Inspection on 23/08/06 for Chapel Lane, 4

This inspection was carried out on 23rd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chapel Lane, 4 17/01/06

Chapel Lane, 4 10/05/05

Chapel Lane, 4 17/11/04

Chapel Lane, 4 10/06/04

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 Chapel Lane, 4 4 Chapel Lane Monkseaton Whitley Bay Tyne And Wear NE25 8AD Lead Inspector Jim Lamb Key Unannounced Inspection 23rd August 2006 10:00 Chapel Lane, 4 DS0000000351.V295850.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 Chapel Lane, 4 DS0000000351.V295850.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. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chapel Lane, 4 Address 4 Chapel Lane Monkseaton Whitley Bay Tyne And Wear NE25 8AD 0191 2518734 F/P 0191 2518734 No Email www.care-ltd.co.uk CARE (Cottage and Rural Enterprises Ltd) 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) Miss Sylvia France McKenzie Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Chapel Lane was built within the last few years to provide a home for up to six adults who have a learning disability and who need residential care. Nursing care is not provided. It is within walking distance of local shops and other facilities. The house is detached and has three storeys. The home provides single bedrooms on the ground and first floor. The staff facilities are on the second floor. The first and second floor are reached by a staircase. There are a suitable number of bathrooms and toilets. A yard is available to the rear of the building and a small paved garden area to the front. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first annual unannounced key inspection visit. The inspection took place during the morning and early afternoon. Time was spent talking to the homes two deputy managers, five service users and one support worker. Two service users care records were inspected together with other records relating to the management of the home. Two staff files were also seen. What the service does well: What has improved since the last inspection? The decoration and furnishings are being gradually improved providing a very comfortable and safe environment. New carpets and furniture for the communal areas are on order and a new kitchen is about to be fitted. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 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. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Each service user has a contract/statement of terms and conditions. Prospective service users have enough information about the home to help them to make a choice about where to live. All service users are appropriately assessed prior to admission to the home. EVIDENCE: Details of the extra charges and what these are for, are in the contract given to service users and are agreed prior to their admission. Contracts have been produced in a form of clip art. (Pictures) to help service users understand. The homes Statement of Purpose and the Service Users Guide both contained the full range of information required. Two service users’ files were checked and each included a full needs assessment. They contained a range of appropriate information. The service users are involved in drawing up both these initial assessments and the home’s subsequent service user plans. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 9 The 2 service user plans checked by the inspector were comprehensive, and listed details of service user’s needs and actions taken by the staff to meet these needs. The service users said their needs were met and they were happy with the care offered to them. Two care plans were checked and staff interviewed, confirmed that a range of specialist services was provided to service users. Staff interviewed had had a range of relevant training and experience. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social care plans have been completed and risk assessments agreed and signed by the service users. The service users keep a copy of their individual person centered plans. EVIDENCE: There are comprehensive assessments in the service users’ care plans. There is also a comprehensive risk assessment of service users. These have been agreed and signed by service users. There are advocacy arrangements, as well as family input, to represent service users. Each service user has an allocated key worker. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 11 Care plans are drawn up with service users. Plans are amended and reviewed on a regular basis. There are systems in place that will ensure that the placement and the service users plans are reviewed annually. These can involve the care managers and the service users representatives. Service users can use a range of external agencies that promote independence. Any rights that are restricted are linked to risk assessments. Each service user receives support from staff to manage their finances. Service users’ said that they are able to make decisions for themselves, and that they are happy with all aspects of the care that they receive. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to live a normal life in the community. They have regular access to a wide range of community activities. They receive support and encouragement to enable them to be in control of their own lives. EVIDENCE: Each service user has personal life skills assessment carried out. This is reviewed and updated on a regular basis. All service users participate in this process. Service users use a range of community-based services, which promotes and provides opportunities to learn and use life skills. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 13 Service users are supported to live a normal life in the community. They are supported and encouraged to be in control of their own lives, to enjoy their own interests and to continue their education, or take up paid employment. The staff team liaise closely with external agencies in order to monitor each service user’s progress. All service users are supported to maintain very close links with their families. They can choose who they want to see and when. All have been on holiday this year and another is planned for October. Daily routines promote independence, choice and freedom of movement. Service users are involved in housekeeping tasks. The Home’s menus are based on the known likes and dislikes of the service users. At least two hot meals are provided each day. Service users have access to the kitchen and can prepare snacks for themselves if they wish. One-service users requires a special diet, professional advice is being sought to ensure he receives a nutritional and well-balanced diet. The home is about to introduce nutritional assessments; the format seen by the inspector appears to provide very good information. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place to protect service users from abuse or harm. All staff have undertaken Safeguarding Adults training. EVIDENCE: Service users do not have any moving and handling needs. Service users need minimal help with personal care tasks, such as bathing and dressing. Privacy and dignity are respected at all times. Service users do not need any technical aids or equipment. Service users care records showed that they have access to external health care services. G.Ps visit when necessary. Service users are referred for specialist health care if appropriate. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 15 All service users receive regular health care checks. The medication systems were examined for ordering, receiving, administering and disposal. These were well managed. A one-service user is able to manage his own medication. All staff has had accredited medication training. Controlled drugs are prescribed for one service user and the correct procedures are being followed. The dispensing pharmacist offers good support and advice. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Procedures are in place to protect service users from abuse or harm. All staff has undertaken Safeguarding Adults training. EVIDENCE: There is a complaints procedure. It contains details of how to contact the CSCI to make a complaint, if complainants are not happy with the homes investigation and response. The procedure is written in a way that ensures service users fully understand its contents. The service users said that they had been given copies of the procedure and that staff listened to their concerns and dealt with them fairly. The home keeps a record of complaints. There have been no complaints received during the last twelve months. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 17 The home has a Whistle Blowing policy and the Local Authorities Vulnerable Adults procedures. The home also has a copy of the Department of Health’s document, “NO SECRETS”. The Home keeps detailed financial records on behalf of the service users. Each has an individual bank account. Receipts of personal spending are kept and regular audits are carried out. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 18 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): 24,25,26,27,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users live in a very homely, comfortable and safe environment. The home is maintained to a very high standard. EVIDENCE: The home was clean, well decorated and well maintained. The home is in a residential location. The grounds were tidy, safe, attractive and accessible. The home has an appropriate amount of sitting, recreational and dining space. There are enough rooms for a variety of activities to take place. Service users can see visitors in private in their own rooms. Furnishings and fittings were domestic in design and in very good condition. Lighting was bright and domestic in design. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 19 Doors have privacy locks. Room sizes meet the minimum required. There is space on either side of beds when necessary, to enable access for carers and specialist equipment. Service users’ bedrooms have opening windows. The rooms were centrally heated and the heating level could be controlled within each bedroom. Radiators and pipes were guarded. There was emergency lighting throughout the home. Water is stored at over 60°C. Valves at water outlets ensure water is provided close to 43°C to prevent scalding. The home was clean and free from offensive odours. The laundry facilities are well organised. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 20 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): 32,34,35 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The staff are competent and skilled and committed to meeting the holistic needs of the service users EVIDENCE: Staff levels on the day of the inspection met the agreed level. Rotas showed the required numbers of staff were on duty: 2 staff between 8am and 9pm with one sleep-in between 9pm and 8am. Staff said that staffing levels were appropriate. All the staff were over 18 years of age and those left in charge were at least 21. Training needs of staff are identified in supervision and appraisal sessions. The training programme meets The National Training Organisation requirements for the first six months. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 21 The two staff files examined, demonstrated that the organisation has a rigorous staff recruitment and selection process to ensure that all appropriate checks and references are in place prior to employment. The home has a low staff turnover. 95 of the staff team have achieved NVQ level 2 and 3. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 22 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): 37,39,40,42 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. A good system is in place for self-monitoring, review and development. The home is well maintained and the health and safety of the service users is promoted and safeguarded. EVIDENCE: The manager has many years experience in senior management. Staff were clear about their responsibilities. Staff spoke positively about the manager saying she had encouraged both staff and service users to contribute to the development of the service. She said that the “care provided was excellent”. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 23 Service users are told when inspections take place and they are shown inspection reports. These are also summarised and discussed in service users monthly meetings. Copies are available for relatives and others to see. The organisation has developed a range of new policies and procedures which have been linked to the National Minimum Standards. The records inspected were found to be appropriately completed. These included the fire log book, accident records, personal allowance records and Health and Safey manual. There are appropriate maintenance contracts for the home. Water storage tanks, gas and electrics are checked annually. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 X 4 X 5 3 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 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 2 X 3 X Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirements Timescale for action 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. YA40 Refer to Standard Good Practice Recommendations. Provide staff with equality and diversity training and implement specific policies and procedures. Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Chapel Lane, 4 DS0000000351.V295850.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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