Inspection on 06/09/05 for Basra

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Basra 06/10/06

Basra 11/01/06

Basra 13/01/05

Basra 23/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

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

CARE HOME ADULTS 18-65 Basra Station Road Rowlands Gill Gateshead NE39 1JP Lead Inspector Eileen Hulse Unannounced 6 September 2005 at 9:00am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Basra Address Station Road Rowlands Gill Gateshead NE39 1JP 01207 545879 Not Known Not Known Northgate and Prudhoe NHS Trust Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Prospective Manager Mrs Donna Batey Care home only 4 Category(ies) of LD Learning disability (4) registration, with number PD Physical disability (4) of places LD(E) Learning dis - over 65 (2) PD(E) Physical dis - over 65 (2) Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13/1/05 Brief Description of the Service: Basra is a home run by Northgate and Prudhoe Trust, which provides residential care for four people who have learning and physical disabilities.The home is a large bungalow situated in Rowlands Gill in a quiet setting yet close to local shops and a variety of amenities. There are gardens to all sides of the bungalow that are accessible to all service users. Within one section of the garden is a gazebo, a sensory footpath and two solar water features that have recently been developed.The bungalow has been adapted to meet the needs of the people living there. There is an overhead tracking system, a raised bath and other relevant aids that enable and encourage comfort, safety, and independence.The home is staffed by home support workers, who support service users with their personal care and activities, and enablers, who solely enable service users to access activity outside the home.The activities available are varied and include short breaks away from the home. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 22nd June 2005 by one inspector (Eileen Hulse), it was un-announced and was carried out as part of the annual inspection programme. It took 7hrs to complete that included 1hr 30mins to prepare for the inspection. The focus of the inspection was to gain insight into the quality of life and services received by service users who live in the home. Time was spent chatting to service users and talking with the staff who were on duty and inspecting some records. The records included care plans, risk and needs assessments, medication, complaints and POVA policies and procedures and staff records. A tour was made of the premises accompanied by a member of staff. What the service does well: What has improved since the last inspection? A Manager has been appointed to Basra and staff commented that there was now some leadership within the home. In discussions with the staff on duty, the following comments were made: ‘We have a fair and approachable Manager’ ‘The Manager likes staff to take the initiative’ ‘I have worked in several areas but I enjoy working here’ Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Good assessments are in place for all service users that help to form the basis of their care plan to ensure that all care needs are met on a day-to-day basis. EVIDENCE: Assessments within the plans of care show that annual reviews are held for each service user living in the home. The assessment plan is reviewed and kept up to date with any changes that are necessary and details how other professionals are involved in the service user’s care, the reason for the referral and how staff can support individuals with changing aspects of their care. This ensures that the Manager and staff are aware of the changes and care plans will reflect this to ensure all care needs are addressed. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 The care plans are comprehensive, detailed and give specific information about service users as individuals and include good risk management plans. EVIDENCE: The care plans follow the ‘Person Centred Planning Approach’ and include information that ensures the needs of the service users are identified in detail in both personal and social care. Guidance for staff is informative and easy for them to follow that ensures a complete programme of care to service users. Staff appear to be knowledgeable about the service users and it was evident there is a good rapport between staff and service users. The service users have complex needs including no speech, and the communication links that have been developed helps to effectively communicate their needs and choices to staff through facial expression and body gestures and through these individual ways of communication, this enables the home to provide a good quality of care. Detailed risk assessments are held within the individual care plans. One service user has been re-assessed by an occupational therapist regarding the need to have bedrails in place. The risk management plan is written in detail and Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 10 includes, the reason for their use, the harm that can occur and the action to be taken by staff to minimise the risks and keep the service user safe. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 17 Service users are well integrated within the local community and use many of the local and leisure facilities to ensure they are involved in appropriate facilities of their choice. Menus show that service users are offered nutritious and well balanced meals. Due to the complex needs of service users, they are supported and guided by staff in choosing what they would like for their meals. EVIDENCE: Records and discussions with the staff on duty evidenced that service users lead active lives. Documents evidenced service users visit Disco’s at Washington and Clara Vale, the multi sensory room at Gateshead Leisure Centre, and enjoy outings in the home’s own adapted vehicle. During the inspection, a visit was made from a man who visits the home every week to sing and to work with the service users playing musical instruments. This was clearly enjoyed by all. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 12 All service users have enjoyed a summer holiday. One service user had just returned home from a holiday at Haggerston Castle and plans were underway to organise another holiday in the coming weeks. The Inspector shared a lunchtime meal with the service users and it was likened to that of a large family with the meal prepared by staff, as service users are not able to help in this area. The lunchtime snack meal consisted of cold meat, sandwiches and crisps with one service user having an alternative of shepherd’s pie. Service users dietary needs are assessed regularly and recorded in the plans of care and weights are monitored and also recorded every week. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 The staff team have been trained in the use of the specialist equipment used within the home. Records evidenced a number of specialist professionals are currently accessed and used by service users that include, physiotherapist, an occupational therapist and a podiatrist visits the home. EVIDENCE: All moving and handling techniques are detailed in the service users individual plans of care with records well maintained and up to date risk assessments in place that helps to protect service users by ensuring safe working practice at all times. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a file with records relating to complaints or concerns made to the home. However, this information needs to be updated and reviewed and all of the staff team require training on complaints and POVA. The home has no policy or procedure for dealing with an abuse situation. EVIDENCE: All complaints that have been made to the home are held on file that also includes a monitoring sheet that is reviewed and signed on a monthly basis by the home Manager and the Locality Manager. However, the records also show that when a complaint is made it details a number of areas such as: whom the complaint was made by and a date by which a response must be given but it does not state what the complaint was about. The complaints procedure is detailed and gives good guidance for the staff to follow. However, during discussions with the senior member of staff on duty, they were unable to state how they would deal with a complaint and were not aware of any policy or procedures on the protection of vulnerable adults. All staff must have complaints training and POVA training should they receive a complaint while on duty or a POVA issue arises so that service users are protected at all times Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 26 Overall the building was noted to be clean, well furnished and generally well decorated. EVIDENCE: Service users bedrooms are personalised to suite individual tastes and the communal areas of the home are comfortable with no offensive odours, making it comfortable and homely for the people who live there. However, the two large front windows of the home must have the wood frames replaced as the wood is rotting. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 34 Whilst the home had adequate numbers of staff on duty they lacked sufficient experience to be able to manage the home competently leaving service users unsupported by qualified staff. Staff recruitment and training records were unavailable for inspection, therefore, it is not known if the home has achieved 50 of staff holding a qualification. EVIDENCE: There were three members of staff on duty, one member of staff has been employed in the home for 14 weeks, one member of staff for 6 weeks and another for only three weeks. Staff were unable to locate various records that were requested or to state what they would do in various situations such as what they would do if someone made a complaint to the home or an abuse situation took place. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,41 and 42 There is a prospective Manager who has been in post since April 2005. All of the records required by regulation were evident but they were not up to date and poorly maintained, therefore they do not ensure the health and safety of service users and staff. EVIDENCE: The Manager must now make an application to the Commission for Social Care Inspection to become the Registered Manager as a matter of urgency. The current method used to record accidents was not compliant with the Data Protection Act and was poorly recorded and maintained. Previously recorded accident entries 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. The accident records showed that the last four accidents recorded remained on the duplicate copy log and had not been sent to the appropriate departments within the organisation or that the appropriate staff guidance had been followed. The accident recording book is Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 18 bulky with eight pages attached to each entry and not all of the entries were completed in full. This kind of recording does not comply with the Data Protection Act. Staff fire training and instruction has not been completed since May 2005. According to the fire records, the member of staff in charge during the inspection had not received any fire training since being employed by the home. The member of staff stated she had received this training but there was no evidence to support this. Fire alarms and fire fighting equipment has not been tested since the 13 and 15 of August 2005 and must be tested on a weekly basis. An immediate action report was given to the person in charge to ensure this issue was addressed immediately. Outside of the back door, there were many items lying around the paths that were tripping hazards particularly to one service user who spent most of the day walking in the surrounding gardens. Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 1 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x x x 3 Standard No 31 32 33 34 35 36 Score x 1 2 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Basra Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 1 x x x 1 1 x B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA22 Regulation 22 Requirement Records must detail the content of the complaint and the staff team must have training in relation to complaints POVA procedures must be made available to staff and the staff team must have POVA training A door guard or self closing device must be fitted to the laundry door. The two large window frames at the front of the house must be replaced The planned adaption to a service users bedroom must be carried out Staff left in charge must competant and qualified to carry out thid duty The training files for staff must be accessible at Inspection Recruitment policies and procedure and staff files must be available for Inspection The prospective manager must apply to the CSCI to be registered The method used to record accidents must comply with the Data Protection Act Fire training and instruction must B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Timescale for action 1 Jan 2006 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Basra YA23 YA24 YA24 YA26 YA32 YA33 YA34 YA37 YA41 YA42 10 23 23 16 18 18 19 9 17 13 1 Jan 2006 Immediatel y 1 Jan 2006 1 Jan 2006 Immediatel y Immediatel y Immediatel y Immediatel y Immediatel y Immediatel Page 21 Version 1.40 12. YA42 13 13. YA42 13 be carried out at times as stated in the firelog book Fire alarms and fire fighting equipment must be tested on a weekly basis in line with the fire log book Staff must be made aware of all health & safety aspects in the home y Immediatel y Immediatel y RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA7 YA24 Good Practice Recommendations The plans that have been made to access the services of an advocate for an identified service user should be followed up A previous assessment to remove the sink in one of the bedrooms should be addressed Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Baltic House Port of Tyne, Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Basra B52 B02 S7381 Basra V220093 10 Aug 2005 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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