Inspection on 20/02/06 for Clayton Road, 62

This inspection was carried out on 20th February 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clayton Road, 62 27/09/07

Clayton Road, 62 11/09/06

Clayton Road, 62 26/07/05

Clayton Road, 62 23/02/05

Clayton Road, 62 25/08/04

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 Clayton Road, 62 62 Clayton Road Jesmond Newcastle upon Tyne Tyne & Wear NE2 1TL Lead Inspector Anne Brown Unannounced Inspection 12 20 February 2006 th Clayton Road, 62 DS0000033054.V257754.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 Clayton Road, 62 DS0000033054.V257754.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. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Clayton Road, 62 Address 62 Clayton Road Jesmond Newcastle upon Tyne Tyne & Wear NE2 1TL 0191 281 1956 0191 281 1956 frank.martin@newcastle.gov.uk 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) Newcastle City Council Social Sevices Department Mr Frank Martin Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The ground floor only must be used to accommodate service users who have a physical disability 26th July 2005 Date of last inspection Brief Description of the Service: 62 Clayton Road is a care home registered to provide personal care for ten adults with learning disabilities. It is a local authority resource offering respite care. The home is located in a residential area of Jesmond, Newcastle Upon Tyne. The property was converted into a care home and has been extended since it was built. Accommodation is over three floors. A passenger lift is not provided and service users with physical disabilities are accommodated in ground floor rooms. There is easy access to local facilities, shops and public transport networks. The registered manager is absent from the home at present and Mrs Alayne Dugdale is currently acting manager. Clayton Road, 62 DS0000033054.V257754.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 six and a half hours. A tour of the premises took place and a sample of care records were inspected along with the fire log book, accident book, maintenance contracts, complaints and compliments and minutes of meetings held in the home. Three staff files were examined at the Personnel Department, Newcastle Civic Centre. Eight of the nine service users were seen and five members of the care staff were spoken to. An interview was held with the acting manager on the first day of the inspection and a further visit was made to speak with the service users. What the service does well: What has improved since the last inspection? Assessments have been carried out for all service users to ensure they are given a key to their bedroom, if appropriate, during their stay in the home. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 6 The staff confirmed that they now receive annual training on challenging behaviour. A decision has now been made to advertise for a deputy manager to assist the acting manager. 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. Clayton Road, 62 DS0000033054.V257754.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 Clayton Road, 62 DS0000033054.V257754.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 and 4. Prospective service users are provided with sufficient information to make a choice about coming to stay in the home. Service users have their individual needs assessed prior to admission. Prospective service users are invited to visit and spend time in the home. EVIDENCE: A comprehensive Statement of Purpose and Service User Guide is provided. The service user guide is issued to all service users. At the last inspection the Acting Manager explained that the Service User Guide was being reviewed with the assistance of an advocacy service to provide formats which will be more accessible for the people staying in the home. As yet no feedback has been received. The resource continues to conduct a thorough pre-admission assessment. This includes obtaining the Care Management Assessment and, where applicable, information is sought from carers/relatives, health care professionals and other care services that the service user has accessed or continues to use. There is a carefully phased introduction to the resource with visits and initial overnight stays. Initial care/support plans are devised as a result of assessment of needs. Clayton Road, 62 DS0000033054.V257754.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 and 9. The format of the care plans is easy to understand and contained very detailed guidelines to address complex needs. However some evaluations were out of date. The care staff support the service users to take risks as part of their lifestyle. EVIDENCE: Four care plans were examined and they contained a great deal of detailed information about the personal, social and complex health care needs of the service users. The plans are evaluated at the end of each stay. However the evaluations in two care plans were out of date. The six monthly reviews on one care plan were out of date. There was evidence to show that the staff support the service users to take risks to encourage independence in their everyday lives. A letter from a relative was available on one service user’s file giving consent for them to visit the local shops without a staff escort. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 10 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, 14, 15, 16 and 17. Links with the community and opportunities to participate in social and personal development activities are good. The service users are encouraged to mix with other people and participate in worthwhile activities. Well-balanced menus are in place and alternatives are offered. EVIDENCE: At the beginning of each stay service users make choices about how they wish to spend their time. This information is recorded in the daily reports. External activities include visiting local shops, cafes, pubs, theatre, museums and other local places of interest. A member of staff said three service users were going out to the local pub that evening. One service user confirmed this. One member of staff stated that one of the service users liked to visit a local church and is escorted by a member of staff. The majority of service users attend local day centres during the week. Staffing levels are increased at weekends to ensure the service users have access to activities of their choice. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 11 The menus are varied and nutritious. The service users were enjoying an evening meal during the inspection. The staff were observed to be offering choice and dealing with the needs of the individual service users in a caring and sensitive manner. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 12 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 and 20. The health care needs of the service users are well met and recorded in the care plans. Aids and adaptations are provided and moving and handling training is provided for the staff team. The staff give the residents the personal support they require and according to their preferences. An appropriate system is in place for dealing with medications. EVIDENCE: The staff on duty confirmed that their mandatory health and safety training was up to date. Adequate equipment is provided throughout the home. Service users are supported with healthcare needs and there are detailed guidelines on the individual care plans. Visits to health care professionals are recorded in the case files. A random sample of medication records and the system for storage and handling medication were looked at and found to be appropriate other than external and internal medications were not stored separately. Also photographs of the service users should be placed on their individual medication records. The acting manager stated she had contacted the Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 13 Community Pharmacist to request a refresher course for the staff team on the administration of medications. The acting manager has produced written guidance for relatives and carers when sending medications to the home. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home has a satisfactory complaints system and training in adult protection has been provided for the staff, which helps to protect the service users from abuse. EVIDENCE: A suitable complaints procedure is in place. A complaints log is maintained to record any complaints received and the outcome of the investigation. No complaints have been received since the last inspection. The manager confirmed that all staff had undergone training on the protection of vulnerable adults. The staff on duty were aware of the procedure to follow if they suspected abuse. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The home is well maintained, safe, homely and comfortable. Some areas are showing signs of wear and tear. Communal lounges are available on each floor and a pleasant, secluded garden is provided at the rear of the premises The home is clean, hygienic and free from offensive odours. EVIDENCE: The staff make every effort to ensure the home is safe and comfortable for the service users. However the following areas are showing signs of wear and tear:Bedroom 1 – The wallpaper border was loose. The metal vent under the windowsill was not screwed down. The lighting in the room was dull. Bedroom 2 – No wardrobe was available. Bedroom 3 – The wallpaper was damaged and the border was loose. Bedroom 4 – Cord on resident call system was snapped and not accessible. Bedroom 5 – The wallpaper border was loose. Bedroom 6 – The wallpaper was damaged behind the bed. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 16 Downstairs lounge – The three-piece suite was split in several places. Upstairs lounge – There was a large crack in the plaster on the wall. Downstairs shower room – The shower chair had fallen off the wall and the tiles have not been replaced. A different type of shower chair is on order. Kitchen – Some kitchen unit doors and drawer fronts were loose. Three different types of wall tiles had been used to repair damages. The doorbell cannot be heard by the staff in all parts of the building. All areas were observed to be clean, hygienic and free from offensive odours. A member of staff has been nominated to be the link person with the infection control nurse. Training on infection control issues will be cascaded to the staff team. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 17 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 and 36. The staff team are well trained and competent to support the service users. The recruitment policy and practice supports and protects the service users. The needs of the service users are met by appropriately trained staff. The staff team are well supported. However some supervision sessions are out of date. EVIDENCE: Seven members of staff have achieved NVQ Level 2 or above and two are undergoing this training. The acting manager confirmed that more staff are to be enrolled for this training in the near future. The home will be closed for the first week in April to enable the staff team to complete training on Equality and Diversity, moving and handling updates, time management and autism. The staff on duty confirmed that they receive good training to carry out their roles. A visit was made to Newcastle Civic Centre and three staff files were examined. They contained the appropriate information and Criminal Records Bureau checks and two written references had been obtained. A full-time domestic is currently on long-term sickness leave. The temporary replacement has now terminated their employment. Some staff on duty felt it Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 18 was sometimes hard to cover the domestic tasks at weekends when all the service users are in the home. Some formal supervision sessions are out of date. The manager stated this was due to the fact that she is covering for the manager and no deputy is in post. The Local Authority is to advertise a vacancy for a deputy manager as soon as possible to ease this situation. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 19 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 and 42. The home is well run to benefit the service users. The management and staff team respect the service users views regarding the running of the home. The health, safety and welfare of service users are protected. EVIDENCE: The acting manager has experience in working with adults with learning disabilities and currently undergoing NVQ Level 4 in management. The staff team and service users, who commented, confirmed that she is supportive and approachable. Regular meetings are held to discuss any issues that arise and to ensure the home is run in the best interests of the service users. Minutes of the meetings were available for inspection. There are comprehensive policies and Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 20 procedures in place to safeguard the rights and best interests of the service users. The staff confirmed that they receive regular health and safety training. One care assistant is currently undergoing a ten-week course on health and safety issues. A shower shelf is required for some service users. A risk assessment had not been completed. A stair gate is fitted at the bottom of the stairs for the safety of one service user. A risk assessment has not been carried out. An examination of the fire logbook revealed that a fire drill had not been carried out since July 2005. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 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. 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 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Clayton Road, 62 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000033054.V257754.R01.S.doc Version 5.0 Page 22 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 2 Standard YA6 YA20 Regulation 15(2)(b) 13(2) Requirement Care plan evaluations and reviews must be up to date. External and internal medications must be stored separately and photographs must be placed on medication administration records. Minor repairs must be addressed throughout the premises. (Some repairs remain outstanding from the last inspection). Wardrobe must be provided in bedroom 2. Management must take steps to cover shortfall in domestic hours. Formal staff supervision sessions must be up to date. Risk assessments must be in place for shower tray and stair gate. Fire drills must be carried out every six months. Timescale for action 31/03/06 03/03/06 3 YA24 23(2) 31/03/06 4 5 6 7 8 YA24 YA35 YA36 YA42 YA42 16(2)(c) 18(1)(a) 18(2) 13(4)(a) 23(4)(C) 31/03/06 03/03/06 31/03/06 03/03/06 27/02/06 Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 23 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 YA24 Good Practice Recommendations A doorbell should be installed that is audible in all parts of the home. Clayton Road, 62 DS0000033054.V257754.R01.S.doc Version 5.0 Page 24 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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