Inspection on 17/11/05 for Denewell Avenue (17)

This inspection was carried out on 17th November 2005.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Denewell Avenue (17) 30/05/07

Denewell Avenue (17) 09/02/05

Denewell Avenue (17) 02/08/04

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 Denewell Avenue (17) Low Fell Gateshead Tyne & Wear NE9 5HD Lead Inspector Miss Nic Shaw Announced Inspection 17th November 2005 1:00pm Denewell Avenue (17) DS0000007385.V253841.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 Denewell Avenue (17) DS0000007385.V253841.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. Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Denewell Avenue (17) Address Low Fell Gateshead Tyne & Wear NE9 5HD 0191 487 5068 0191 487 6512 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) Northgate & Prudhoe NHS Trust Anne Osborne Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2005 Brief Description of the Service: 17 Denewell Avenue is owned and managed by Northgate and Prudhoe NHS Trust, The Trust. It provides ordinary housing for people who have a learning disability. Deanwell Avenue can provide personal care for three adults. The service cannot provide nursing care. The home is a four bedroomed semi detached house and offers single bedroom accommodation, a lounge, dining room and kitchen/diner. All bedrooms are located on the first floor and as access to these are via stairs, the home would not be suitable to people who have a physical disability. There is a lawned garden and patio to the rear and a smaller garden to the front of the home. The home is situated in the Low Fell area of Gateshead near to local amenities and facilities including shops, public houses, and places of worship. There are bus stops nearby which link with the main regional centres and the home has its own transport, which is shared with another nearby Trust home Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours in November 2005 and was a scheduled announced inspection. The inspection process involved observing interactions between the staff and service users as well as talking to the service users, staff, and a visiting relative. A pre-inspection questionnaire had been completed by the manager prior to the inspection and this, together with questionnaires completed by the relatives of service users, were also used to assist with the inspection process. A sample of records were examined including care plans, medication and the quality assurance system. A tour of the building took place which included all communal areas. The judgements made are based on the evidence available on the day of the inspection. What the service does well: The staff have a good understanding of the service users health and personal care needs and continually provide opportunities for the service users to try different activities within the community. Relatives spoken to said that the staff helped them to maintain regular contact with their family member. Relatives said that they were always invited to attend review meetings and staff always let them know of any changes to their family members health care. The service users are able to make choices for themselves and this includes choosing what to eat and what activities to take part in. In order to provide continuity of care the staff involve day centre staff in the care planning process and invite them to attend review meetings. The meals provided in the home are nutritious and attractively served and service users are encouraged to help in the kitchen with the meal preparation. The home provides a safe and comfortable environment that is well maintained, attractive and reflects the likes and preferences of the service users. The back garden is well maintained and has a garden swing which one service user said they loved using in the warmer weather. Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Denewell Avenue (17) DS0000007385.V253841.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 Denewell Avenue (17) DS0000007385.V253841.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): This standard was not assessed during this inspection. It was assessed as met during the last inspection. EVIDENCE: Denewell Avenue (17) DS0000007385.V253841.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): 7 The staff ensure that support is available so that service users are able to make decisions about their lives as an integral part of living independently. EVIDENCE: Discussion with relatives confirmed that the staff always involve them in the decision making process as advocates on behalf of their family members. One relative spoke of how the home fully consulted with them in relation to their family members health care needs. Relatives spoken to also confirmed that the staff had involved them with the decision making process in relation to reducing the number of staff on duty during the night. The staff continually strive to develop innovative ways of communicating with the service users in order to further enable them to take part in day to day decisions. For example; a collage of different meals has been created and displayed within the kitchen. Service users use the pictures as a visual aid to communicate to staff what they would like to eat. The service users are also involved in shopping for provisions and supported by staff to decide what to buy. Denewell Avenue (17) DS0000007385.V253841.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): 12,15,16&17 Service users are assisted to lead active and fulfilling lifestyles by having the opportunity to take part in range of activities with their rights as individuals being respected. This will assist in them leading an empowered, fulfilling and enjoyable life. This is supported by good contact being maintained between service users and their relatives. A good range of meals is available to service users which meet their dietary needs. EVIDENCE: On the day of the inspection service users had been attending their day services which is a consistent part of their daily activities. Service users and their relatives spoke enthusiastically of the range of leisure activities provided by the service both within the home and the local community. These include trips to the cinema, Metro Centre, attendance at a local line dancing class and outings further away to Sunderland Winter Gardens. In order to ensure that all of the service users are provided with equal opportunities of taking part in leisure activities, regardless of risk factors associated with their behaviour, the Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 11 manager has developed an activities programme. This provides guidance for staff as to which service users have been out and whose turn it is to participate in a 1:1 leisure activity. This programme is to be developed further with photographs of activities in order to enable service users to be actively involved with this process. In addition to these regular activities each service user is supported by staff to enjoy a holiday, paid for by the Trust, independent of one another. In order to meet the social needs of one service user additional staff hours have been provided during the day. For this service user this means that they can choose not to attend their day service, but instead can enjoy 2:1 staff support with leisure activities in the community. As a result of this positive intervention the manager stated that this particular service user has begun to request to go out, which has not before been observed. This is a good example of how, with staff support, the service users have gained in confidence and therefore empowered to speak out for themselves. It was evident that service users have much contact with their relatives. The relative spoken to confirmed that they could visit the home at any time and were always made to feel welcome by the staff. The service users are encouraged by staff to live independently and this is reflected in the care plans which include details of each service users strengths and abilities. Service users are provided with a key to their bedroom and staff were observed to interact positively with the service users encouraging them to take an active part in the inspection process. Although the evening meal was not sampled it was evident that the service users enjoyed the food. The meal was nicely presented and the service users were able to help themselves to condiments and as well as desired quantities of salad. A dietician has been involved with one service user and has provided staff with guidance on the menu planning process. As a result of this intervention this service user has been supported to loose weight and now actively chooses to eat certain vegetables, which previously they refused to eat. Denewell Avenue (17) DS0000007385.V253841.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): 20 Good systems for storing and administering service users medication are in place to ensure that service users get the treatment which they have been prescribed. EVIDENCE: Medication policy and procedures are in place, which cover the storage, handling and administration of medication. When examined, the records of medication held at the home accurately matched the numbers held in stock. Staff support some of the service users to use prescribed shampoos. Although this prescribed medication needs only to be applied once a day, the medication record indicated that it was required twice daily. The staff had signed each morning to confirm that the shampoo had been used and each evening signed the medication administration record using the code “F” to indicate that it had not been given. Discussion was held with the manager that as the medication was required each morning only then is was not necessary for the staff to complete the medication administration record in this way. The manager agreed that this could be potentially confusing for staff and agreed to address the issue. The service users medication is regularly reviewed. This was confirmed in discussion with the service users relatives who said that the staff always fully involved them with this process. Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 13 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): These standards were not assessed on this occasion. They were assessed as met during the last inspection. EVIDENCE: Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 14 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 The service users are provided with a homely, clean, comfortable environment, in which to live. EVIDENCE: 17 Deanwell Avenue is an ordinary semi-detached house located within a pleasant housing estate of the Low Fell area of Gateshead. In addition to service users having their own bedroom, where they are able to spend time on their own should they so choose, there are two lounges and a spacious kitchen/dining area. The three service users living in the home have very different needs and observations of the space available in the home confirmed that this is clearly of benefit to them with each service users choosing to spend time in different areas of the home. There is a pleasant well maintained garden to the rear of the home with a garden swing, which one service user indicated they loved to use. Since the last inspection the stair carpet has been replaced. In addition to this the lounge carpet and furniture have been professionally cleaned. The manager stated that as part of the on-going maintenance of the home, during the forthcoming year the hallway and doors throughout the home are to be redecorated. Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 15 Throughout the inspection staff demonstrated an awareness of control of infection, for example by using protective aprons when handling food and all areas of the home viewed were found to be clean. Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 16 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&36 The service users benefit from a well trained closely supervised staff team who are sufficient in number to meet their assessed needs. Staff records are not held within the home and as such it was not possible to confirm that the service users are supported and protected by the home’s recruitment practices. EVIDENCE: Discussion with the manager, and information provided within the preinspection questionnaire, confirmed that the staff are provided with a range of training by the organisation. In addition to the NVQ level 2 qualification in care, of which 50 of the staff have now achieved, this has included autism awareness, protection of vulnerable adults and risk assessment training. The manager and deputy manager carry out a supervision with each member of staff every eight weeks. The dates of forthcoming supervisions are displayed in the office so that staff have the opportunity to prepare an agenda. In order to assist the deputy manager with this process the manager has provided her with training in this area. Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 17 There are no staff recruitment records available to inspect in the home as required by the Care Home Regulations but these are available at the Trust’s main office. As such it was not possible to fully assess the staff recruitment procedures in order to ensure that they are robust and protect the service users. Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 18 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): 39&42 The service users health and safety is promoted and protected, however, systems need to be implemented so that the service users and their relatives know that their views will be listened to and acted upon. EVIDENCE: Discussion with the staff and manager confirmed that staff are trained to ensure the health, safety and welfare of service users. Discussions with staff confirmed that they had attended mandatory training including first aid and moving handling, however, as with staff recruitment records certificates of attendance are not routinely held in the home but are available within the Trust’s central training department. The accident book was inspected and found to be satisfactory. Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 19 During the last inspection two potential risks to the health and safety of the service users were identified; the unstable garden swing and the worn stair carpet. Both issues have been addressed. The Trust has a quality assurance system entitled “Total Quality Management”. This involves the staff agreeing a number of standards which are to be monitored each month. Discussion with the manager confirmed that recently the cleaning of the home has been monitored. However, the manager agreed that an area for future development is the need to obtain feedback from the service users and their relatives. One relative spoken to confirmed that they had been provided with a copy of the Trust’s annual report, however, this did not include specific information relating to Deanwell Avenue. The manager has begun to address this issue by sending out questionnaires to relatives. Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 20 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 X 2 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Denewell Avenue (17) Score X X 3 x Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 X DS0000007385.V253841.R01.S.doc Version 5.0 Page 21 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 YA34 Regulation 17(2) Requirement Timescale for action 31/03/06 2 YA39 24 Reference must be made to Schedules 2 and 4 of the Care Homes Regulations 2001 in order to ensure that relevant information in relation to care staff is kept in the care home.(Timescale not met 30th September 2005). Evidence must be available to 31/01/06 show that the views of service users and their relatives have been sought and used to develop the service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Denewell Avenue (17) DS0000007385.V253841.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Denewell Avenue (17) DS0000007385.V253841.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. 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