Inspection on 01/08/06 for Coanwood Drive

This inspection was carried out on 1st 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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coanwood Drive 18/04/07

Coanwood Drive 10/11/05

Coanwood Drive 16/08/05

Coanwood Drive 14/01/05

Coanwood Drive 22/06/04

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 Coanwood Drive 22 Coanwood Drive Mayfield Glade Cramlington Northumberland NE23 6TL Lead Inspector Carole McKay Key Unannounced Inspection 1 and 11th August 2006 09:30 st Coanwood Drive DS0000000605.V295429.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 Coanwood Drive DS0000000605.V295429.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. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coanwood Drive Address 22 Coanwood Drive Mayfield Glade Cramlington Northumberland NE23 6TL 01670 739319 F/P 01670 739319 coanwood@stcuthbertscare.org.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) St Cuthberts Care Mrs Marie S S Johnson Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2005 Brief Description of the Service: 22 Coanwood Drive is registered to provide care and support to seven adults with a learning disability. The service is provided in a residential area on the outskirts of Cramlington. The house is within walking distance of the town centre and public transport links. Residents are accommodated at Coanwood Drive for a limited period of up to two years. During that time residents are helped by staff to develop the skills needed to live as independently as possible. An outreach service is provided from Coanwood Drive to support people with learning disabilities within the community. Some of these people moved on from Coanwood Drive and levels of support vary to suit individual needs. Additional staff are provided for this service. The most up to date information that the Commission for Social Care Inspection has indicates that fees are £611.24 per week. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days. The records and procedures were examined. Three staff and three service users were spoken to. The inspector met with the manager Mrs Marie Johnson. Surveys were sent out to service users. A tour of the building was undertaken. What the service does well: What has improved since the last inspection? Staff records contain more information and this makes it easier to identify staff. Some parts of the home have been redecorated. Coanwood Drive DS0000000605.V295429.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. Coanwood Drive DS0000000605.V295429.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 Coanwood Drive DS0000000605.V295429.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 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The home has information for service users about the how the service works. Service users’ needs, wishes and aspirations are assessed. EVIDENCE: The care records contain full assessments that are carried out before and in the weeks after admission. These have a lot of information in them to do with all aspects of people’s lives. People’s strengths and the things they can do are identified, as well as the support they need. The assessment process continues throughout the time a person lives at the home. This is because the service is designed to assess and support people to move out and live independently in the community. Some of the assessments include things that service users have said about themselves and the things they want to achieve. The service has produced an easy to read brochure, and in this it states “the average stay at Coanwood Drive is 12 months, after which we assist people to move into their own accommodation, continuing to offer support at the level assessed as appropriate.” Residents said that they are asked to be involved in the assessment process. They said that they were satisfied that staff knew about their needs before their admission. Copies of the assessments that are carried out by service user’s care managers are also available. The Manager described how the needs of each person are assessed to ensure that right level of support is provided at the time of their admission and during their stay. Risks to do with living independently or a person’s disability are assessed. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 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, Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Each service user has an individual plan of care. Service users are involved in these. Staff support residents to make decisions about how they live their lives. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: Once a person’s needs have been assessed, an individual plan for each person is drawn up. Copies of these are in the service users records at the home. These cover all aspects of life and include a section on the personal preferences of the service user. To help staff follow the plan and understand the service users, a section identifying things that work and things that don’t work for the service user is included. Also peoples’ fears and concerns are written down along with how dreams can be turned into steps that are achievable. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 10 Goals for making practical improvements towards independence are written down. After this each service user meets with the key worker who is helping them, to look at how well these plans are working. These are called Goal Evaluation Meetings (GEM) and they take place once per month. Notes from these meetings are kept in service users’ records. This helps service users to make their own decisions. Service users said that they could tell their key worker about any problems they have at these meetings. Service users are encouraged to take responsible risks as they go about their daily lives. Risks are carefully assessed and staff look at these from time to time and at the GEM meetings. Information that care managers give to the service and details of any risk assessments they have conducted, are sent to the home before an admission into the Home can take place. The Home has a pre-admission assessment. This is used to establish how identified risks will be managed within and outside of the Home. Any risk assessment information is added into the service user plan. Completed risk assessment information was available in all of the care records examined. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 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): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported by staff to become part of, and participate in, their local community. Residents are encouraged to form meaningful relationships with staff and other people living at the Home. Residents’ rights are recognised enabling them to lead valued and fulfilling lives. Residents’ involvement in, and responsibilities for, the Home’s daily routines is encouraged, enabling them to work towards achieving more independence. Residents are able to take part in age, peer and culturally appropriate activities. A healthy diet is provided for residents. Residents are happy with the food provided. EVIDENCE: Each service user plan examined contained information about their desired outcomes for areas of their lives such as: living space, employment, education, social activity, relationships and personal requirements. Goal plans to achieve these outcomes are in place. For example one file contained a goal plan to Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 12 achieve better money budgeting, another for assisting a person to use the local bus service. One service users said that she has two days work at a local hotel. Another person’s plan is to support him with looking for work and a local work placement agency is being used. The internet has been used successfully in finding work for another service user. Other service users attend college and horticultural training units. Service users described being able to use the local community and local transport for shopping and the hairdresser. One service user independently arranged her appointments. The service user guide states “friends and relatives can visit at any time (within reason).” One service user has a friend who regularly comes to see her at the home. This person said that she was free to invite visitors to her room. One person said that they could not have friends over late at night. Service users hold keys to their room doors and can have a front door key if they wish. In the surveys returned most service users said that they could do as they wished. The notice board in the dining room has information about forthcoming social events in the community. One service user described one of these events that she has attended. Food preferences and diet are covered in the service users’ plans of care. The routines for taking meals are very flexible. Some service users make a meal for themselves, as they require it, with minimal support from staff. Others require help and take their meals as part of a group activity. Guidance to do with healthy eating is available in the kitchen. Other domestic routines, such as washing and ironing are also flexible. Service users are supported to carry these things out individually. The arrangements for this are covered in the service user guide. This states that service users will look after their own money, do their own shopping, washing and ironing and cook some of their own meals. How this is done is described in the individual plan of care. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 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): 18,19,20 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Personal support is provided to service users in line with their abilities and preferences. Where needed specialist support is used. Service users’ rights to look after themselves are respected, with arrangements to safeguard service users. The medication systems need to be more closely audited to ensure records are accurate and practice is safe. EVIDENCE: There was evidence in the files that service users are supported, as necessary, to obtain advice on health and personal matters through the use of local GP practices and other support services. For example bereavement counselling services have been used. The staff said that unless the service user was very poorly they would attend the practice rather than call the GP out. The staff said that most people who use the service need no, or a small amount, of support to care for themselves on a daily basis. The care records show that specialist help is used when necessary. These arrangements are reviewed regularly. Service users attend appointments independently where they can and support is provided for some. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 14 A medication policy is in place for staff to refer to. Some of the people living at Coanwood see to their own medication. A small amount of medication is held for safekeeping by the staff for some service users. The risk assessment process identifies who needs help with this and care plans are in place to describe the arrangements. Records are kept of the medication being managed for service users. These, and the stocks of medication, were examined. Small amounts of medication are safely stored. Service users have somewhere to lock medication away. Records are kept of medicines administered to service users. These had some omissions in them and although the system was being audited, this had failed to pick up where dates of records do not correspond. The consent of service users to staff administering medications is now recorded and photographs have been added to the records. The ambient temperature of the room, where medication is stored, is monitored and recorded. There is no hand wash facility in the room where medication is stored. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Procedures are followed to protect service users. Service users are confident to make complaints and expect that these will be addressed. EVIDENCE: The home has a policy and procedure for protecting its service users. This complies with guidance issued. An adult protection issue has been handled properly, since the last inspection. Most of the staff have received training in adult protection. Those who have not and those who need updated training, are booked to receive this in October 2006. The service user guide includes information about how to make a complaint. In service users’ surveys, all those who responded said that they knew who to speak to if they were unhappy and knew how to make a complaint. The home keeps records of complaints. These show that complaints are taken seriously and internal investigations are carried out. Where necessary staff disciplinary procedures are followed. Service users said that they would complain if they felt they were unfairly treated. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is clean and comfortable. Maintenance could be managed better and made easier. The layout of the home is not ideal. EVIDENCE: Coanwood Drive is comfortably furnished and the home is clean throughout. Local transport bus routes pass by near the home and service users said that they use these regularly. The premises are in keeping with the local housing and no signage denotes that it is a registered home. There is a system for auditing the fabric and fittings of the building. The recent audit had identified that the shed needs attention and the front flowerbeds of the home need to be weeded. The weeds detract from the appearance of the home. No action plan had been identified. The service users’ amenity area is situated at the rear of the house. The front is used for parking. The amenity includes lawns, flower beds, a patio and barbecue area. Staff from the home look after these areas. The home has one living room, one dining room, an office, utility and a bathroom and a kitchen on the ground floor. The bedrooms are all on the first floor. These rooms are quite small. The living room, dining room and office are accessed from the front door through the kitchen. The Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 17 manager said that the lack of an alternative communal space mean that visitors had to be accommodated in the office or in the dining or living room. Washing machines are located in the utility room. This is accessed directly from the main entrance corridor. The stairs open onto this corridor. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 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): 32,34,35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff are properly recruited and receive good basic training. On going and special training is also offered. This needs to be linked to the aim of the service and the needs of the service users. EVIDENCE: Staff files include confirmation of identity and checks against their details. Application forms, references and interview records show that the recruitment process has been improved over time. There is evidence that service users are involved in interviews for new staff. Outcomes of interviews are on files. Staff undertake a probation period of three months. Staff job descriptions and contracts are not in the files. A thorough induction checklist is used in files to track staff progress. Target dates for completion are included. Staff are trained. Most have or are in the process of obtaining a recognised care qualification. There is a training programme. This ensures that staff receive the training they must have by law. It also identifies some specialist training. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 19 The special aims of the service, as an assessment service, are not reflected in the training programme. Thought should be given to how these could be linked. For example staff do a lot of lone working, but there is no evidence that they have had training to do with staying safe. Service users’ needs and backgrounds are culturally varied, but there is no evidence that this is addressed in the training schedule. For example a new referral has been made to the service for a person who has a care programme in place. There is no evidence that staff have had training to do with this. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The service is safe and regular checks take place. The auditing process needs to be refined to ensure that all identified problems are addressed EVIDENCE: The records and premises are audited. The manager, Mrs Marie Johnson, said that St Cuthbert’s Care is about to introduce a new quality audit system. The records show that safety risk assessments are carried out for fire, hazardous substances, and infection. Guidance about these things is written down and available for staff. Induction and regular up dated training is provided to staff in health and safety, first aid, food safety and fire safety. The fire alarm and fire equipment tests and servicing is recorded and up to date. Regular meetings take place between individual service users and their key workers. Also, group meetings take place every month. These meetings are recorded. Action plans are developed from these. Service users said that they are encouraged to voice their opinions. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 21 Various staff carry out internal audits. For example, for some of the records and premises, checks had been recorded and dated but omissions had not been picked up or, where faults had been identified, no action plans had been devised. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 4 3 X 4 X 5 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Ensure that: 31/10/06 Hand wash facilities are provided in the room within which medications are stored and administered; All staff are provided with accredited medication training; A record is maintained of inhouse medication training provided to new staff employed at the Home. 01/03/06 timescale not met Ensure that staff files held at the Home contain the following information: A copy of each staff member’s employment contract and job description; 01/04/06 timescale not met A full audit of the premises to be undertaken and action plans devised to address all maintenance items. A staff development programme to be devised taking account of the aims of the service and the needs and abilities of service users. DS0000000605.V295429.R01.S.doc Timescale for action 2. YA34 Schedule 2 31/10/06 3. YA24 23(2)(b) 31/10/06 4. YA35 18(1)( c ) 01/01/07 Coanwood Drive Version 5.2 Page 24 5. YA39 24 The quality auditing system to be used to identify where records are not meeting standards and action plans are not being identified. 01/01/07 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 Serious consideration should be given to improving the front aspect of the home with low maintenance land scaping. Serious consideration should be given to providing an alternative communal space and/or meeting room. Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 25 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 Coanwood Drive DS0000000605.V295429.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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