Inspection on 01/12/05 for CHAD Limited

This inspection was carried out on 1st December 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 no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

CHAD Limited 29/04/09

CHAD Limited 10/05/07

CHAD Limited 05/06/06

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

CARE HOME ADULTS 18-65 CHAD Limited Cordingley House 22 Linden Terrace Whitley Bay Tyne & Wear NE26 2AA Lead Inspector Deborah Haugh Announced Inspection 10:00 1 December 2005 st CHAD Limited DS0000064818.V260057.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 CHAD Limited DS0000064818.V260057.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. CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service CHAD Limited Address Cordingley House 22 Linden Terrace Whitley Bay Tyne & Wear NE26 2AA 0191 251 8724 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) Care Homes for Adults with Disabilities Limited Mrs Julie Ann Henry Care Home 4 Category(ies) of Learning disability (4) registration, with number of places CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Registered 05/09/05 Brief Description of the Service: CHAD is located at Cordingley House in Whitley Bay close to the sea. The home is an Edwardian terraced house close to local amenities such as a library, swimming pool, shops and local transport. The home has 4 bedrooms, 3 toilets, 2 bathrooms and 3 showers. The home can provide accommodation for 4 people with a learning disability. CHAD cannot provide nursing care. CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on 01/12/05 at 10.00 am. The Responsible Person, Company Director Liz Whiteman, Registered Manager Julie Henry and Michelle Millen Company Secretary were present. CHAD was registered on 05/09/05 and this is the homes first inspection. Currently there are no service users living at the home. Time was spent looking around the home to check the facilities although the home was checked during the registration process by the Fire Safety Officer, Environmental Health, Planning Department, Building Control and CSCI. Policies and procedures, documentation regarding practice, quality assurance, staff supervision, recruitment and training were examined. What the service does well: What has improved since the last inspection? Not applicable first inspection. CHAD Limited DS0000064818.V260057.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. CHAD Limited DS0000064818.V260057.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 CHAD Limited DS0000064818.V260057.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): 1, 2,4, Service users will be provided with appropriate information and trial visits to decide if they wish to live at CHAD. The home intends to identify the needs and aspirations of service users EVIDENCE: The Statement of Purpose and Service User Guide provide the required information for potential service users. The Service User Guide provides information regarding phased admissions and trial visits to the home. The home intends to obtain professional assessments of peoples needs and complete their own assessments in consultation with the service user and/or their representatives. CHAD agreed to provide CSCI with assessment documentation and the homes updated Statement of Purpose and Service User Guide. CHAD Limited DS0000064818.V260057.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, 7 & 9 CHAD intends to develop care plans to meet service users needs, identify and manage risks but format are not available. EVIDENCE: The homes Statement of Purpose identifies that service users will have care plans to meet their needs and these will be periodically reviewed informally and formally (6 monthly). The documentation for identifying needs, personal futures planning, risks and challenging behaviour were not available but are to be provided to CSCI. The inspector provided a sample care plan. NMS 7 could not be fully assessed as there are no service users but in principle CHAD intends to enable service users to make decisions about their lives. They intend to do this by care plans, staff training and consultation via quality assurance, home meetings, and 1:1 discussions and through the complaints procedure. CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 10 CHAD Limited DS0000064818.V260057.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): 11-15 CHAD intends to enable service users to fulfil their potential in leisure, education, and employment and have a positive community presence. CHAD intends to support service users to maintain relationships with family and friends. NMS 16 was not assessed as there are no service users in the home. CHAD intends to provide service users with a choice of nutritious food. EVIDENCE: The Statement of Purpose identifies CHAD’s commitment to provide a variety of leisure, self-development, education and employment opportunities for service users. CHAD intends to provide this through consultation with service users and/or their representatives, care plans, quality assurance and staff training. CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 12 In the Statement of Purpose CHAD intends to support service users to maintain relationships with family and friends. A children’s visiting policy should be developed. CHAD intends to be flexible regarding meals and choices and has agreed to provide sample menus (4 weeks) to CSCI. A nutritional audit tool was provided by the inspector for reference. CHAD Limited DS0000064818.V260057.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): 18 & 20 CHAD intends to ensure that service users feel that any personal support is provided with dignity. CHAD has a policy and procedure for medication which will protect service users. NMS 19 was not assessed as there are no service users in the home EVIDENCE: The Statement of Purpose states that service users will be treated with dignity and have their privacy protected. Personal care will be carried out unobtrusively and sensitively. CHAD intends that the dignity of service users will be built into every policy and procedure and is a central philosophy of the registered providers. The home has a policy and procedure for the management and administration of medication. CHAD intends to provide staff with training and until they are competent they will not be able to administer medication. At present there are no service users so an audit of medication could not be made. But the storage arrangements were checked and found to be secure. A copy of CSCI medication audit was given to CHAD by the inspector. CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 14 CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 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 the following standard(s): 22 & 23 Service users can potentially share concerns and make complaints CHAD states that they will be listened to and investigated fully. CHAD has made a commitment that service users will be protected from potential abuse, neglect and harm. EVIDENCE: CHAD has a complaints procedure and the Statement of Purpose states that an advocate will be provided where required to support service users. CHAD has a policy and procedure for the Protection and Prevention of Abuse (POVA), Whistle Blowing, Restraint, Aggression towards Staff and Bullying. The POVA policy and procedure will require more development to include all aspects of abuse awareness and good practice in keeping with No Secrets by the Department of Health. The Restraint policy was examined and the registered providers and manager have received training from an accredited trainer. The British Institute for Learning Disability will also accredit staff training. Minor amendments to the policy are required. (See requirements) CHAD has a Management of Service Users Money and Financial Affairs and advice was provided and amendments are required. (See requirements) CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 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 the following standard(s): 24 & 30 Service users will live in a well maintained and decorated home which has appropriate facilities to meet their needs. EVIDENCE: Although unoccupied the accommodation is homely and spacious. The home has a ground, first and second floor. On the ground floor there are two comfortable lounges (24.35 sq m and 25 sq m). A breakfast/dining room (18.5 sq m) is located next to the domestic style kitchen. On the first floor there is a bathroom with toilet and separate toilet. Bedroom 1 is 13 sq m, bedroom 2 is 18.65 sq m and bedroom 3 is 23 sq m. The staff room is located on the first floor and has an en suite shower. The second floor has a utility room, office and bathroom. Bedroom 4 is 13.06 sq m. Service users will be able to bring their own possessions and personal keepsakes when they move in. CHAD intends to provide service users with TV’s and computers. CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 17 A lockable storage facility is required for each bedroom. Wardrobes must also be secure to the wall once their location is decided. The lighting in the medication room is not adequate. The laundry room is sited on the second floor and noise from the laundry must not disturb service users. The arrangements for infection control are satisfactory but amendments are required for the policy. The Environmental Health Officer visited in June 2005 and was satisfied with arrangements. Some practical considerations were discussed regarding the laundering of service users clothes and not using labels. CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 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 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): 32-35 CHAD intends to provide staff with training which is adequate to meet the needs of the service users. Service users will be protected as staff will be vetted. Staff will receive supervision in order to meet service users needs. EVIDENCE: CHAD has agreed to provide CSCI with their recruitment policy and procedure including documentation. Recruitment arrangements include the requirement for Criminal Records Bureau and Protection of Vulnerable Adults checks and 2 references. An application form was checked and includes the necessary information. CHAD was recommended to introduce Exit Interviews. CHAD states that it intends to ensure that all staff are qualified to NVQ Level 3 in care. CHAD is organising training and agreed to provide CSCI with the programme. Staff will receive a Handbook and Induction Booklet. The General Social Care Council Code of Conduct should be provided to all employees and the management of the home should obtain the Employers Code of Conduct as well. A supervision policy is available but documentation is not in place. The inspector provided a sample. CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 19 CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 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 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 A Quality Assurance system is in place so potentially the service will be reviewed to improve the quality of life for service users. The management at CHAD intend to be competent and obtain appropriate training to meet the needs of service users. Systems are being put in place to protect service users from health and safety hazards. EVIDENCE: A Quality Assurance system is in place based on the National Minimum Standards which CHAD intends to review. CHAD intends to ask service users, other professionals and interested parties for their views. The procedure for Quality Assurance needs to be in place as well as questionnaires to seek views. The Company Director and Secretary will have day-to-day involvement in the home. They are experienced teachers who specialise in autism. They intend CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 21 to provide training to staff. The Registered Manager is experienced and qualified to NVQ Level 3 in care. The management of the home intend to enrol to qualify to NVQ Level 4 in Management and Care once service users are resident. The arrangements for health and safety were checked. The Fire Risk Assessment is being completed and fire checks are underway. Fire instruction to staff must be in more detail regarding the content and who attended. The ‘In the event of a Fire (day and night)’ procedure must be provided to CSCI. All showers and baths are fitted with thermostatic valves but each should also have a thermometer to take readings when they are used as valves become furred. Water quality checks must also be made against bacteria entering the system. Maintenance and cleaning schedules and recording formats must be in place for staff to follow and complete. CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 22 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 3 2 X 2 X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 2 X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 2 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 CHAD Limited Score 2 X 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 1 X DS0000064818.V260057.R01.S.doc Version 5.0 Page 23 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 YA42 Regulation 23 Requirement Thermometers must be provided in each bathroom/shower room. Water quality checks must be made against bacteria entering the system. Details in Fire Log regarding Fire Instruction staff attendance and content must be completed. The Fire Risk Assessment must be completed. Provide CSCI with the ‘In the event of a Fire (day and night)’ procedure. A maintenance and cleaning schedule must be in place for staff to follow including recording formats. 2 3 YA39 24 The procedure for Quality Assurance must be in place. CHAD recruitment policy and procedure including documentation must be DS0000064818.V260057.R01.S.doc Timescale for action 31/12/05 31/12/05 31/12/05 YA36YA35YA34 17,18 CHAD Limited Version 5.0 Page 24 provided to CSCI. CHAD training programme must be provided to CSCI. Supervision formats (including contract) must be provided to CSCI. A lockable storage facility is 31/12/05 required for each bedroom. Wardrobes must also be secure to the wall once their location is decided. Adequate lighting must be provided in the medication room The noise from the laundry must not disturb service users. The Infection Control Policy must include identified amendments and a copy sent to CSCI. The Restraint policy must state that CSCI are to be informed of any incident of restraint being used and staff must receive training in accordance with the Department of Health not as stated the Local Authority. The Whistle Blowing Policy must make reference to Public Interest Disclosure Act 1998 and that CSCI can be contacted by concerned staff. Service users monies looked after by CHAD must be recorded in a hard backed page numbered book and two signatures obtained at each transaction. Staff must not be CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 25 4 YA30YA24 16 5 YA23 13(6)(7) 31/12/05 appointees. POVA policy and procedure must be developed to include abuse awareness and good practice in line with No Secrets Department of Health. 6 7 YA17 YA9YA6YA2 17 schedule 4 15 Sample 4 week menus must be provided to CSCI Assessments, care planning, risk assessment, behaviour assessments and personal future planning formats must be provided to CSCI. An updated Statement of Purpose and Service User Guide must be provided to CSCI. 31/12/05 31/12/05 8 YA1 4&5 31/12/05 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 3 4 Refer to Standard YA36 YA35 YA7 YA15 Good Practice Recommendations Consider undertaking Exit Interviews Obtain General Social Care Councils Code of Conduct for employer and employees. The manager should not be an appointee. Develop a Children’s Visiting Policy CHAD Limited DS0000064818.V260057.R01.S.doc Version 5.0 Page 26 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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