Inspection on 12/09/06 for Calvert Trust Kielder

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Calvert Trust Kielder 16/10/08

Calvert Trust Kielder 17/10/07

Calvert Trust Kielder 08/02/06

Calvert Trust Kielder 17/11/05

Calvert Trust Kielder 15/02/05

Calvert Trust Kielder 24/08/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Calvert Trust Kielder Kielder Water Hexham Northumberland NE48 1BS Lead Inspector Alan Baxter Key Unannounced Inspection 12th September 2006 10:20 Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Calvert Trust Kielder Address Kielder Water Hexham Northumberland NE48 1BS 01434-250232 01434-250015 enquiries@calvert-kielder.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Calvert Trust Mr K G Appleby Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All residents may also have a physical disability Waking night staff will be provided in the event of the admission of any service user assessed by yourselves as likely to be unable to independently summon help or whose care needs may indicate that assistance will be needed. Residents may also be over the age of 65 3. Date of last inspection 8th February 2006 Brief Description of the Service: Calvert Trust Kielder provides holiday accommodation and activities specifically for people with disabilities. Service users who are called guests usually stay for one week though occasionally two or three. The site is remote and rural on the edge of Kielder reservoir and as such is ideally placed for sports and activities. As well as the residential accommodation there are a number of chalets providing holiday accommodation for families and groups of children. This enables the service users to socialise with people of similar and different abilities. Some of the site areas are communal such as dining areas and social rooms. The weekly fees are £735 to £805, depending on the season. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home. It took place in September 2006. The inspection took nearly seven hours. Team Leader Sally Hemingbrough represented the Trust, as the Registered Manager, Kevin Appleby, was on annual leave. The Trust looks upon those who use its service as being the ‘guests’ of the Trust, and that is the description that will be used in this report. Time was spent looking at guests’ care records and other relevant documentation, such as policies, risk assessments, quality assurance systems and staff training records. The building was partly toured. A meal was taken in the dining room. At the end of the day, the inspector joined guests for an archery session, one of the many activities on offer to guests. Guests and staff were engaged in conversation, and asked their opinions. Interactions between staff and guests were observed. One comment card was returned from a guest. This person summed up her experience at the Trust as “Next best thing to Paradise.” What the service does well: The Trust carries out good assessments of guests’ needs, to make sure that it can meet those needs. Once accepted, guests are encouraged to be as independent as possible, to make decisions, and to exercise choice as to how they spend their time at the Trust. Guests are treated as responsible adults and are offered a wide range stimulating and appropriate activities, most with an emphasis on physical activity. Risks to guests are carefully assessed, but guests are supported in taking reasonable risks. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 6 Most of the guests are regular users of this service. Those spoken with said that they really look forward to their stays at the Trust. Guests said that the staff listen to them, that they are treated with respect by the staff at all times, and that their rights are respected. This was confirmed by observation during the day. There are enough staff to meet the needs of the guests. There is a very good level of staff training, and guests are protected from abuse. Personal care is well documented and includes the wishes of the guests and/or their carers. Physical and emotional health needs are properly assessed and met, with the excellent assistance of the attached District Nurses. The accommodation for guests is homely, spacious, safe, clean and hygienic. The Trust was able to demonstrate that it welcomes the inspection process, and responds positively and pro-actively to the requirements and recommendations of such inspections. What has improved since the last inspection? 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. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The needs and wishes of guests are assessed and recorded. EVIDENCE: Care records showed that the Trust will only take a guest when an application form has been received, listing the person’s needs regarding medical conditions; diet; allergies; mobility; communication; nursing inputs; additional care inputs; support with personal care; medications; and behavioural problems. Only in an emergency would a guest may be accepted without this information. As the same information is requested each time a guest applies for a stay, there is sometimes reluctance by the person or family carer to repeat this exercise, and staff will accept a verbal instruction that there is “no change” since the previous referral. This is recorded, with date and signature, on the previous application form. The application form also asks the referrer to provide any other relevant information or existing care plans, and some very detailed and informative examples of this were seen. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The assessed needs of each guest are now being met in more detailed care plans than previously. Guests are encouraged to make decisions about their actions and activities during their stay at the Trust. Guests are encouraged to be as independent as possible and are supported to take reasonable risks at the Trust. EVIDENCE: Care plans were examined. As discussed in previous inspection reports, the short-term nature of the respite service offered has lead to an acceptance that care plans will be more basic than those expected for long term care. Nevertheless, significant improvements have been made in clearly describing the personal care needs of guests. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 10 The Trust is now developing care plans to a standard that would allow a member of staff unfamiliar with a guest to be able to give the required care in a manner acceptable to and stipulated by that guest. The majority of guests are ‘repeat bookings’ and are well known to the staff. In this situation, the staff review the care plans from previous stays, update as necessary, and a senior carer signs and dates that it is still relevant. In other instances, the Trust’s pre-admission request for all relevant information from referrers has yielded some good quality care plans from referring homes/agencies; and some very detailed descriptions of the care the guest needs, from family carers. Anecdotal evidence was given of one guest who drew up her own plan of care. In the small number of referrals where none of the above applies (and especially with new referrals), the Trust has now speeded up its drawing up of care plans, with no care plan taking more than 48 hours to be completed for a new guest. This is a much-improved situation. However, as the Trust often receives referrals, with completed assessment documentation, many weeks in advance, it should now consider whether or not it could be drawing up care plans in advance, to relieve the ‘logjam’ of drawing up new care plans in that first 48 hour period. It was a requirement of the last inspection report that care plans must identify moving and handling risk assessments with enough detail to guide staff. This has been implemented, and was described as now giving good prompts to staff. In addition, an ‘activity risk assessment’ has also been introduced, and this gives a much better overview than previously. All care staff are involved in care planning. This is good practice. Guests confirmed that they are encouraged to make their own decisions about their stay at the Trust. Examples given were guests’ decisions about when they want to rise and retire (including having a ‘lie-in’ in the morning, if they so wished); and what activities (if any) they wish to join in. Staff were seen to respect guests’ choices, and to listen carefully to their wishes. Guests’ rights to make their own decisions are limited only through the assessment process, which includes consultation with the guest, and any restrictions are recorded in the guest’s care plan. An example seen was the limitation of a guest’s alcohol intake, for agreed medical reasons. Appropriately detailed general and environmental risk assessments are in place. The senior activities leader has drawn up extensive risk assessments Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 11 about activities and equipment, and gives a safety talk to the guests before each activity starts. It was a requirement of the last inspection report that care plans must identify moving and handling risk assessments with enough detail to guide staff. This has been implemented, and was described as now giving good prompts to staff. In addition, an individual ‘activity risk assessment’ has also been introduced, and this gives a much better overview than previously. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Guests are able to take part activities suitable to their age and abilities. Given the short-stay nature of the service provided, guests do not have much opportunity to become part of the local community. Guests are offered an excellent range of activities during their stay. Guests accept some limitations to their relationships, due to the short-stay nature of the service provided. Staff respect the rights of the guests at all times. Guests have a healthy and nutritious diet at the Trust. They have a good degree of choice and said they enjoy the food. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 13 EVIDENCE: Guests are able to take part in, peer and culturally appropriate activities at the Trust. The stated purpose of the Trust is to offer short-term activities-based holidays and so there is no emphasis on educational and employment opportunities. Again, as the guests have chosen to come for the activities offered at the Trust, there is only very limited opportunity to take any meaningful part in the local community The Trust specialises in providing activities for people with physical, learning or sensory disabilities. There is a focus on providing outdoor activities, with fully trained staff to assist and support guests. Activities offered include climbing, abseiling, zip wire, orienteering, archery, golf buggies and an adventure course, which is planned to expand. Located close to Kielder Water, the Trust can also offer a wide range of water sports, such as sailing, canoeing, motor cruising and kayaking. There are also good indoor facilities, with a hydrotherapy swimming pool, sports hall, and a wide range of imaginative activities, including arts and crafts, available to guests. There are ‘themed’ weeks, examples of which include Irish, Scottish, Halloween, Medieval, Sci-Fi, Country & Western and Pirate weeks. There is a team of experienced, skilled activities staff who work with the support of the care staff. Specialist equipment is in place to allow guests the fullest possible access to the activity facilities, subject to risk assessment. Overall, the provision of activities well exceeds the requirements of this standard, and is highly commended (as is the fact that guests are not obliged to do any activity, should they so choose). Usually, guests are seeking a break from family and/or normal carers when they come to the Trust. Therefore, there is obviously less emphasis on maintaining links with families and friends than there would be in a long-stay home. The Trust is also very aware of the responsibility it has for the protection of its guests while they are with them. Therefore, intimate relationships are discouraged between guests during their short stay at the Trust, and there is a Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 14 house rule that guests do not go into each other’s rooms (this will be specified in the Statement of Purpose and the Service User guide, it was agreed). Exceptions would be made where there is an established relationship between two guests and where the involved social workers confirm that there has been a positive assessment of mental capacity for both parties. Staff were seen to demonstrate their respect for the guests and their rights in their interactions with them. Staff knocked on doors and asked guests’ permission before entering bedrooms; spoke quietly and respectfully to guests; and listened carefully to their views. Staff communication skills appeared to be very good. Guests spoken with confirmed that they are treated with respect by all the staff. Care plans also demonstrated that staff value their guests and take their rights seriously. Where there were restrictions placed on any behaviour such as smoking or drinking, such restrictions were agreed with the guest in advance, recorded in the care plan, and were clearly based on good practice. Dietary needs are assessed as part of the pre-admission assessment. A copy of any special dietary needs/wishes is kept in the kitchen. The menu was examined. There is a wide range of choice available, and the menu seemed well balanced and nutritious. Lunch was taken in the dining area. Soup was available, as was a cold meat bar and a salad bar, with a light hot course. Staff were seen to interact well with guests, giving sensitive assistance with feeding, where required. The main meal is the evening meal, with choice of two contrasting hot dishes, plus a daily vegetarian option. There is a good range of vegetables served, and fruit is always available. One guest said that the food was home cooked, healthy, gave good choice and was good quality. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Guests are given personal care and support in the ways that they would wish. Their emotional and physical needs are met. Guests may take responsibility for their medication, if they are able to do so. Otherwise, staff protect the guests by their careful storage and administration of their medicines, but should check the accuracy of the medication list that comes with the guest. EVIDENCE: The Trust’s policies and the service user guide stress the need to provide an individualised service that is informed by each guest’s needs and wishes. This is apparent in the assessment record and in the care plans drawn up to meet guests’ needs, and was also confirmed by those guests spoken with. The assessment record records any preference for male/female staff to give personal care. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 16 Examples were given of guests who request “their room” when booking, and of guests who request how their room should be set out. Staff demonstrated that they respect guests’ privacy throughout the inspection. Staff appeared sensitive to the dynamics between individual guests and staff, and respond appropriately to the expressed and implied preferences of guests to particular carers. There was documentary, anecdotal and observational evidence of guests being given choice in all areas of daily living. There is a comprehensive range of equipment in place to ensure the best practices in moving and handling of guests (including ceiling tracking); technical aids, such as alarm calls, deaf fire alarms; and automatic doors, ramps, etc., for ease of access. Health and emotional needs are also part of the initial, pre-service assessment, and the Trust is very well supported by its local nurse specialists, and other health therapists, ensuring that any nursing needs are fully met. Staff receive specialist training, where appropriate. This year this has included understanding catheter and stoma care, Diabetes awareness, and a talk by an Infection Control nurse. All care staff receive such training. This is good practice. As noted in standard six, above, the trust now carries out individual moving and handling risk assessments. It was a requirement of the last inspection report that the following medication requirements must be addressed; - Record fridge temperatures once a day when medication is refridgerated. - Produce procedures for the use of gasses (oxygen) - obtain specific directions for ‘as directed’ ‘when required’ medication. All these have been carried out. Fridge temperatures are recorded, a policy has been drawn up regarding gasses, and specific instructions are now obtained and entered on the medication record. Guests are asked on admission if they wish to be responsible for keeping and taking their own medicines. If they request this, then a risk assessment will be carried. Staff would keep a discrete eye on any guest who was selfmedicating. It was a recommendation of the last inspection report that the Trust provides photographs for guest identity for medication administration. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 17 This was being implemented, but has recently lapsed, due to the camera being mislaid. The Medicine Administration Record (MAR) was studied. The information held on different guests varied. Some came with a GP/Chemist ‘print-out’ of their medicines (one example of which was some months out-of-date); others with just a handwritten list. The source and accuracy of such lists are not always clear, and a clearer record is advised (for example, a written entry such as “Medications confirmed with parent/carer by phone”, signed and dated). REQ Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Guests confirmed that their views are listened to, and are acted upon, but some comments made in the feedback book had not been responded to. Guests are protected from abuse, neglect and self-harm. EVIDENCE: Throughout the inspection, it was observed that staff listen carefully to the guests’ views and opinions; give choices; and respond to the guests’ decisions. This was confirmed in conversations with the guests. No formal complaints have been received or logged in the past year. A ‘feedback book’ is available to guests, to record their experiences and degree of satisfaction with the service being offered. This contained lots of extremely positive feedback about the staff and about the activities. It also contained a couple of negative comments. There was no evidence that these comments had been followed up. A system to do this must be introduced. (See also standard 39, Quality Assurance, below.) The Trust is aware of its obligations to report any allegations of abuse. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 19 Its ‘Adult Protection’ procedures are up to date and reflect current best practice. There is a simple, clear flow chart for staff to follow, in conjunction with Northumberland County Council ‘Practice Guidance for the Protection and Empowerment of Vulnerable Adults’. All established staff have received ‘Protection of Vulnerable Adults’ (POVA) training. In addition, the Team Leader and the Director of Operations have attended a more advanced ‘train the trainer’ course on how to respond to allegations of abuse. As a result of this, they are developing an in-house POVA course, specifically tailored for their work with adults with learning difficulties. This is good practice. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Guests are provided with a pleasant, comfortable, well-equipped and safe environment. All facilities seen were clean and hygienic. EVIDENCE: The buildings and indoor facilities were toured. Bedrooms are well furnished and pleasantly decorated. Some also reflected the personality of the guest currently in residence. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 21 Communal areas are similarly well appointed, with comfortable seating and a bar that opens in the evenings. Environmental risk assessments are thorough and up to date. All facilities seen were clean and hygienic. The quality of the water in the hydrotherapy swimming pool is checked several times each day. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Guests benefit from having a competent, experienced and qualified staff team. There are sufficient staff to meet the needs of the guests. Guests are supported and protected by the Trust’s recruitment policy and practices. The needs of the guests are met by appropriately trained staff. EVIDENCE: One guest said that the carers are “…experienced, trained, untiring, patient, kind and fun”. It was a recommendation of the last inspection report that 50 of care staff should obtain National Vocational Qualification (NVQ) level two or equivalent. This has been implemented. Seven of the nine care staff now hold NVQ level three, rather than level two. This exceeds the requirements of this standard and is commended. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 23 The staff rosters were studied. Staffing levels vary with the dependency levels of each group of guests, but are always enough to meet the needs of the guests. More staff are on at the busiest times of day. The Trust has robust policies and practices in the area of staff recruitment. Two written references are always obtained for new staff; proof of identity and a recent photograph is kept on each staff member’s personnel file; and criminal record checks and POVA list checks are available for inspection. The Trust has a commendable commitment to staff training. There is a training and development plan, for which team leader Sally Hemingbrough is the designated person, and each staff member has had an individual training and development assessment. There is an appropriate training budget. Staff training this year has focussed on staff achieving the National Vocational Qualification (NVQ) in care. The minimum standard requires NVQ level two, but seven of the nine care staff now hold NVQ level three, which is good practice. Mandatory training is given to new staff as part of their induction process. The Trust is currently looking to tailor training even more specifically to its client-group. To this end, it is negotiating with Businesslink, a funding organisation, and with Future Strategies, a training company, to design its own course, based on the Learning Disability Award Framework (LDAF). Again, good practice. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Guests benefit from a well-run organisation. The Trust is developing quality assurance systems to make sure that the views of guests are used to improve the service being given. The health, safety and welfare of guests is promoted and protected. EVIDENCE: The Registered Manager has 21 years experience in care, 7 of which are in management. Mr Appleby has 2 degrees in Human Organization and Psychology. He has a Post Graduate in Human Resources Management and a Diploma in Senior Management. He is voluntarily undertaking the Registered Managers Award (RMA) to support his Team Leader complete her RMA. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 25 The Trust has worked with Aberdeen University to provide it with an Outcome Monitoring System to ensure that the service provided is appropriate, and is being reviewed and developed. All respite users are asked to complete a twosided questionnaire, covering areas such as daytime and evening activities, personal development, interactions with staff, food and the environment. This project is ongoing, and the overall figures are still being collated. It was agreed that the outcomes would be published each year in an updated service user guide. However, there was documentary evidence that staff are already responding promptly to negative comments and to positive suggestions from guests. The Trust has informal systems in place, such as daily verbal checks of guests’ satisfaction and a ‘Feedback’ Book, which is available to guests to record their experiences and degree of satisfaction with the service on offer. As noted in Standard 22, above, there should be an acknowledgement and follow-up of any issues raised in this book. Guests are able to e-mail the Trust with comments following their visit. It was agreed that a copy of the annual development plan (unavailable on the day of inspection) would be sent to the CSCI. It was a requirement of the last inspection report that the Trust provides thermometers in bathrooms to test the hot water temperatures each time a person bathes and record; and that a record must be made of emergency lights being checked monthly. These have been carried out. It was a further requirement of that report that the Trust must provide CSCI with an electrical wiring certifcate. This has not been carried out, and this requirement is repeated in this report. Servicing and maintenance documentation was seen to be in place. The fire logbook was studied. All the required checks and tests of equipment were recorded as having taken place at the required intervals, as was the inhouse staff fire safety training. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 26 Risk assessments have been extended to each individual guest, as well as cover equipment, activities and environment, and staff are given annual refresher courses in moving and handling, fire safety, infection control, food handling, first aid and safe working practices. This is good practice. The Trust’s accident book showed that there are relatively high levels of accidents, reflecting the ‘hands-on’, activity- based ethos of the Trust. Accident recording is reasonably detailed, but should include ‘follow-up’ entries by a senior staff member. There is a quarterly analysis of accidents. Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 N/A 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 28 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 YA20 Regulation 13(2) Requirement The accuracy of the list of medicines that comes with guests must be checked. Complaints recorded in the ‘Feedback’ book must be investigated and responded to. The Trust must provide CSCI with an electrical wiring certificate. (This requirement is outstanding from 30/06/06) Timescale for action 12/10/06 2. YA22 22(4) 12/10/06 3. YA42 23(2) 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations Provide photographs for guest identity for medication administration Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Calvert Trust Kielder DS0000000602.V296373.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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