Inspection on 13/01/05 for Basra

Care Homes For Adults (18 – 65)BasraStation Road Rowlands Gill Gateshead Tyne & Wear NE39 1JPUnannounced Inspection13th January 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Basra Address Station Road, Rowlands Gill, Gateshead, Tyne & Wear, NE39 1JP Email address Tel No: 01207 545879 Fax No: NO FAXName of registered provider(s)/company (if applicable) Northgate & Prudhoe NHS Trust Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 4Category(ies) of registration, with (number of places) Learning disability (4), Learning disability over 65 years of age (2), Physical disability (4), Physical disability over 65 years of age (2) Registration number B020000037 Date first registered Date of latest registration certificate 30th July 1996 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspection 28th October 2004 yes NO 23.06.04 If Yes refer to Part CBasraPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 313th January 2005 10:00 am Mrs Elsie Allnutt X X X X Kath JacksonID Code074590 X X XName of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionBasraPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 – 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s AgreementBasraPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Basra. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.BasraPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 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 activity outside the home. The activities available are varied and include short breaks away from the home.BasraPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspector’s Summary (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection took place over one day in January 2005. Many of the minimum standards that were inspected were met and some were exceeded. As the inspection was unannounced the views of service users, their families and the professionals involved in their care were not sought prior to the inspection. However on the day of the inspection service users demonstrated their satisfaction in relation to the service provided. Although on the day of the inspection the home was warm and welcoming and staff were observed delivering care in a sensitive and competent way, it was disappointing to note that the current staffing situation at the home is unsatisfactory. The service has been running without a manager in post since the last Registered Manager transferred to another Trust home in October 2004. A senior member of staff from Basra has been acting as manager during this time. Staff vacancies have not been filled and sometimes sickness has not been covered. This unsatisfactory situation has been brought to the attention one of the Trust’s Locality Managers who is to address the problem and forward short term plans to CSCI. Not all of the national minimum standards were inspected on this occasion. Those not inspected on this occasion will be addressed at the next inspection. Choice of Home (Standards 1 - 5) Of the 1 standard assessed 1 was met. There is currently one vacancy at the home. The home is currently following their admission policies and procedures to ensure that the prospective service user meets their criteria and is compatible with the service users already living at the home. Individual Needs and Choices (Standards 6 – 10) Of the 2 standards assessed 1 was met. Each service user has a care plan developed by their key worker that clearly outline their needs and how they are to be met. Through observed care practice and from the evidence outlined within service users notes, it is evident that staff in the home aim to promote service users independence and assist them in developing their skills. There are clear guidelines in relation to risk assessments, however some need to be reviewed and signed. Due to the high needs of the service users it is important that staffing levels meet their needs. However currently due to staffing problems in the home it has proved difficult for staff to assist service users on activities outside the home and to make or respond to impromptu decisions to assist service users out of the house.BasraPage 6 Lifestyle (Standards 11 – 17) Of the 1 standard assessed 0 was met. The service continues to attempt to actively engage service users in various activities both in the home and the local community. So that one service user receives independent assistance to form choices and make decisions, the home has referred them to a local advocacy service. This process is currently taking a long time and should be followed up by the home. Personal Healthcare and Support (Standards 18 – 21) Of the 1 standard assessed 1 was met. Staff working at Basra are able to promote and monitor service users healthcare needs and personal care is handled in a discreet manner. All of the people using this service have complex needs and care has been taken to have the equipment necessary to enable the service users to live comfortable and dignified lives while promoting of independence. Concerns, Complaints and Protection (Standards 22 – 23) Of the 1 standard assessed 1 was met. The home has accessed the “No Secrets” document and a training session on the local authority’s procedures on Adult Protection has been delivered to staff at the home. The home has adopted a policy to follow these procedures, a copy of which is kept in the home. Clear guidelines are in place in relation to challenging behaviour. Environment (Standards 24 – 30) Of the 2 standard assessed 1 was met. At the time of the inspection the home was clean and well maintained. One of the service users has an individualised easy chair, custom designed to meet their needs and there are attractive gardens with sensory objects to meet the needs of the people living there. An effective refurbishing programme has taken place in some areas of the home. A health and safety issue was brought to the attention of staff in relation to the laundry door being propped open. Staffing (Standards 31 – 36) Of the 3 standards assessed 2 were met. Staff demonstrated the appropriate skills and attitudes to the needs of the service users living at this home. Extra funding from Gateshead Social Services was recently allocated to finance an extra member of staff to support the increased needs of an identified service user. This meant that the home could meet the identified required staffing level. There should be at least 3 staff on duty at any time during the day. It was concerning to find that the home is not currently providing this number due to staff sickness and vacancies. At the time of the inspection and for some weeks previous only 2 members of staff have been on duty. In order to meet the high needs of the people living at this home the level of 3 staff on duty must be maintained. Conduct and Management of the Home (Standards 37 – 43) Of the 3 standards assessed 0 were met. A permanent manager is not in place in this home. Staffing records were not accessed on this occasion although staff confirmed that regular supervision takes place. Apart from the accident book all other records necessary were satisfactorily in place.BasraPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)BasraPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action Now that the local authority has allocated extra funding for an extra member of staff at the home in relation to the needs of one service user the staffing ratio of 3 members of 1 18(1)(a) YA12YA33 care staff in duty must not be decreased at 15.02.05 any time without consultation with the CSCI. (Previous requirement from 23.06.04 not currently being met.)213(4)YA42YA9The risk assessment and management plan in relation to the safe use of bedrails must be available for staff to follow. Such plans should be reviewed regularly and signed by the service user or their representative As a matter of urgency, and with the safety of the service users and staff in mind, a door guard or other self-closing device must be fitted to the laundry door. Until this takes place the door must be kept closed.15.02.05323(4) & 13(4)(c)YA42YA2428.02.05416(2)(c) & 23(2)(a)(f)YA26The identified service user must be reassessed so that it is clear whether the planned adaptations to their room remains necessary. If so then the work needed to be carried out should be followed up immediately.28.02.05BasraPage 9 5 68 (1)(2) Data Protection Act 1998YA37 YA41The appointed manager must take up post in the home as a matter of urgency.14.02.05The method used to record accidents must be 28.02.05 compliant with the Data Protection Act.RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard * It is recommended that the plans to arrange for an advocate to be involved in the life of an identified service user should be followed up so that the service user can be given assistance in determining choice and making decisions. So that all parts of the building are maintained to the usual high standard it is recommended that the areas of the house that are showing signs of wear and tear, mainly as a result of wheelchair use, should be addressed. If the need to remove the sink in one of the bedrooms remains an issue, as previously assessed, this also should be followed up.1YA72YA24* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire YES YES NOBasraPage 10 • Records • Care plans / Care pathways • Meals • Activities • Other enter details here ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES YES YES NO YES NO YES NO YES YES NO NO NO YES NO YES 3 1 X NO NO YES YES X X 13/01/05 10:00 5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met Basra (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls) Page 11 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.BasraPage 12 Choice of HomeThe intended outcomes for the following set of standards are: • • • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 – 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Key findings/Evidence Standard assessed at previous inspection.Standard met?0Standard 2 (2.1 – 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.BasraPage 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The home has comprehensive policies and procedures to follow in the event of a prospective new service user moving into the home. As there is currently a vacancy at the home these procedures are being followed to ensure that, a prospective service user is appropriately placed, the home can meet their needs and the person’s personality is compatible with the other service users’ living at the home. This home does not accommodate emergency admissions.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? Standard assessed at previous inspectionBasraPage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: • • • • • 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.Standard 6 (6.1 – 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Each service user has a care plan that clearly records all aspects of their personal and social care. The documentation follows the “person centred planning approach” and is divided into three different files each systematically containing different records of care. Discussion took place at the last inspection in relation to condensing the information into one main file where information could be more easily tracked by staff. However the three documents remain and appear easier to follow now that the system is fully in place. The care plans inspected clearly demonstrate how the service meets the needs of the service users. Risk assessments are in place with clear guidelines for staff to follow, some from other professionals,. There was evidence that the plans are monitored and reviewed.BasraPage 15 Standard 7 (7.1 – 7.7) Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Through observing the interaction between staff and service users it was evident that good relationships have been developed, and the communication needs of the service users have been established. This enables service users, who have complex needs including no speech, to effectively communicate their needs and choices to staff through facial expression and body gestures. Such individual ways of communication are recorded clearly in service users’ care plans. In addition to this a picture diary is used to determine choice of food and travel brochures have been used to establish holiday choices. So that all of the service users choices and decisions are effectively met the possibility of finding an advocate for one service user was discussed at the last inspection. Although this process had been put into action and someone suitable has been identified the full process has not yet been completed. It is recommended that this should be followed up so that the service user can be given assistance in determining choice and making decisions.Standard 8 (8.1 – 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? Standard not assessed.BasraPage 16 Standard 9 (9.1 – 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? It was evident when carrying out an inspection in February 2004 that a service user had been re-assessed by an occupational therapist relating to the need and suitability of the bedrails then in use. This confirmed that the bed and rails in use were suitable. Arrangements had also been made for the suppliers to regularly check the equipment. Although at the last inspection a risk management plan for their use with guidelines for staff to follow was evident, these were not available on the day of this inspection. It is thought that these must have been missed in the transition of information from one file to another. Staff assured the inspector that this would be addressed and the risk assessment and management plan would be put into place in the appropriate file. Other risk assessments and risk management plans appropriate to the needs of the service users were in place with clear guidelines for staff to follow. Although most were signed and reviewed regularly, some were not. All care plans should be signed by the service user of a representative and reviewed regularly.Standard 10 (10.1 – 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.BasraPage 17 LifestyleThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 11 (11.1 – 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.Standard 12 (12.1 – 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 2 Key findings/Evidence Standard met? None of the service users currently attend college or are engaged in employment. However care plans show that a wide variety of activity is offered through support of the carers within the home and a team of support workers from the “Enabling Service”, a service that provides staff to work 23 hours a week to assist service users to partake in activities in the local community. This did not take place during this inspection but a walk by one service user was planned for the following day. However currently due to staffing problems in the home it has proved difficult for staff to assist service users on activities outside the home and to make or respond to impromptu decisions to assist service users out of the house. One service user in particular enjoys and benefits from long walks in a quiet location with one to one attention. Although every effort is made for this to happen, this currently is not happening as much as needed by the person and identified in the care plan. As well as the activities already mentioned specialists in music and aromatherapy also visit the home weekly.BasraPage 18 Standard 13 (13.1 – 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.Standard 14 (14.1 – 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? Standard assessed at previous inspection.0Standard 15 (15.1 – 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.BasraPage 19 Standard 16 (16.1 – 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.Standard 17 (17.1 – 17.9) The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.BasraPage 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: • • • • 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.Standard 18 (18.1 – 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Through observation and reading through care plans it was evident that good care practices take place in this home. Staff were observed working sensitively with the service users, showing discretion when assisting with personal needs, and demonstrating respect and sensitivity when interacting generally. Service users demonstrated positive response through facial and body gestures. With reference to individuals’ dignity and comfort, personal care plans included clear guidelines for staff to follow in relation to service users’ individual preferences and for the different pieces of equipment used. Individual care plans were in place in relation to the use of different pieces of equipment supported by risk assessments in relation to their safe use. This is good practice.Standard 19 (19.1 – 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence Standard assessed at previous inspection. Standard met? XX 0BasraPage 21 Standard 20 (20.1 – 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.Standard 21 (21.1 – 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.BasraPage 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: • • Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 – 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Standard assessed at previous inspection. X X X X X X X Standard met? 0BasraPage 23 Standard 23 (23.1 – 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? The home follows procedures relating to the local authority’s policies and procedures on the Protection of Vulnerable Adults (POVA). A copy of the document is available in the home. Currently staff from the home are attending a training programme in relation to the procedures. Some staff confirmed that they had attended the training while others are still to attend. All staff have now attended training in relation to dealing with physical and verbal aggression. Guidelines were in place in relation to challenging behaviour and the protection of individuals from self-abuse. The plan and guidelines were regularly reviewed and were supported by a psychology report. This is good practice. The home has appropriate policies and procedures to follow in relation to the service users finances.BasraPage 24 EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 24 (24.1 – 24.13) The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The home that is in keeping with the other houses, is a large bungalow situated in Rowlands Gill, in a quiet residential setting, yet close to local shops and a variety of amenities. There are gardens to all sides of the bungalow that are accessible with assistance to all service users. Within one section of the garden is a gazebo, a sensory footpath and two solar water features that have been developed over recent years. 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 plans discussed at the last inspection to improve the environment in one service user’s rooms have now been addressed. However there are parts of the communal areas of the house that are showing signs of wear and tear mainly as a result of wheelchair use. So that all parts of the building are maintained to the usual high standard it is recommended that these areas are addressed. At the time of the inspection the laundry door was propped open with a piece of metal. This poses a high risk to service users in relation to fire starting in the laundry area. This was addressed at the inspection 10.02.04 when the inspector was advised that a door guard was on order for this door, so that it could be safely left open when carrying laundry to and from this area. The inspector was also ensured that in the meantime the door was kept closed. As a matter of urgency, and with the safety of the service users and staff in mind, a door guard or other self-closing device must be fitted to this door.BasraPage 25 Standard 25 (25.1 – 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) – single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence Standard not assessed. YES NO NO 4 X X X Standard met? 0 4 X4 X X XBasraPage 26 Standard 26 (26.1 – 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? All of the service users have a single room which are furnished to a good standard and individually personalised. Although none of the bedrooms have en suite arrangements, the bathrooms and toilets are nearby. One bedroom has been suitably decorated and refurbished with sensory objects to provide stimulation for the service user, since the last inspection. This has provided a much improved environment for the service user who prefers to spend most of the day on their own. There were also plans to remove the sink from this room to provide a more appropriate space for the bed. This was in response to the service user’s needs and behaviours exhibited at the time. The manager and staff should reassess the needs of the service user so that it is clear whether this adaptation to the room remains necessary. If this need is necessary then the work to be carried out should be followed up.Standard 27 (27.1 – 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.Standard 28 (28.1 – 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.BasraPage 27 Standard 29 ( 29.1 – 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.Standard 30 (30.1 – 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.BasraPage 28 StaffingThe intended outcomes for the following set of standards are: • • • • • • 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.Standard 31 (31.1 – 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 0 Key findings/Evidence Standard met? Standard not assessed.Standard 32 (32.1 – 32.6) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.BasraPage 29 Standard 33 (33.1 – 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme Key findings/Evidence X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXXStandard met?2BasraPage 30 As previously stated the staff appeared to have the skills and attitudes needed to work effectively with the service users within the house, however there was a restraint on planned and impromptu activity out of the house. Although enablers are employed to engage in some activity with service users this was not evident on the day of the inspection. In previous inspections it was identified that this home failed to meet the required staffing levels to effectively meet the assessed needs of the service users. Prior to the last inspection extra funding from Gateshead Social Services was allocated to finance an extra member of staff to support the increased needs of an identified service user. This was so the service user could receive more one to one attention and experience activities they enjoyed out of the house. This meant that the home could meet the identified required staffing level of at least 3 members of care staff on duty at all times during the day. The manager at the time stated that staffing was reviewed and increased appropriately above this number depending on the activities organised. At the time of the inspection it was evident, through observation and inspecting staff rotas, that the home was again failing to meet this requirement. Staffing levels had been reduced to 2. So that the required staffing levels agreed by the regulatory body are met this must be addressed as a matter of urgency. A discussion in relation to this issue took place following the inspection with the Locality Manager who is to address the issue.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? As the manager was not available at this inspection this standard could not be assessed.BasraPage 31 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. 3 Key findings/Evidence Standard met? The home continues to access the Trust’s training programme by submitting individual training needs, evident in the staff training profiles, to the head office. Staff confirmed that they were up to date with mandatory training and that regular training in relation to the needs of the service users takes place. New members of staff work through the TOPSS induction programme, this includes the Learning Disabilities Framework Award.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Staff confirmed that they receive both formal and informal regular supervision from the person currently in charge of the home. It was good to hear that although the home has gone through a difficult period since the recent sudden death of a service user, the staff felt that the strength of the staff team had been evident in the support that they were able to give each other.BasraPage 32 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 37 (37.1 – 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO1 Key findings/Evidence Standard met? Although a senior member of staff is currently in the position of acting manager and in charge of the home, there is no appointed or registered manager in place. This is concerning as this has been the situation since October 2004 when the previous registered manager moved within the organisation to another post. Although someone for the post has been appointed from within the organisation they have not yet been released from their current post. At the time of the inspection the person in charge of the home was not available, however one of the two staff on duty, who was an experienced carer identified themselves as in charge of the shift. The home must address this situation as a matter of urgency. A telephone call to the Locality Manager, for the home took place following the inspection. She is to address the situation.BasraPage 33 Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.Standard 39 (39.1 – 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? Standard assessed at previous inspection.Standards 40 (40.1 – 40.6) The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? Standard not assessed.BasraPage 34 Standard 41 (41.1 – 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met ? All of the records required by regulation, apart from the accident book, were evident, up to date and satisfactory. The current method used to record accidents was not compliant with the Data Protection Act. Personal information in relation to the previous recorded accident must not be available for anyone to access. Each record must be stored separately either in the person’s individual file or an identified file that can be stored securely away. Other personal records required were kept securely under lock and key, accessible to the service users and used in accordance to the Data Protection Act 1998. Standard 42 (42.1 – 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? There is a comprehensive Health and Safety file that contains all relevant policies and procedures. Staff were aware of their responsibilities relating to these and a completed Health and Safety poster was evident in the office. Staff confirmed that they are up to date with training appropriate to health and safety however health and safety issues were evident in relation to the safe use of bedrails and the wedging open of the laundry door. These were brought to the attention of the staff on duty.Standard 43 (43.1 – 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Standard not assessed.BasraPage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorElsie AllnuttSignature Signature SignatureRegulation Manager Jeannie EschleBell DateBasraPage 36 Public reports It should be noted that all CSCI inspection reports are public documents.BasraPage 37 PART DD.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 13 January 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include providers responses in the published report. In the meantime, responses received are available on request.Action Basra Page 38 taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 4 March 2005 , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOBasraPage 39 D.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Moray Allan of Northgate and Prudhoe Trust confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I I Moray Allan of Northgate and Prudhoe Trust am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.BasraPage 40 Basra / 13th January 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000007381.V144531.R01© This report may only be used in its entirety. 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