Inspection on 08/02/06 for Calvert Trust Kielder

This inspection was carried out on 8th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 5 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 12/09/06

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 Deborah Haugh Unannounced Inspection 8th February 2006 10:00 DS0000000602.V273016.R01.S.doc Version 5.0 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 DS0000000602.V273016.R01.S.doc Version 5.0 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. DS0000000602.V273016.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Calvert Trust Kielder Address Kielder Water Hexham Northumberland NE48 1BS 01434-250232 01434-250015 enquiries@clavert-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 DS0000000602.V273016.R01.S.doc Version 5.0 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 independantly 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 17th November 2005 Brief Description of the Service: Calvert Trust 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. DS0000000602.V273016.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 08/02/06 at 10.00am until 3.45pm. At the time of this inspection Mr Kevin Appleby, the Registered Manager was on duty. There were 6 guests staying at the Calvert Trust and staffing levels were checked. Lunch was shared with the guests and all of the guests were spoken with. The inspector spoke to staff. Time was spent looking at the requirements made at the last inspection. Time was also spent observing the contact between guests and staff. Care planning arrangements were examined. Arrangements for the administration of medication, staff National Vocational Qualifications (NVQ), health and safety and quality assurance were checked. What the service does well: What has improved since the last inspection? The care plans and risk assessments are being developed by the Trust to ensure that they are completed within 48 hours of the guest arriving and that risk assessments are completed for individual guests. The staff are completing NVQ in social care and 38 are qualified to NVQ Level 3 (the minimum standard is 50 of staff qualified to at least NVQ Level 2 or above by 2005). In previous inspections the Trust has met the minimum but changes in staffing have affected this percentage. DS0000000602.V273016.R01.S.doc Version 5.0 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. DS0000000602.V273016.R01.S.doc Version 5.0 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 DS0000000602.V273016.R01.S.doc Version 5.0 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): NMS 2 was assessed and met at the last inspection. EVIDENCE: DS0000000602.V273016.R01.S.doc Version 5.0 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 & 9 (NMS 7 was assessed and met at the last inspection) 6) Guests’ assessed needs are reflected in their individual plans but moving and handling information must be in more detail. 9) Guests are supported to take responsible risks by the Trust’s general environmental and activities risk assessments. EVIDENCE: 6) The issue of how detailed a guest’s individual plan of care needs to be, given the nature of the service being provided and its ‘short stay/holiday’ nature, has been previously discussed at length in previous inspections, and a basic level of care planning has been accepted. About three-quarters of the guests are ‘repeat bookings’ and are well known to the staff. In this situation, it is acceptable for the Trust to use care plans from previous stays. Staff are now reviewing the content and a senior carer signs and dates that it is still relevant or updates it, as necessary.) DS0000000602.V273016.R01.S.doc Version 5.0 Page 10 Each assessed need of a guest must be addressed in a care plan within 48 hours of the person arriving. Staff are working to achieve this and progress will be monitored at future inspection. 9) At the last inspection it was found that there were virtually no risk assessments of the individual guests. Given the relatively high risk of the client group, due to their various disabilities, and the relatively high risk of the physical activities available to the guests, this should be addressed. The Trust is addressing this in the care plans. Progress will be monitored at future inspection as the new holiday season had just commenced. DS0000000602.V273016.R01.S.doc Version 5.0 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 the following standard(s): 13,15 & 17 (NMS 12 is not applicable, 14 & 16 were met at the last inspection) 13) Guests are able to participate in the community whilst on holiday. 15) Guests are able to maintain relationships and visitors are made welcome. 17) Guests have a healthy and nutritious diet, with choice, and they said they enjoyed their meals. DS0000000602.V273016.R01.S.doc Version 5.0 Page 12 EVIDENCE: 13) The Calvert Trust also proves holiday accommodation for families and groups of children. This enables the guests to socialise with people of similar and different abilities. Some of the site areas are communal such as dining areas and social rooms. The activities available at the Trust enable guests to engage in community activities. 15) Visitors are welcome at the Trust. Sometimes relatives will stay at a Chalet whilst the guest stays in the house. 17) Lunch was shared with guests in the dining area. Soup was available, as was a cold meat and a salad bar, with a light hot course. Staff interact well with guests, giving sensitive assistance with feeding, where required. Guests said they enjoyed the food. The lunchtime meal was relaxed and enjoyable. DS0000000602.V273016.R01.S.doc Version 5.0 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 the following standard(s): 19 & 20 (NMS 18 was assessed and met at the last inspection) 19) Guests’ physical and emotional health needs are met but moving and handling risk assessments must improve. EVIDENCE: 19) 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 guests’ nursing needs are fully met. Care plans were examined and there was not sufficient assessment and guidance for staff to meet guests moving and handling needs. It is clear from speaking to staff that they know the needs of peoples needs and spend a long time establishing guest’s requirements and preferences. Guests confirmed that staff discuss their care needs and are very supportive. 20) An audit of the medication was undertaken in the presence of the Team Leader and arrangements are satisfactory but some areas must and should improve (See Requirements and Recommendations). The Inspector provided the Manager with the Pharmaceutical Society Guidance and CSCI Pharmacy guidance on the storage and care plans for Gasses (Oxygen). DS0000000602.V273016.R01.S.doc Version 5.0 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 the following standard(s): NMS 22 & 23 were assessed and met at the last inspection. EVIDENCE: DS0000000602.V273016.R01.S.doc Version 5.0 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 the following standard(s): NMS 24 & 30 were assessed and met at the last inspection EVIDENCE: DS0000000602.V273016.R01.S.doc Version 5.0 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 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 (NMS 34 & 35 were assessed and met at the last inspection) 32) The Calvert Trust ensures that guests are cared for by staff that are competent and qualified 33) Staffing numbers were appropriate to the assessed needs of the guests, size, layout and purpose of the home on the day of the inspection. DS0000000602.V273016.R01.S.doc Version 5.0 Page 17 EVIDENCE: 33) The staff are completing NVQ in social care and 38 are qualified to NVQ Level 3 (the minimum standard is 50 of staff qualified to at least NVQ Level 2 or above by 2005). In previous inspections the Trust has met the minimum but changes in staffing have affected this percentage. - 3 carers have NVQ Level 3 - 3 carers are completing NVQ Level 3 - 1 carer, Team Leader is completing the Registered Managers Award and assessor’s award. 32) There were 6 guests staying at the Trust at the time of the inspection. The following staffing were on dutyThe Manager’s hours are supernummery. Through the morning there were 3 carers on duty and the afternoon/evening there were 2 carers (one a designated senior). One senior sleeps on the premises and is available should guests use the emergency call. Staffing levels increase depending on the occupancy and assessed needs of the guests. DS0000000602.V273016.R01.S.doc Version 5.0 Page 18 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 37) Services uses live in a home that is managed by an experienced manager. 39) Quality Assurance systems are being in place but the views of service users are obtained. 42) Service users live in a safe home but some areas must be addressed. EVIDENCE: 37) 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. 39) Aberdeen University are working to provide the Trust with an Outcome Monitoring System to ensure that the service provided is appropriate and reviewed/developed. The Trust has informal systems in place such as a ‘Feedback’ Book, which is available to guests to record their experiences and DS0000000602.V273016.R01.S.doc Version 5.0 Page 19 degree of satisfaction with the service on offer. Guests are able to e-mail the Trust with comments following their visit. CSCI Comment cards are available to service users with self-addressed, postage paid envelopes to return any comments to CSCI. Future progress will be monitored. 42) A check of the health and safety checks was undertaken. A Fire Risk Assessment was completed in July 2005 and will be reviewed July 2006. The Trust has additional fire protection due to its location such as 45minute fire doors. Appropriate servicing of the fire alarm, emergency call and emergency lighting systems in the Trust. Checks are in place for emergency lights (monthly) but there were gaps in records. An Electrical Portable Appliance test was completed and passed 22/10/05. The water system receives regular chlorination testing as the Trust has a swimming pool. A Gas Safety certificate is in place 16/02/05. A qualified electrical contractor must carry out annual and 5 yearly inspection and tests. Evidence that the electrical wiring is satisfactory was not available for inspection. Moving and handling equipment was serviced in August 2005 and February 2006. Thermometers must be available in bathrooms to test the hot water temperatures each time a person bathes and a record made. DS0000000602.V273016.R01.S.doc Version 5.0 Page 20 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 X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 N/A 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 3 X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000000602.V273016.R01.S.doc Version 5.0 Page 21 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 YA6YA19 Regulation 13(4)(5) & 15 Requirement Care plans must identify moving and handling risk assessments with enough detail to guide staff. Provide thermometers in bathrooms to test the hot water temperatures each time a person bathes and record. A record must be made of emergency lights being checked monthly. The Calvert Trust must provide CSCI with an electrical wiring certifcate. 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. DS0000000602.V273016.R01.S.doc Timescale for action 30/06/06 2 YA42 13(4) 09/02/06 3 YA42 23(2) 30/06/06 4 YA20 13(2) 31/03/06 Version 5.0 Page 22 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 YA32 YA20 Good Practice Recommendations 50 of care staff should obtain NVQ Level 2 or equivalent. Provide photographs for guest identity for medication administration DS0000000602.V273016.R01.S.doc Version 5.0 Page 23 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. 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