Inspection on 10/02/06 for Chirton Resource Centre

This inspection was carried out on 10th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chirton Resource Centre 11/10/06

Chirton Resource Centre 09/08/05

Chirton Resource Centre 21/02/05

Chirton Resource Centre 30/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Chirton Resource Centre Headlam Way Byker Newcastle Upon Tyne NE6 2DX Lead Inspector Elaine Malloy Unannounced Inspection 10th February 2006 11:40 X10015.doc Version 1.40 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 DS0000042084.V263850.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 Older People. 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. DS0000042084.V263850.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chirton Resource Centre Address Headlam Way Byker Newcastle Upon Tyne NE6 2DX 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) 0191 276 2195 0191 224 1929 Newcastle City Council Social Sevices Department Mrs Andrea Mary Marshall Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places DS0000042084.V263850.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 3 beds can be flexibly used to accommodate service users aged 55 to 64 years old, or service users over pensionable age. 9th August 2005 Date of last inspection Brief Description of the Service: Chirton Resource Centre is a registered care home for 20 older people. 3 beds can be used to accommodate people aged 55 to 64 years old. It is operated by Newcastle City Council Social Services. The centre is located within the Byker Wall in Newcastle upon Tyne. It provides short stays for community rehabilitation, respite care and emergencies. The staff team is supplemented by a range of health and social care professionals. Accommodation is provided over two floors and a passenger lift is available. All service users have single bedrooms. There are no en-suite facilities. DS0000042084.V263850.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5 hours. Standards were inspected through discussion with management, staff and service users, and examining records. The building was also inspected. Each area that the home was asked to improve at the last inspection was checked. Surveys were made available to service users and their relatives/visitors to ask their opinions of the service. What the service does well: What has improved since the last inspection? Action had been taken on the previously recommended improvements concerning lighting in the centre, and the staff recruitment process. DS0000042084.V263850.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. DS0000042084.V263850.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000042084.V263850.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. All service users have their care needs thoroughly assessed. EVIDENCE: Evidence was seen that service users have their care needs assessed via a comprehensive ‘Baseline Assessment’. Care Management assessment and information from health care professionals is also obtained where applicable. Risk assessments are documented. The resource uses admission and discharge checklists to ensure all necessary recording systems and tasks are completed. Assessments are updated for service users who have regular stays at the centre. DS0000042084.V263850.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9. Service users needs are care planned and reviewed. The medication recording system continues to require improvement. EVIDENCE: Service user care records demonstrated thorough assessment of needs, up to date care plans and individual care reviews. Care plans were well recorded. Health, personal and social care needs were addressed, and included evidence of input from the Community Rehabilitation Team. At the last inspection a Requirement was made for deficits to medication recording to be rectified. These were: • Some unexplained gaps to signatures • Unclear directions recorded for creams and eye drops • Medication had not been available for a period of time for one service user The Manager said the medication system had been reviewed, including audits of records. Competency based assessments are carried out for staff who administer medication. Further staff training was also being organised. DS0000042084.V263850.R01.S.doc Version 5.0 Page 10 Examination of records found that there continued to be gaps to signatures/codes and unclear directions. Some records did not have a photograph of the service user for identification purposes. The following discrepancies were also evident: • The code for ‘not available’ was used when medication was in stock • An example of a night time medication being signed as given in the morning • Medication signed for then code for ‘refused’ written over the signatures DS0000042084.V263850.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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, and 14. Provision of daily social activities continues to require improvement. Contact with family, friends and the local community is supported. Service users are encouraged to make choices and decisions in daily living. EVIDENCE: At the last inspection a Requirement was made for the resource to provide a varied social activities programme for service user stimulation, and maintain daily records of provision. Activities were said to be planned from weekly unit meetings with service users. This was unable to be evidenced from records in the social diaries. Entries were more about how service users had spent their days, with only the occasional entry relating to activities provision. Service users spoken with during the inspection were not aware of any social activities taking place that day. One service user who has regular respite praised the service but said it gets boring at times. Social events since the last inspection included a ‘Burns Night’ and ‘Chinese New Year’. Celebrations were being planned for St Valentines Day and Easter. Outings were taking place approximately every two weeks. DS0000042084.V263850.R01.S.doc Version 5.0 Page 12 The resource aims to take service users from the local area. Visitors are welcome at any reasonable time. Service users choose whom they wish see and can receive visitors in the privacy of their bedroom or communal areas. Visitors are asked to respect the privacy of service users during meals. The support of family and friends is encouraged, for example attending care reviews, accompanying to hospital appointments, invites to social events. Links have been forged with a nearby Community Centre. A local resident, whose relative is a service user, comes in regularly to take orders from service users for newspapers etc. A relative nominated the resource for a Carers Award that it won, and this was recently presented. Service users are kept involved throughout the process of assessment, care planning, reviews and discharge. Access to personal care records is facilitated. Relatives advocate on service user behalf where necessary. Advocacy information is available. Service users are encouraged to keep control of their personal finances where they have capacity to do so. Service users can bring personal possessions into the resource for their bedroom. DS0000042084.V263850.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Improvement is still needed to show how complaints have been acted upon. There are procedures and staff training to protect service users from abuse. EVIDENCE: At the last inspection a Requirement was made for full details of action taken as a result of complaints to be maintained. A summary list of comments and complaints is recorded and information is provided from the Social Services Directorate. One complaint had been received in the period since the last inspection. This was raised by a service user at review and was subsequently dealt with by a senior member of staff. However there was no evidence that the proposed action to take the issue to the next staff meeting was followed up. The resource has policies and procedures for the protection of vulnerable adults, prevention of abuse and whistle blowing (informing on bad practice). The Manager has been cascading Protection of Vulnerable Adults training to the staff team. There have been no allegations of abuse since the last inspection. DS0000042084.V263850.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 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 and 25. The building was clean, comfortable and generally well maintained. Lighting has been reviewed to ensure service user safety. EVIDENCE: A short tour of the building was conducted. In the period since the last inspection a number of bedroom carpets had been replaced. There were plans to redecorate the ground floor corridor and some bedrooms, and fit dining areas with new units and wash hand basins. At the last inspection a Recommendation was made for lighting in some areas of the building to be reviewed to ensure service user safety. This had been addressed. DS0000042084.V263850.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. There are good staffing levels to meet the needs of the number of residents. The standard for the number of care staff who have achieved care qualifications is exceeded, and more staff are studying. The recruitment process has been improved by following good practice when obtaining references. Staff receive a range of training relevant to their work with older people. EVIDENCE: At the time of the inspection there was 16 service users. The resource works to a standardised 3-week rota and a sleep-in ‘on-call’ system with other resource centres. A minimum of 4 carers is provided across the waking day, plus the Manager or a Team Leader, and 2 carers at night. There are good weekly catering and domestic staffing hours. The numbers of staff with, or studying for NVQ qualifications is commendable. One Team Leader has achieved NVQ Level 4 and is studying the Registered Manager Award. The other Team Leader is currently studying NVQ Level 4. Seven senior staff have achieved NVQ Level 3, and three are now studying Level 4. Five carers have achieved NVQ Level 2 and two carers are studying. All domestic staff have achieved NVQ’s in Housekeeping. DS0000042084.V263850.R01.S.doc Version 5.0 Page 16 At the last inspection a Recommendation was made for good practice to be followed regarding obtaining second/additional references for the recruitment of new staff. This had been addressed. Three new carers were in the process of completing Skills For Care induction training. Personal Development files were being introduced for all staff. Senior staff have completed Moving and Handling facilitator training. Training provided over the past year had included safe working practices, stress awareness, falls prevention, challenging behaviour, recording skills, health and safety and risk assessment, spiritual needs and multi-cultural environment, and counselling skills. DS0000042084.V263850.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 37 and 38. The resource uses a range of methods to monitor the quality of the service. The Registered Person, or their representative was not conducting monthly visits to the resource and reporting on findings. Health and safety checks are carried out and records are kept. Fire alarms need to be tested weekly. EVIDENCE: The resource has methods for monitoring the quality of the service provided. Unit meetings are held with service users. Surveys are given to service users upon discharge and collated findings are sent to all service users. It was recommended that findings also be included in the Service User Guide. Regular checks and audits are built into the daily running of the resource. These include senior staff, carer, kitchen staff and domestic duties and responsibilities, health and safety, and care records. DS0000042084.V263850.R01.S.doc Version 5.0 Page 18 Service users spoken with during the course of the inspection were very complimentary about the service. One service user said the resource was like a 5 star hotel. Another service user said it was her first time staying here. She said she was being looked after very well and had received a lot of input from medical professionals. Carers were described as wonderful, very nice, kind, and give all help that is needed. CSCI comment cards were made available to service users and their relatives/visitors to obtain their views on the quality of the service. 6 service users completed comment cards. 3 said they liked living/staying here, 2 said sometimes and 1 said they do not. Each said they feel well cared for and staff treat them well. 5 said their privacy is respected and 1 said sometimes. 1 said they wished to be more involved in decision-making within the home and 1 said sometimes. 4 said the home provides suitable activities and 2 said sometimes. Each said they like the food. Each said they feel safe here. 5 said they know who to speak to if they were unhappy with their care, and 1 indicated uncertainty. Additional comments were made as follows: “Enjoys being at Chirton however prefers to be at home”. “Has been happy at Chirton, has no complaints and will miss Chirton when she goes home”. “Would prefer to be home however understands needed to come to Chirton to facilitate a safe discharge home as his home needed adaptations completing”. “Has been happy at Chirton and will miss the staff and company”. No relatives comment cards were returned to date. The Registered Person, or their representative must visit the resource at least monthly and prepare a written report on the conduct of the resource. No visits had taken place since August 2005. Staff are provided with training in safe working practices – fire safety, moving and handling, food hygiene and first aid. Regular health and safety checks are carried out. Risk assessments are devised for the environment, and according to individual service user vulnerability. Records of fire safety checks, tests and instructions were examined. These were carried out at the required frequency with the exception of weekly fire alarm tests. Records are maintained of accidents and incidents, and accidents are analysed to identify any patterns. DS0000042084.V263850.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X 3 X STAFFING Standard No Score 27 3 28 4 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X 2 2 DS0000042084.V263850.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13(2) Requirement (Outstanding Requirement) Deficits to medication recording must be rectified, as detailed in this report. (Outstanding Requirement) The resource must provide a varied social activities programme for service user stimulation, and maintain daily records of provision. (Outstanding Requirement) Full details of action taken as a result of complaints must be maintained. (a) The Registered Person, or their representative must visit the home at least monthly and prepare reports on the conduct of the home. (b) Copies of reports must be submitted to the CSCI monthly. Fire alarms must be tested weekly and recorded. Timescale for action 10/02/06 2. OP12 16(n) 10/02/06 3. OP16 22 10/03/06 4. OP37 26 10/03/06 5. OP38 23(4) 10/03/06 DS0000042084.V263850.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP33 Good Practice Recommendations Findings from service user surveys should be included in the Service User Guide. DS0000042084.V263850.R01.S.doc Version 5.0 Page 22 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 DS0000042084.V263850.R01.S.doc Version 5.0 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!