Inspection on 17/10/07 for Calvert Trust Kielder

This inspection was carried out on 17th October 2007.

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 no outstanding requirements from the previous inspection report, but made 2 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 12/09/06

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 17 and 30 October 2007 10:00 Calvert Trust Kielder DS0000000602.V346564.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.V346564.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.V346564.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 teamleader@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.V346564.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 12th September 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 £805 to £875, depending on the season. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 12 September 2006. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 17 and 30 October 2007. During the visit we: • • • • • • Talked with people who use the service, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. What the service does well: The Trust carries out good assessments of guests’ needs, to make sure that it can meet those needs. Guests are encouraged to be as independent as possible, to make decisions, and to choose how they spend their time at the Trust. Guests are offered a wide range stimulating and appropriate activities, with an emphasis on physical activity. Any risks to guests during their stay are carefully assessed, but guests are treated as responsible adults and supported in taking reasonable risks. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 6 Many 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. There are enough staff to meet the needs of the guests. There is a very good level of staff training. Guests are protected from abuse by the Trust’s policies and procedures and by the quality of the staff training programme. 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. It has a genuine commitment to steadily improving the service it provides to its guests. What has improved since the last inspection? An area of the ground floor communal area has been fitted out and furnished as a ‘quiet lounge’. Improvements to the activity facilities include the introduction of a sailing week and of two new activities, the king swing and a ‘low ropes’ course. A climbing wall is currently being built, and will be operational in the new year. More guests are becoming involved in describing the ways in which they want their personal care to be given by staff. All the requirements and recommendations made in the last inspection report have been carried out by the Trust. Better checks have been introduced to make sure that the lists of medications brought in by guests are accurate. The Trust has also brought in a system of photographic identification to make sure that the guests get their own medications, and that no mistakes are made. The Trust has introduced a system to show that it is responding positively to any concerns expressed by guests in any of the ‘feedback’ systems that are in place. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 7 The Trust has clarified the ‘flow-chart’ it has devised to show staff how to report any allegations of abuse. 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. The summary of this inspection report can be made available in other formats on request. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 8 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.V346564.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. The needs and wishes of guests are carefully assessed and recorded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Assessment of Needs: 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. (An emergency admission had been taken the previous week, being admitted within 48 hours of referral: a good range of basic information was in place, and care plans were in the process of being drawn up.) Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 10 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. Where this is the case, staff will accept a clear verbal instruction that there is “no change” since the previous referral. This is recorded, with date and signature, on the previous application form. There was also evidence of existing assessments being updated, where appropriate. 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. The Trust is adding a ‘Frequently Asked Questions’ information sheet to the information pack it sends out to guests. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good quality outcomes in this area. The Trust draws up care plans to meet the assessed needs of its guests, and wherever possible, includes the particular wishes and choices of each guest in their own care plan. 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. We have made this judgment using a range of evidence, including a visit to this service. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care Plans: 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. The Trust is still 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. Where necessary, the care plan is updated. In one example seen, however, there had been numerous amendments at various parts of the plan, with the result that the plan was no longer clear and easily assimilated. In such cases, the care plan must be redrawn to reflect only the current situation. 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. There was evidence of an increase in the involvement of guests in drawing up care plans for their own care over the past year. Examples were seen of very detailed and highly personalised care plans drawn up by guests themselves. The Trust hopes to gain better funding, to allow more administrative time to be committed to drawing up care plans. In the small number of referrals where none of the above applies (and especially with new referrals), the Trust now draws up care plans within 48 hours of admission. However, as the Trust often receives referrals, with completed assessment documentation, many weeks in advance, it was recommended that 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. This has been carried out to the extent that the basics of the care plan are now drawn up in advance, although some areas such as moving and handling needs can only be assessed in situ. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 13 Although the quality of care planning continues to improve, the Trust must be alert to situations where a guest may have an unusually complex and/or dangerous medical condition that requires more detailed care planning than is the accepted norm at the Trust. An example of this was discussed with the care manager. Independence and Decision-making: There was ample evidence throughout the assessments and care plans that guests are actively encouraged to be as independent as possible, and to make their own decisions. Some guests give very detailed written and/or verbal instructions to the care staff. A typical example was the written request by one guest for staff, after knocking on the bedroom door, to wait for permission to enter. Other examples of independent decision-making given by guests included choice of bedroom; the way the room is laid out and equipped (e.g. for a lefthanded guest); whether or not to join in any activity; choice of meals; and when to rise and retire. There was also evidence that the Trust is aware of, and takes seriously, its obligations regarding equality and diversity. An example of this is the widespread use of ‘WIDJIT’ sign language around the communal areas, giving key information to guests regarding fire precautions, routines, activities etc. The Trust is considering its training needs in this important area. Independence and Risk-taking: Whilst the emphasis is on the guests enjoying themselves and accessing the widest range of equipment and activities possible at the Trust, there is a careful assessment of the various risks that they may be exposed to. General risk assessments and a risk management summary are in place, as are assessments of risks from the use of equipment, and moving and handling risks. There is also a brief pressure area assessment. External activities are separately regulated and inspected by the appropriate bodies, such as the Royal Yacht Association Training Centre. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. People who use the service experience good quality outcomes in this area. Guests are able to take part activities suitable to their age and abilities. Being limited by the short-stay nature of the service provided, guests do not have much opportunity to become part of the local community. They may, if they choose, access local shopping and leisure opportunities. Guests are offered an excellent range of enjoyable and stimulating 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.V346564.R01.S.doc Version 5.2 Page 15 This judgement has been made using available evidence including a visit to this service. EVIDENCE: Age-, Peer- and Culturally-appropriate Activities: Guests are able to take part in activities appropriate to their age, peer group, and cultural background at the Trust. However, as the stated purpose of the Trust is to offer short-term activities-based holidays, there is obviously no emphasis on educational and employment opportunities. Guests are able to use the licensed bar at the Trust. There is also a cigarette machine, because of the distance of the Trust from the most local shops. The application form is currently being updated to request and record information on religious and cultural needs. Involvement in Local Community: As guests have chosen to come for the activities offered at the Trust, there is only limited opportunity to take any meaningful part in the local community. However, where opportunities such as local farmers’ shows and festivals are available, guests are encouraged and supported to take part. Shopping trips are also organised, where there is demand for such a service. The Trust has also started to take advantage of local and national agencies ie, the National Parks, Northumbria Wildlife Trust and other local experts. These Trusts provide environmentally based talks, to enhance the service we provide. These are sometimes done in an evening or part of wider projects, ie BBC ‘Springwatch’ programme. Leisure Activities: 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, Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 16 abseiling, zip wire, orienteering, archery, golf buggies and an adventure course, which is planned to expand. Located close to Kielder Water, the Trust also offers 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, Pamper 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). Since the last inspection, the Trust has introduced a sailing week for people with a specific interest in developing skills in this area. Also, two new activities have been introduced, the king swing and a low ropes course, which have added new interest to the programme of activities. An indoor climbing wall is currently being built and should be in place by the new year. Personal, Family and Sexual Relationships: Usually, guests are seeking a break from family and/or normal carers when they come to the Trust. Therefore, there is 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 house rule that guests do not go into each other’s rooms (this must be specified in the Statement of Purpose and the Service User guide). Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 17 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. Guests’ Rights and Responsibilities: The independence of the Trust’s guests and their right to make choices as to how they spend their time are supported by the staff at all times. No one is forced or pressured to join in any activity. Guests may choose when they get up and go to bed, have keys to their rooms and lockable storage within their rooms. They have unrestricted access to all communal areas of the building (subject to risk assessment) Staff knock before entering bedrooms; address guests by their preferred name or title; and give any mail to a guest unopened. They were seen to be relaxed with the guests and to treat them with respect. Diet and Meals: The Trust operates a four-week menu that offers choice for every meal, and alternative dishes on request. A cooked breakfast is available every morning. Hot and cold drinks and light snacks are available throughout the day. Guests spoke highly of the catering, confirming its good quality and the degree of choice. An enjoyable meal was taken in the dining room with the guests. Staff were seen to be attentive to the needs of guests, and to meet those needs in a sensitive and patient manner. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. Guests are given personal care and support in the ways that they would wish. Their emotional and physical needs are understood and met. Guests may take responsibility for their medication, if they are able to do so. Otherwise, staff protect the guests by the careful storage and administration of their medicines. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal Support: The Trusts policies and the service user guide stress the need to provide individualised service that is informed by each guests needs and wishes. The care plans record any preference for male/female staff to give personal care. The care plan also has a section to include a person’s room preference Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 19 and the ability for them to request a room and choose its layout (one guest has given staff a photograph of how he wishes his room to be prepared). There is a comprehensive range of equipment in place to ensure best practice in moving and handling of guests; technical aids, such as alarm calls, deaf fire alarms; automatic doors, ramps etc. Staff receive specialist training (see standard 35, below). Guests, parents and carers may submit written guidance on how they wish their care to be given, when staying at the Trust, and this information is kept on file. Detailed examples of such directions were seen. Physical and Emotional Needs: The assessment process includes asking for details of any medical conditions or disabilities, allergies and/or sensitivities, sensory impairments etc. It also contains a section identifying any nursing needs, as such input is provided only by District Nurses from local practices, and their input needs to be booked well in advance. Study of a sample of guests’ care records showed that their physical and emotional care needs had been identified and met within the Trust. A new ceiling track hoist has been installed in one of the respite care rooms. New pool hoist trolleys have been purchased, and a special reclining shower chair is planned. A new bath has been installed in another respite care bedroom, with en-suite facilities replacing the current bath. The Trust has succesfully raised funds for a pressure relief matteress. Other equipment has been updated and replaced, profiling beds and matteresses, and a mobile hoist. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 20 Medications: It was a requirement of the last inspection report that the accuracy of the list of medicines that comes with guests must be checked. This has now been carried out. 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, in conjunction with family and/or carers, where appropriate. Staff keep a discrete eye on any guest who was self-medicating. It was noted that the Trust has agreed with the district nurses to have an annual meeting about any communication issues and procedures it needs to consider in its work with the district nursing services. The first meeting was in January this year. Ongoing communications happen as a matter of course for individuals but this has allowed more general conversations about service delivery. It was a recommendation of the last report that photographs should be obtained to help identification of guests when administering medicines. This has been carried out. The Trust has developed a medication sheet that incorporates a digital photograph onto it and more detailed explanations being sort from carers/families when required. Examples were seen. The Medication Administration Records (MAR) are completed using information sent in with the guest’s application form. Quantities of medicines received are signed in by to staff, for safety. A list of staff names amd initials used in the MAR is being drawn up, to assist in auditting of medicines. Handwritten entries by staff are signed and dated. Any ‘Controlled Drugs’ are properly stored and recorded. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. Guests’ views are valued by the Trust, and are listened to and acted upon. Guests are encouraged to say how they wish their care to be given. Guests are protected by the Trust’s policies and procedures on keeping guests safe, and by appropriate staff training in this important area. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Service Users’ Views: It was a requirement of the last inspection report that complaints recorded in the ‘Feedback’ book must be investigated and responded to. This has been carried out. Documentary evidence of responses to ‘feedback’ complaints was found in minutes of team meetings. It was agreed that a more central focus for such recordings be introduced. There has been some limited involvement by some guests in informally interviewing potential new workers. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 22 Feedback questionnaires are given to every guest at the end of their stay, and these are collated on an annual basis, and acted upon. The service acts where an area for improvement has been identified, but guests nearly always rate the service highly, and little negative feedback is received. One guest asked to speak with the inspector. This person said that staff treat guests with respect at all times; that guests can and do genuinely influence how their care is given; that staff do ‘with’ guests, rather than ‘to’ guests; and that the privacy of guests is respected and protected. This guest could not think of any ways in which the service could be improved. One formal complaint has been received in the past year. This alleged a number of poor care practices. Documentary evidence showed that this complaint was thoroughly investigated by the Trust. It was not upheld. Protection from Abuse, Neglect and Self-harm: The trust is aware of its obligation to report abuse. Adult protection procedures are up to date and the use of the flow chart enables all staff to understand the process. The flow chart coincides with the Northumberland County Councils Policy. It is being amended to reflect the fact that Social Services have the responsibility for co-ordinating safeguarding issues, but that the Commission must also be informed by the Trust of any significant issues. It was checked that the system in place is appropriate for guests who travel from other parts of the country. It was confirmed that Northumberland Social Services would take the responsibility for logging any safeguarding issues that arise and for passing them onto the appropriate local authority for the guest in question. The Team Leader and the Director of Operations have attended an advanced ‘train the trainer’ course on how to respond to allegations of abuse, and provide ‘in-house’ safeguarding of vulnerable adults training to staff. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. Guests are provided with a pleasant, comfortable, well-equipped and safe environment. All facilities seen were clean and hygienic. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Environment: 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.V346564.R01.S.doc Version 5.2 Page 24 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. No smoking is allowed in the building. CCTV cameras have recently been installed at certain points within the building for security purposes. It is recommended that they be re-sited to cover only external doors, for the privacy of guests. Hygiene and Cleanliness: 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.V346564.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. People who use the service experience good quality outcomes in this area. Guests benefit from having a competent, experienced and qualified staff team. Guests are supported and protected by the Trust’s recruitment policy and practices. The needs of the guests are met by appropriately trained staff. Guests have the benefit of having a well-supervised and supported staff group. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Staff Qualifications and Competency: Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 26 60 of care staff have been trained to National Vocational Qualification (NVQ) level 3 in care. This exceeds the standard, which looks for at least 50 being trained to the lesser NVQ level 2. This is good practice. Recruitment and Selection: 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. Staff Training: Staff receive appropriate specialist training. This year has included training from the district nurses on catheter care, stoma care, diabetes awareness and PEG feeding. An agency delivered training about learning disabilities and autism. There is a training and development plan in place for 2007, and each staff member has had an individual training and development assessment. There is an appropriate training budget. There is annual training in fire safety, food hygiene, infection control, moving and handling, and training regarding the Control of Substances Hazardous to Health (COSSH). Staff Supervision and Appraisal: Study of staff supervision records showed that all care staff are receiving the required six annual supervision sessions. One of these sessions incorporates the individual’s annual appraisal. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 27 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience good quality outcomes in this area. Guests benefit from a well-run organisation. The Trust has 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. We have made this judgment using a range of evidence, including a visit to this service. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 28 EVIDENCE: Management of the Home: The Registered Manager has 22 years experience in care, 8 of which are in management. Mr Appleby has 2 degrees in Human Organization and Psychology. He has a Post Graduate degree in Human Resources Management and a Diploma in Senior Management. He also is a member of IOSH and CIMA. The Team Leader of respite care, Sally Hemingbrough, has 12 years experience working in care. She has a degree in Social Policy, GNVQ level 3 in Health and Social Care and is currently working towards an NVQ4 in Care Management. Quality Assurance: There was documentary evidence that the Trust actively encourages guests to express their opinions, both verbal and written. Staff are available to help guests to fill in questionnaires if they so require. Guests are also able to email comments following their visit. As a result of feedback questionnaires the Trust has introduced a quiet area, which also encorporates free internet access which is now more accessible than its previous position. A sailing week has been introduced as a direct result of guests asking about this type of holiday and there are plans to move to a new boathouse, with improved facilities. This should allow further development of the sailing week and other water based experiences. Guests confirmed that they feel that the management and the staff team listen to them, and that their suggestions are responded to. Health, Safety and Welfare: Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 29 There are appropriate policies and procedures in place for keeping guests, staff and visitors safe. 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. 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. It was a requirement of the last inspection report that the Trust must provide CSCI with an electrical wiring certificate. (This requirement is outstanding from 30/06/06). This has been carried out. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 30 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 3 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 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 31 NO. 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 YA6 Regulation 15.2 Requirement The content of the care plans for each guest must reflect the complexity and severity of the assessed needs. Care plans must be redrawn whenever the revisions made to the original plan affect its clarity. 2. YA15 6 The Trust’s statement of purpose must reflect any restrictions in place on the free movement of guests within the Trust. 31/12/07 Timescale for action 31/12/07 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 Close Circuit Television cameras should be re-sited to cover only external doors. Calvert Trust Kielder DS0000000602.V346564.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V346564.R01.S.doc Version 5.2 Page 33 - 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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