would like for their meals and the menus show that service users are offered nutritious and well-balanced meals. Observation showed the staff are committed and through daily activities they are able to support Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 12 service users to choose their meals and retiring times and offer alternatives on what they would like to do. The Inspector shared a lunchtime meal with the service users and it was likened to that of a large family with the meal prepared by staff, as service users are not able to help in this area. The lunchtime snack meal consisted of cold meat sandwiches and crisps. Records evidenced that service users dietary needs are assessed regularly and recorded in the plans of care and weights are monitored and also recorded every week. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home has a policy and procedure regarding the safe management of medication held within the home. This helps to ensure service users are kept safe when receiving their medicines. EVIDENCE: A monitored dosage system is used and is overseen by the local pharmacist and records detail an agreement with the pharmacy has been made for the pharmacist to carry out a drugs audit annually. An audit of the medication held in the home was checked and correct and the medication administration records that are held on one file and detailed with good information confirmed this. Medicines are stored safely and securely that follow the Royal Pharmaceutical guidelines. No controlled drugs are held within the home at this time. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 14 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 The home has a file with records relating to complaints or concerns made to the home. However, this information needs to be updated and reviewed and all of the staff team require training on complaints and POVA to ensure everyone knows how a concern or complaint will be dealt with. The home has no policy or procedure for dealing with an abuse situation and therefore staff may not recognise when an incident of abuse has occurred and service users will not be protected. EVIDENCE: All complaints that have been made to the home are held on file that also includes a monitoring sheet that is reviewed and signed on a monthly basis by the home Manager and the Locality Manager. However, the records also show that when a complaint is made, it details a number of areas such as: who made the complaint and a date by which a response must be given. However, in a different record it states what the complaint is about. This information needs to be collated into one area so that all the information is accessed easily if it needs to be. The complaints procedure is detailed and gives good guidance for the staff to follow and the Trust have also produced a video for service users on how to make a complaint, the Manager is also currently accessing complaints training for the staff team from the Trust’s training department. However, although the home have a copy of the Department of Health’s No Secrets document, they do not have Gateshead’s Local Authority POVA procedures that staff could follow and some staff have not received the Local Authority’s training on POVA. All staff need to receive training should they receive a complaint while on duty or a POVA situation takes place so that service users are protected at all times. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 15 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, 26 and 30 Overall the building was noted to be clean, well furnished and generally well decorated ensuring a nice comfortable home for service users to live in. EVIDENCE: Service users bedrooms are personalised to suite individual tastes and one of the bedrooms has had the sink repositioned following a risk assessment of the room. The communal areas of the home are comfortable with no offensive odours, making it comfortable and homely for the people who live there. However, no work has been carried out to the two large front windows of the home that must have attention to the wood frames. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 16 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): 32 and 35 The Manager ensures that experienced staff are left in charge in the absence of the Manager or team leader. However, there is no guidance to ensure this happens at all times. Service users must be supported by competent staff at all times. Over 50 of the staff team have acquired an NVQ qualification. EVIDENCE: Although the Manager has revisited the staff rotas to ensure that experienced and competent staff are left in charge of the home in her absence there are no guidelines in the home to support this and therefore staffing rotas do not guarantee that service users are supported at all times by competent and experienced staff. All staff have individual training files that are organised and provide evidence of courses they have attended with certificates enclosed. Both the Manager and staff contribute to the file following discussions in supervision on identified training needs. A recording sheet within the file details the date the course was attended and if a certificate was given. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 17 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 and 39 It is disappointing that The Commission for Social Care Inspection has not yet received an application from the acting Manager. The Manager must be registered to ensure the home is managed effectively. Quality is currently assessed within the home but is not devised into one system. Therefore, an annual review of the service does not take place. EVIDENCE: The acting Manager is a qualified nurse and has an RNMH qualification. After gaining her qualification, she worked in a hospital until 1996 then left to take up a Team Leader’s position in a community home. She is competent and able to lead the staff team and has managed Basra since February 2005 and she is currently completing NVQ Level 4 in management. An application must be made to the Commission for Social Care Inspection to become Manager of the home following an interview and when all references and checks have been received. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 18 The home has a matrix system that includes areas of the service such as care planning, statement of purpose, views of service users, quality of meals, and staff supervision and meetings. The matrix ensures that various aspects of the service have been monitored and carried out but it does not give an overall developmental view of the service. The Trust is currently devising a new quality assurance system and every month a different aspect of the service will be looked at and developed to ensure the annual review shows the quality of the service is good. Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 2 X X X 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Basra Score X X 3 x Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X X x DS0000007381.V264367.R01.S.doc Version 5.0 Page 20 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 YA22 Regulation 22 Requirement Records must detail all of the complaint and the staff team must have training in relation to complaints (Previous timescale of 01 Jan 2006 not met) POVA procedures must be made available to staff and all of the staff team must have POVA training (Previous timescale of 01 Jan 2006 not met) A door guard or self-closing device must be fitted to the laundry door. (Previous timescale of 10 Aug 2005 not met) The two large window frames at the front of the house must be repaired or replaced (Previous timescale of 01 Jan 2006 not met) The acting manager must be registered with CSCI (Previous timescale of 10 Aug 2005 not met) Timescale for action 03/04/06 2. YA23 10 03/04/06 3. YA24 23 03/04/05 4. YA24 23 03/04/06 9. YA37 9 03/04/05 Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 21 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 YA7 Good Practice Recommendations The plans that have been made to access the services of an advocate for an identified service user should be followed up Guidelines should be in place for staff to follow regarding which staff can be left in charge of a home. 2. YA32 Basra DS0000007381.V264367.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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