Inspection on 01/06/05 for Self Unlimited North East

This inspection was carried out on 1st June 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Self Unlimited North East 03/10/06

Self Unlimited North East 11/05/06

Self Unlimited North East 01/11/05

Self Unlimited North East 30/08/05

Self Unlimited North East 14/10/04

Self Unlimited North East 13/07/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Care Ponteland North Road Ponteland Newcastle Upon Tyne NE20 0BW Lead Inspector Elaine Wright Unannounced 1 June 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Care Ponteland Address North Road Ponteland Newcastle Upon Tyne NE20 0BW 01661 860333 01661 821830 careponteland@btconnect.com CARE (Cottage and Rural Enterprises Ltd) Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Diane Louise Kirwan CRH 42 Category(ies) of LD Learning disability (42) registration, with number of places Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Two service users only are accommodated in Crastor Cottage. Nine service users only are accommodated in Kielder Cottage, two of whom live in self contained flats within the cottage. Fifteen service users only are accommodated in Cheviot Cottage, one of whom lives in a self contained flat within the cottage. Sixteen service users only are accommodated in Burnside Cottage, two of whom live in self contained flats within the cottage. Date of last inspection 14 October 2004 Brief Description of the Service: CARE Ponteland is located on the outskirts of Ponteland village, in open countryside, close to local amenities which include shops, public houses, restaurants, health centre, churches and swimming pool. Accommodation comprises four purpose built residential units, 5 independent flats, workshops, central kitchen, dining room and administrative offices. A maximum of 42 younger adults with a learning disability live at CARE and access employment and educational opportunities both on and off site. Nursing care is not provided. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection by Elaine Wright was carried out on the 1 June 2005, at 9.30 am and last until 2.00 pm. The focus of the inspection was the requirements made at the last inspection in October to ensure that they had been completed. As part of the assessment process residents care records and daily records written by staff were checked in three of the home’s cottages (Cheviot, Burnside and Kielder) together with the homes complaints records, medication recording and dispensing systems. The newly appointed manager Mr John Curry was on duty throughout the visit but did not accompany the Inspector around the site. Eleven service users and 7 members of staff (2 of whom were house managers and 1 an acting house manager) were spoken to during the inspection and all were very helpful. The manager reported that a bid for funding in support of the Business Plan had not been submitted late last year. This had lead to a considerable delay in decisions being made about plans for the Ponteland site. However, during a follow up inspection visit on the 22 June 2005, the Inspector was advised by the Director of Operations that the bid will be submitted in July 2005. What the service does well: Staff maintain regular contact with service users care managers, family and other appropriate professionals. Staff actively advocate on behalf of service users. Service users are encouraged and enabled to access and integrate with the local community, some taking part in the Great North Walk. Access to educational and employment opportunities is promoted. Service users spoke about the recent outing to Light Water Valley. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 6 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these standards were assessed at this inspection. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 and 10 Service user needs, personal goals and achievements are not fully reflected in their individual plans. Staff support service users to make choices and decisions and recordings are kept in a confidential manner which protects individual service users. EVIDENCE: Service user plans showed limited progress towards the implementation of Person Centred Planning (PCP). Staff have completed PCP training but in one of the cottages the manager reported that 50 of the staff trained had now left the employment of CARE. Some parents of service users have also completed the PCP facilitator training. Staff have completed PCP questionnaires with service users and are working on behavioural records. A meeting is planned for the 9 June between the Supported Employment Officer and trained Facilitators to draw together an action plan for the progressing PCP. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 10 Two service users were observed making choices with the assistance of care workers about how they were going to spend their day. Staff spoke about the process of using training plans as a means of increasing a service users independence. One service user was accessing separate dining facilities within a cottage to enable them to make choices about when and what they ate without inconveniencing other service users. This service user also has regular contact with a dietician. Service users have their own group called Speaking Up Ponteland at which they discuss social events and any issues affecting their life at CARE. A limited number of risk assessments are in place to support daily living activities, educational, employment and social opportuntiies. CARE have clear policies and procedures on confidentiality and how staff should handle information. Service users were observed being spoken to in a sensitive and supportive manner. Daily recordings by staff were being recorded on tick box sheets, the reverse of the sheet also provided a space for additional information. Staff were not using these fully. Care plans in place did not provide the evidence that outcomes were being met for service users. Staff have maintained a programme of contacts with care managers and service users families. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17. Staff encourage and enable service users to access educational, employment, social and leisure opportunities and thereby lead fulfilling lives and inclusion in the local community. A comprehesive range of meal and healthy diet choices are provided to promote the health and welfare of service users. EVIDENCE: Twenty three service users had recently visited Light Water Valley and during the inspection one service user who was viewing photographs of the outing on the computer told the Inspector that he had really enjoyed himself. On the evening of the inspection 8 service users were going to take part in the Great North Walk and one service user confided that they were going to have a relaxing afternoon in readiness for taking part in the event. Staff were working sensitively with a service user who wished to travel abroad this summer but encountered problems when eating out. A plan to increase Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 12 the service users confidence and familiarise them with the type of restaurants they would be visiting was underway. The lunchtime meal choices are displayed daily on a menu in the dining room and service users can select from two hot choices or the salad bar. All meals are freshly prepared. Alternatively service users may eat their meal in their cottage. Service users make clear choices about where and whom they wish to sit with in the dining room and often follow their meal with socialisation and a game of pool before returning to their chosen activity. Family members regularly visit CARE and some service users make visits to their family home at weekends. CARE also holds family days throughout the year and encourage and welcome family involvement. Two service users had requested assistance to enable them to move towards independent travel opportunities. Staff expressed concerns about difficulties they were experiencing trying to access and actively involve care managers in the lives of three service users. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 and 21. Staff consult with a range of health care and other professionals on a regular basis thereby promoting and safeguarding the health and well being of service users. Staff adhere to CARE policies and procedures when dealing with medications thus protecting the health of service users. EVIDENCE: Medication guidelines, advice on allergies and side effects were all seen to be in place. A random sample of medications checked were correct and the associated recordings up to date. A photograph of each service user is filed with their medication administration records for the purposes of identification. Medication is securely stored within each cottage and staff conduct and record regular audit checks. Staff had actively approached a Consultant with regard to one service user’s medication and a behavioural deterioration. The resulting change of medication had promoted a rapid improvement in the service users mood who was observed during the inspection warmly interacting with staff and service users. Difficulties with another service user which sometimes impacted on other service users were being addressed in a manner which limited distress to others living in the cottage. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 14 Two cottage managers alerted the Inspector to difficulties they were encountering with care managers for three service users which was impacting on their life. One service user was no longer able to undertake some activities and access the local community. Staff had been unable to engage care managers in the re-assessment and support of these service users who were experiencing emotional and physical difficulties. One manager had identified the need, as part of the PCP process, to update records with regard to service users wishes in the event of their death. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Both the complaint and protection of vulnerable adult procedures are confidently used to protect the welfare and welbeing of service users. EVIDENCE: CARE has a comprehensive policy and procedure in place to support the acceptance, recording, investigation and reporting of complaints. Service users files contained evidence that they had had the complaints procedure explained to them. Throughout the inspection service users were observed raising issues and quesitonning staff in a confident manner. Staff displayed patience and understanding at these times. Staff have received training in the Protection of Vulnerable Adults (POVA) and are aware of the procedure to follow. They did raise an issue where by a care manager had been reluctant to refer an incident for investigation through the Local Authority POVA procedure, and had chastised a manager for speaking to the Commission for Social Care Inspection. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24. The fabric of the properties and standard of decoration is deteriorating and approaching an unacceptable level to the detriment of service users. EVIDENCE: A full inspection of the fabric of all four cottages was not undertaken. In Cheviot Cottage the lounge still required some increased personalisation. The flooring in the dining area was lifting and had been poorly repaired in some areas. Kitchen cupboard and draw fronts were loose together with “kick boards” at the base of units. The ceiling in the staff bathroom showed evidence of a leak and paintwork was discoloured/peeling. Paint in a ground floor toilet was peeling. Safes in two of the cottages were not secured. Each of the properties is in need of repair, renovation and redecoration. At the follow-up inspection visit the Inspector was advised that CARE are to advertise and appoint an Estates Manager. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 17 Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 and 35. There is a high turnover of staff and deployment of agency workers which is having a detrimental affect on the delivery of care to servcie users. EVIDENCE: All staff have clear job descriptions and work within a specific cottage team. A key worker system is in operation. Opportunities for staff to undertake training is promoted but staff raised the issue of high turnover and how CARE intended to try and retain staff. Retention of staff was causing particular problems in Cheviot Cottage where waking night staff had to be female. Day time workers were being deployed to cover night shifts and agency workers were being brought in for day time cover. Staff also said they would benefit from access to a clear statement of CARE’s aims and objectives for their site. Waking night staff have been deployed in Cheviot Cottage but some disquite is caused by them being paid the same rate as sleep in staff in other cottages. Records of staff night time calls to service users in Cheviot Cottage average 8.6 per night. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 19 Cottage managers expressed concerns about staffing levels in Kielder Cottage, where four one to one packages of care are being delivered, not fully meeting service user needs. CARE have undertaken a national exercise regarding pay and conditions of service and a report has been before the Trustees. Staff were due to be advised of the outcome of the review on the afternoon of the follow-up inspection visit (22 June). Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39. A comprehensive and effective quality assurance system is not in place. EVIDENCE: A meeting was due to be held week commencing 6 June 2005, with Headquarters Staff regarding the implementation of the Quality Asssurance (QA) system. Questionnaires for service users were in place and access to an outside advocate to enable service users to complete them was being explored. The member of staff progressing the implementation of QA had left and an replacement had not been identified. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 Care Ponteland 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 2 2 2 x 2 x Version 1.20 Page 22 B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc 16 17 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 2 3 3 Standard No 37 38 39 40 41 42 43 Score x x 2 x x x x Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 23 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 6 Regulation 15 Requirement The introduction of person centred planning and service user care plans must be progressed. (Previous timescale of 30 March 2005 not met.) The range of risk assessments must increase with the implementation of person centred planning. Staff must receive training in record keeping. Timescale for action 30 September 2005 30 September 2005 2. 9 13(4) 3. 4. 5. 6. 7. 8. 9. 10. 7 7 19 23 24 24 24 24 18 15 14 13(6) 23(2) 23(2) 23(2) 23 30 September 2005 Care plans must detail intended 30 outcomes for service users. September 2005 Care managers must be 30 July accessed to assess and re-assess 2005 service users needs. Local Authority POVA procedures 30 June must be implemented. 2005 The floor in Cheviot dining room 30 July must be repaired or replaced. 2005 The kitchen in Cheviot must be 30 repaired or replaced. September 2005 The staff bathroom and ground 30 July floor toilet in Cheivot must be 2005 repaired and redecorated. Safes in the cottages must be 30 July secured in a manner to protect 2005 staff health and safety. Version 1.20 Page 24 Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc 11. 12. 13. 32/33/35 32/33/35 39 18 18 35 Staffing in Cheviot Cottage must be reviewed. Staffing in Kielder Cottage must be reviewed. Implementation of quality assurance system must be progressed. (Previous timescale of 30 March 2005 not met.) 30 July 2005 30 July 2005 30 September 2005 14. 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 21 33 Good Practice Recommendations Review the service user information held regarding wishes in the event of their death. Consideration to be given to the payment system for waking night and sleep in staff. Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection 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 Care Ponteland B53-B03 S598 Care Ponteland V221768 010605 Stage 4.doc Version 1.20 Page 26 - 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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