Inspection on 23/06/04 for Basra

Care Homes For Adults (18 – 65)BasraStation Road Rowlands Gill Gateshead Tyne & Wear NE39 1JPAnnounced Inspection23rd June 2004 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) Mrs Janine Sarah Fish 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 16th February 2004 yes NO 10.02.04 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 323rd June 2004 10:00 am Mrs Elsie Allnutt X X X X Janine FishID 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 June 2004. Many of the minimum standards that were inspected were met and some were exceeded. As the inspection was announced the views of service users, their families and the professionals involved in their care were sought prior to the inspection. All surveys returned were complimentary about the care received at the home. 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 4 standards assessed 4 were met. Clear information is available to prospective service users about the services and facilities on offer at Basra. The Statement of Purpose and the Service Guide have been updated to reflect the recent changes in the service. Separate illustrations are now used in conjunction with the formal service user contract in an attempt to make it more accessible to service users. The facilities provided and the skills, abilities and approach of the care staff enables service users’ needs to be effectively met. Individual Needs and Choices (Standards 6 – 10) Of the 4 standards assessed 4 were 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. A discussion took place with the manager in relation to the new format now being used. 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. Due to the high needs of the service users effective communication skills are seen as a high priority in this home and such information relating to this is clearly recorded in individual care plans. This was also observed on the day of the inspection. Lifestyle (Standards 11 – 17) Of the 7 standard assessed7 were met. The service continues 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. Staff assist service users to develop their confidence and to maintain a positive presence in integrated settings. A varied menu is available in the home reflecting the service users’ choice and dietary needs. Personal Healthcare and Support (Standards 18 – 21) Basra Page 6 Of the 2 standards assessed 2 were 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 address the equipment necessary to enable the service users to live comfortable and dignified lives while addressing the promotion of independence. Concerns, Complaints and Protection (Standards 22 – 23) Of the 2 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 some staff at the home. The home has adopted a policy to follow these procedures, a copy of which is kept in the home. Environment (Standards 24 – 30) Of the 7 standard assessed 4 were met. At the time of the inspection the home was clean and well maintained. Three of the service users have individualised easy chairs, custom designed to meet their needs and there are attractive gardens with sensory objects to meet the needs of the people living there. The manager has identified areas of the home that need attention in order to maintain the high environmental standards. One of these areas is the bedroom of one of the service users that was also highlighted at the last inspection. Staffing (Standards 31 – 36) Of the 3 standards assessed 2 were met. Currently there is 64 percent of qualified staff, which is a good achievement since the last inspection. Staff demonstrated the appropriate skills and attitudes needed. Since the last inspection extra funding from Gateshead Social Services has been allocated to finance an extra member of staff to support the increased needs of an identified service user. This now means that the home can meet the identified required staffing ratio of at least three members of care staff on duty at all times. In order to meet the high needs of the people living at this home this ratio must be maintained. The home continues to contravene Regulation 17(2) by not making available all records relating to staff identified in this standard and regulation. Conduct and Management of the Home (Standards 37 – 43) Of the 5 standards assessed 2 were met. Management systems appear to be effective. Those records inspected appeared accurate and well maintained. The manager is currently accessing the training needed to qualify for the Registered Managers Award.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 action 1 17(2) YA34 All of the recruitment documentation as stated in this regulation must be kept in the home. A copy of this year’s results (2003/04) of the quality assurance process must be forwarded to the NCSC on completion. 29.03.04 On completion .224(1)(2)YA39Action 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 Standard 1 YA37 The manager should complete the necessary units required for the Registered Managers Award by 2005.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)BasraPage 8 BasraPage 9 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 1 13(6)&18(1 YA23 )(c)(i) 13(40(a)& 2 16(2)(c)& 23(2)(f) YA26YA25 YA24 All staff must attend training challenging behaviour training. The requirements relating to the poor standard of décor and furnishings in one of the bedrooms must be addressed. 29.10.0429.08.04318(1)(a)YA33Now that the local authority has allocated extra funding for an extra member of staff at the home in relation to the needs of one Immediate service user the staffing ratio of 3 members of care staff in duty must not be decreased at any time without consultation with the CSCI. The manager must ensure that staff who work during the night must receive fire training Immediate every three months.423(4)(e)YA42RECOMMENDATIONS 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 *BasraPage 10 1 2 3YA6 YA28 YA39Consideration should be given to condense the information currently spread in three care files into one working file where information can be more easily tracked. The plans to commence a re-decoration programme throughout the home should go ahead. A copy of Annual Plan reflecting the results of the Quality Assurance process should be forwarded to the CSCI.* 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 • 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: YES YES YES YES YES YES YES NO YES NO YES NO YES YES YES YES NO YES NO YESBasraPage 11 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)4 X X NO NO YES YES 11 1 23/06/04 10:00 6.5The 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 (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)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. 1219.88 X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? The Statement of Purpose and Service User Guide have been reviewed and updated to reflect the changes in the home and now includes the full cost in fees for people using the service. To make the Service User Guide further accessible to service users it is supported with pictures and is in audio format.Standard 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. 3 Key findings/Evidence Standard met? As part of the inspection process a sample of care files was inspected. It was evident that the necessary assessments had taken place prior to admission and a care plan that addressed the needs of the individual service users had been developed. Risks had been identified and guidelines in risk management plans were evident for staff to follow.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. 3 Key findings/Evidence Standard met? The home continues to meet the needs of the service users. However to address the complex needs of the service users living at this home, and to meet them effectively, the staff access assistance from relevant other professionals. Guidelines from a physiotherapist describing movement techniques relating to keeping an individuals hip mobile were evident for one service user, and behavioural guidelines from the community learning disabilities nurse were evident for another. Staff appeared to be equipped with the skills and expertise to address the needs of the service users. It was evident that staff received training to equip them with the necessary skills.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. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion but will be addressed at the next inspection.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. 3 Key findings/Evidence Standard met? A contract has been developed, a copy of which is available in the care file of each service user. This covers the criteria of this standard. A separate sheet with information relating to the fees to be charged and the room to be occupied are inserted into the document. Since the last inspection pictures have been developed to use as illustration to assist in making the document more accessible to service users. This is good practice.BasraPage 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? At the last inspection the care plan documentation had been reviewed and was gradually being transferred to a new format that follows the “person centred planning approach”. This now has been completed. The documentation is divided into three different files each systematically containing different records of care. It is the view of the inspector that this would be a more effective system if the information is condensed into one working file where information is easily tracked by staff. 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 the service users, who have complex needs including no verbal speech, to effectively communicate their needs and choices to staff through facial expression and body gestures. In addition to this a picture diary is used to determine choice of food and travel brochures have been used to establish holiday choices. It was good to hear that the home has recently approached Gateshead’s Befriending Scheme and as a result one of the service users is currently waiting to be allocated an advocate who will hopefully assist 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 on this occasion but will be addressed at the next inspection.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. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion but will be addressed at the next inspection.BasraPage 16 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. 3 Key findings/Evidence Standard met? Evidence was available in the home to demonstrate that the standard continues to be met. Discussion held with staff indicated that staff have received training in this area during their induction and now as part of their mandatory training. A statement on confidentiality is at the front of all care plans and a policy on confidentiality in relation to partner agencies has been developed. This now meets the requirements of this standard. This is good practice.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. 3 Key findings/Evidence Standard met? When reading records, and talking with staff, and generally observing, it was evident that great emphasis is directed to assist service users to develop their confidence and positive presence in integrated settings. This is achieved through the development of good personal care routines, service users being assisted to dress appropriately in attractive clothing, and staff taking the time to explain what the clothing looks like and praising individuals on their appearance. Staff felt that integration was more discreet and effective when service users were assisted into the community individually or in twos instead of in a large group. This is good practice.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. 3 Key findings/Evidence Standard met? None of the service users currently attend college or are engaged in employment. However care plans showed that a wide variety of activity is offered. This is supported by 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. One service user in particular benefits from this as they enjoy long walks in a quiet location with one to one attention. This was evident on the day of the inspection. 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. 3 Key findings/Evidence Standard met? The home generally continues to enjoy good relationships with the neighbours and also continues to use the local community facilities. This includes using local shops, where individual service users enjoy going with a member of staff, health centres where they visit their GPs and pubs where they enjoy a drink and sometimes a meal. Although there is difficulty in accessing some of the local transport one service user has begun to enjoy using the low level bus and the metro has been used as part of a journey to the airport for a day out. The home has its own transport that is used for some outings and in addition to this local taxis are used. Staff were aware of the rights of the service users all have attended training related to the Disabilities Discrimination Act.Standard 14 (14.1 – 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? As previously stated a variety of activities continue to take place in the home and the local community. On the day of the inspection two service users were escorted to go shopping while another was watching the television, and another listening to music in the privacy of their room. Later in the day one service user was assisted to go out for a walk and another was offered the chance to go with them but declined the offer. Other activities include visits to the local shopping centre and local country parks. Staff described how two of the service users enjoy going to the theatre to see musicals and concerts. Although it means that staffing ratios need to be increased individual holidays have been planned to take place in Haggerston Castle, Berwick and the Lake District. This is good practice. As previously mentioned it was good to hear that an independent advocate is being sought for one service user who is finding difficulty in communicating their interests. It is hoped that this will help to establish their likes and dislikes.BasraPage 19 Standard 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). 3 Key findings/Evidence Standard met? Not all of the service users have contact with family members however when inspecting service user’s bedrooms it was evident that staff encourage family links by displaying photographs of family members. One of the service users also keeps in contact with two friends she had before moving into the home, some family/friends visit the home and staff assist other service users to keep contact by assisting to send cards and letters.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). 3 Key findings/Evidence Standard met? Although the design of the house allows easy access to all areas, the physical abilities of the service users limit independent access. Everyone needs assistance to access the garden which is now equipped with sensory objects to provide extra stimulation. A gazebo provides protection from the sun for one service user with sensitive skin. Although locks are fitted to bedroom doors none of the service users have the ability to use the key. The staff however demonstrated their respect for the service users privacy by assisting them to use their rooms for their own time. Staff were observed interacting with the service users with sensitivity and respect. The good practice of staff assisting service users to open their own mail continues. As well as having tropical fish in a large tank the home now has two cats which two service users in particular have taken ownership of.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. 3 Key findings/Evidence Standard met? A varied menu is available in the home reflecting individual service user’s choice. Service users choose what food they like and want through the use of a pictures put together in a file. Despite service users needing a soft diet due the high risk of choking, different foods have recently been introduced for example Italian food. Risk assessments were in place related to foods that may cause choking, and the dietician has advised that a thickener should be used in liquids for one service user with a swallowing problem. Records reflected this. Records also reflected that the weight of certain service users was monitored due to one experiencing weight loss and another weight gain. A dietician continues to visit the home and a member of staff, who is the food representative for the home, continues to attend the Food Representative Meetings with the Trust. Basra Page 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. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion but will be addressed at the next inspection.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) 2X3 Key findings/Evidence Standard met? Service users are registered with a local GP and an annual health check takes place in the privacy of the service users bedroom. Medication is reviewed six monthly by the GP. At the time of the inspection it was good to see that all of the service users were in relative good health.BasraPage 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. 3 Key findings/Evidence Standard met? Records examined in relation to medication were satisfactory showing evidence that the homes policies and procedures are being followed appropriately. Most of the staff have attended the recommended training in the administration of medication and the remaining staff are waiting for places. The medication record book was used appropriately and no anomalies found however a full audit of medication was not carried out.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 not assessed on this occasion but will be addressed at the next 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 1 1 X X X X 100 Standard met? 3The home follows the Northgate and Prudhoe Trust’s policies and procedures relating to complaints. These have been adapted for the home and are satisfactory. These have now been made accessible to the service users in picture format. This was achieved by using symbols and pictures, such as faces showing expressions. This is good practice. It was evident that the complaint recorded had been appropriately recorded and dealt with.BasraPage 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 YESX2 Key findings/Evidence Standard met? The home has now accessed information relating to the local authority’s policies and procedures on the Protection of Vulnerable Adults (POVA) and a copy of the procedures is available in the home. At the last inspection the manager confirmed that the local authority’s POVA (Protection of Vulnerable Adults) coordinator had visited the home and presented a training session for the staff on the local authority’s POVA procedures. However not all staff were present so further training has been organised for staff to attend over the next 9 months. Some staff confirmed that they attend training on challenging behaviour, however the manager confirmed that this does not include all staff. Considering that one of the service users occasionally displays challenging behaviour all staff must attend training in this area. 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 around 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. However the plans discussed at the last inspection to improve the environment in one service user’s rooms has not been addressed. Apart form this area the home is maintained to a high standard both externally and internally. An internal decoration programme has been developed recently and there are plans to decorate a service users bedroom and one of the bathrooms while two of the service users are on holiday. This is good planning and will reduce the inconvenience for those people. The carpets throughout the home have been professionally cleaned since the last inspection and as a result have brightened up all areas of the home. Newly bought items in the home include a dining table, fridge freezer, crockery, cutlery and kettle. The garden has been equipped with new garden furniture and seasonal plants.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 YES NO NO 4 X X X Standard met? 2 X X4 X X XBasraPage 26 At the last inspection the inspector was informed that due to the needs of one of the service users’ and in particular in relation to their extreme self harm behaviour there were plans to remove the washbasin in their room in order to provide a safer and more practical environment. The manager involved the Trust’s Health and Safety Executive with this issue who supported the plan. The regulatory body at the time also supported this change. Discussions also took place relating to how the furniture in the room could be rearranged to reduce the risk of self-harm during periods of challenging behaviours and to increase the person’s social awareness and social presence. The manager and staff discussed good ideas on how to make the room more attractive and stimulating for the service user. It was disappointing to find that no work had taken place to achieve these plans. The room does not meet the needs of the service user, is stark and uninviting and has an institutional look due to the thick foam protection that has been fixed to the wall with the aim of protecting the service user.BasraPage 27 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. 2 Key findings/Evidence Standard met? The standard of furnishings and fittings throughout the home apart from the bedroom mentioned in the previous standard continues to be of a good quality. Three of the bedrooms are equipped well with furniture and furnishings relevant to the needs of the service users. Here each person’s personality is reflected in the decoration of personal possessions in each room. Two of the service users have special beds related to their needs, one has recently been renewed and there are plans to renew the other in the near future. Both beds have bedrails which are integral to the design of the beds and their specifications. Although the service users do not use keys to their rooms there are locks on the doors and keys are available. Although staff have attempted to improve the look of the room as previously mentioned, in this report and previous reports, one of the bedrooms is poorly decorated and furnished. It has an institutional look and must be addressed. The service user spends most of the day in the room on the bed and it has been discussed with the manager and staff during this inspection and others how the room could be more effectively rearranged to meet their needs. It is strongly recommended that: • • • • • • Plans to remove the sink should go ahead. The bed should be moved into the corner where the sink is so that the service user can have a view into the main part of the home where daily activity takes place. The foam on the wall must be removed and replaced with less institutional protection, this may need to be a thinner and more discreet piece of covered foam. The room must be decorated to meet the standard set throughout other areas of the home. New furnishings should be purchased to meet the needs of the service user and to reflect their personality. Stimulating effects should be purchased in relation to the service users needs.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. 3 Key findings/Evidence Standard met? The number of toilets and bathrooms remain appropriate to the needs of the service users. There are two bathrooms equipped to meet the needs of the service users, one has overhead tracking and the other is a raised bath. There are plans to decorate and up date these areas.BasraPage 28 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. 3 Key findings/Evidence Standard met? The home is generally furnished to a good standard and offers spacious communal areas that are accessible to all service users. As stated previously there are plans to commence a re-decoration programme throughout the home. The dining area and kitchen were decorated prior to the previous inspection. The garden is well maintained, and attractively displayed with summer flowers and shrubs. New garden furniture offers accommodation to service users during the warm weather when barbecues are enjoyed. Furniture throughout meets the needs of the service users. Three service users have specially made chairs to accommodate their comfort and needs. A recent inspection from the environmental health officer proved to be positive there were no issues raised.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. 3 Key findings/Evidence Standard met? All of the necessary equipment is in place to meet the complex needs of the service users this includes overhead and a mobile hoists, special baths and beds. This equipment is serviced six monthly by a reputable firm.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. 3 Key findings/Evidence Standard met? As found during previous inspections the home has a high standard of cleanliness and was clean and free from any odours on the day. Someone is employed on a part time basis to address the domestic duties in the main areas of the home. Staff receive training related to infection control and the home has a contract with a clinical waste firm who empty the clinical bins weekly.BasraPage 29 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 on this occasion but will be addressed at the next inspection.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. 3 Key findings/Evidence Standard met? Over the past year there has been good progress in the percentage of staff qualified in NVQ 2 or above. Currently there is 64 percent of staff qualified, which is a good achievement. The manager stated that 3 of the remaining staff will be registering for the qualification this year. The staff observed on the day of the inspection demonstrated the appropriate skills and attitudes needed they appeared interested and motivated and interacted with the service users effectively.BasraPage 30 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 4 X X X 7 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 450 Nursing X X XXX3 Key findings/Evidence Standard met? In previous inspections it was identified that this home was failing to meet the required staffing levels to effectively meet the assessed needs of the service users. Since been the last inspection extra funding from Gateshead Social Services has been allocated to finance an extra member of staff to support the increased needs of an identified service user. This now means that the home can meet the identified required staffing ratio of at least three members of care staff on duty at all times. The manager stated that staffing was reviewed and increased appropriately above this number depending on the activities organised. This ratio must not be decreased at any time without consultation with the CSCI. As previously stated the staff appeared to have the skills and attitudes needed to work effectively with the service users. It was also evident that regular staff meeting take place where issues relating to the running of the home and the development of the service are discussed.BasraPage 31 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. 2 Key findings/Evidence Standard met? The home follows the Trust’s recruitment policies that are thorough and meet the requirements of this standard. However although the majority of the records required by regulation to be kept in the home were available, the employees’ application forms and references were not. These are kept at the Trust’s central office. As identified in Regulation 17(2) Northgate and Prudhoe Trust must meet this regulation by keeping all of the identified records in the home available to the inspecting officer.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’. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion but will be addressed at the next inspection.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion but will be addressed at the next inspectionBasraPage 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]. NO2 Key findings/Evidence Standard met? The manager has recently completed the A1/A2 Assessors Award and is progressing well through the Registered Managers Award. She is confident that this will be complete in early 2005. The manager who is now registered with the CSCI is also up to date with mandatory training and attends other training opportunities relevant to her role.Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Although there has been a high turnover of staff recently in this home the staff team appeared to work together well and showed interest and enthusiasm about their work. They showed relief that an extra member of staff had been allocated to the home and appeared positive about the future. There was a good atmosphere in the home and the manager appeared to interact with staff and service users openly and with respect.BasraPage 33 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. 3 Key findings/Evidence Standard met? The Quality Assurance System recently developed by the Trust is now in use and there were plans in place for the home to be visited by the Quality Assurance Monitoring Officer later in the week of the inspection. An annual plan, covering all aspects of the service and including how the needs of the service users were met, is available and identifies the review of the previous years goals and an action plan for 2004. A copy of this plan should be forwarded to the CSCI.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 on this occasion but will be addressed at the next inspection.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 those identified in Standard 34, were evident, up to date and satisfactory. Personal records were kept securely under lock and key, accessible to the service users and used in accordance to the Data Protection Act 1998.BasraPage 34 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 was evidence that the home’s safe working practices and risk assessments were up to date. The fire log and accident books were examined and were satisfactory, however all staff who work during the night must receive fire training every three months not six. Evidence of repairs and maintenance referrals, and dates when they were carried out, were documented in the appropriate records. A matrix demonstrating that staffs’ mandatory training is up to date was also evident.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 addressed on this occasion but will be addressed at the next inspection.BasraPage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateElsie Allnutt Jeannie Eschle-BellSignature Signature SignatureBasraPage 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 enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Basra Page 38 Amendments to the report were necessaryComments 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 accurate Note: 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 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 planYESOther: enter details here BasraPage 39 D.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of 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 of 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 - 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. 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