Inspection on 22/10/07 for Eastbourne Avenue

This inspection was carried out on 22nd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 Eastbourne Avenue 285-289 Eastbourne Avenue Gateshead Tyne and Wear NE8 4NN Lead Inspector Mr Lee Bennett Key Unannounced Inspection 22 and 23rd October 2007 10:00 nd Eastbourne Avenue DS0000069991.V350666.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 Eastbourne Avenue DS0000069991.V350666.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. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastbourne Avenue Address 285-289 Eastbourne Avenue Gateshead Tyne and Wear NE8 4NN 0191 4206368 01661 824458 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) Ashdown Care Homes Limited Mr Gary Candlish Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning Disability - Code LD, maximum number of places: 7 The maximum number of service users who can be accommodated is 7. Date of last inspection 11th January 2007 Brief Description of the Service: Eastbourne Avenue is a care home, providing personal care for up to seven people with a learning disability related need. Nursing care is not provided, but District, Learning Disability and Psychiatric Nursing services can be arranged where necessary. It is an adapted, terraced care home with accommodation provided over two floors. The first floor is accessed by a flight of stairs, and there is stepped access into the home and on the ground floor. This means the home would not be suitable for a person with a physical disability. There is a small paved garden to the front, and an enclosed yard to the rear of the home. The home is situated within walking distance of central Gateshead, and is near to local public transport links and a wide range of local facilities, including a health centre, a library, leisure centre, shops, pubs and places of worship. The fees charged here are between £577.48 and £1690.00 per person per week (2007/08) Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last ‘key inspection’ visit in October 2006. • Information gained during a briefer ‘random inspection’ visit in January 2007. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on the 22nd October 2007. An announced visit was made on 23rd October 2007. During the visit we: • Talked with people who use the service, staff and the manager. • Observed life in the home. • Looked at information about the people who use the service & how well their needs are met. • Looked at other records, which must be kept. • Checked that staff had the knowledge, skills & training to meet the needs of the people they care for. • Looked around parts of the building to make sure it was clean, safe & comfortable. • Checked what improvements had been made since the last visit. We told the manager what we had found. What the service does well: Staff make sure that the people living here have access to health care and community services and facilities, such as shops, libraries, cafes, and so on. The people living here lead an active life, and are helped to go out and about to various places of interest. Some people also go to council run day services. This is what people said about living here: • • • “I’m okay here.” “I’ve been on holiday.” “I’ve been going to college.” Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 6 Staff will also help speak up for service users where necessary, and have a pleasant approach. Care planning arrangements are broad ranging. The practice of testing staffs’ knowledge of each service users’ care plans and needs, by a questionnaire, is an area of continuing good practice. Bedrooms are homely and the owner has arranged for further work to keep the building well decorated. Recruitment checks include the taking up of references and Criminal Records checks. These help to ensure safe recruitment practices are in place. Staff also receive regular training to keep them up to date with current good practice. This also means their work is focused on service users’ needs. The manager is experienced and has had training to keep her up to date with good practice. What has improved since the last inspection? What they could do better: This inspection highlighted the need for improvements in several important areas. Before moving here, each person must have their needs assessed by a social worker. This is to find out what it is they need, and identify where these needs can be met. A copy of this assessment has to be obtained by the manager before agreeing to a person coming here to live. This has not been done. Arrangements for the two people who have moved here recently were rushed. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 7 After moving in, a plan of care has to be developed. This is a written plan, drawn up with the person concerned, to agree and explain how their needs are to be met. These are in place, but contain too much information to be clear or effective. They need to be made clearer, and drawn up with the involvement of the people living here. Staffing arrangements also need to be carefully looked at. Not only are current staff levels below what is needed, the levels of training and supervision are poor. Managers are required to meet with staff on a one-to-one basis at least six times a year. This is so issues can be discussed and dealt with, training planned, and so on. Two staff have received no formal supervision at all. 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. The summary of this inspection report can be made available in other formats on request. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 8 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 Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective service users needs have not been fully assessed prior to their admission to the home, although adequate information has been obtained about their needs in other ways. Detailed assessments can help ensure that the service can be planned in a way that meets service users needs and wishes. Before moving here people have had only limited opportunities to visit and stop over in the home. Such opportunities are important to allow people to get to know these who live and work here already, and to ensure that people feel comfortable about their move. The residency agreement does not adequately safeguard service users interests, nor does it adequately reflect the responsibilities of third parties, such as the local Council. This could leave service users vulnerable should a dispute emerge between the service user and the care provider. EVIDENCE: When a person needs help with their personal care; things like washing, getting dressed, meal preparation, and so on, they are entitled to an Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 10 assessment from Social Services. This is to help identify what help and support a person needs, and what sort of service can best meet these needs. Social Services will also ‘re-assess’ these needs when they change significantly. If necessary they will help a person choose between several alternative services. For the two people who have moved here this was not the case. Both moved from care homes operated by Ashdown Care Homes Limited without a new assessment being carried out or obtained by the manager. One person moved on an ‘emergency’ basis. Information about this person’s needs was obtained from their previous home, as was the case with the second person. Information in the form of a care plan file was obtained, but no new assessment was carried out by the home’s staff. It is normal that once an assessment has been carried out, that a person will be helped to choose where they want to move (from the available alternatives). Once a home has been found they should be offered the chance to visit and to stay over before a trial stay is offered. For both the people concerned this was not the case. One person was initially told that her stay was ‘for a holiday’, implying a short-term placement. The other was told of his move five days before he came here. A decision had been reached between the social worker and representatives of the home three days earlier, with no representation for this person. Once agreement has been reached that a move here is taking place, a contract is agreed between the service users and the home’s owners. A representative may sign this on behalf of the service user if they do not understand it. The contract was looked at in detail during a previous inspection visit. Several changes were recommended to help better protect service users rights. These have only been partially addressed. Areas not addressed include clauses that place responsibilities on service users that they do not hold, for example the payment of fees, that are arranged by the council and the homes owner, who controls each service users benefits. The contract between social services (acting on behalf of the service user) and the home was not available for inspection and must be. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. Service users’ care plans are in place, and reflect their observed needs to an adequate level. They contain too much information to be effective. Good care planning can help to set clear goals for people, offer guidance to care staff regarding care practice and ensure consistency where necessary. Service users are, as far as is practicable, consulted on and participate in the life of the home. This can help in the development of an inclusive service for those living there. Service users are supported to take risks in a planned way, irrespective of their age, gender or disability. These need to be reviewed more often if they are to remain up to date. Effective risk assessment can help ensure people’s independence is promoted, balanced against a judgement about any risks involved. This can also help promote an awareness of safety and ensure equality of access to community facilities and activities. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 12 EVIDENCE: The communications skills and needs of the people living here vary greatly. Most people can state what they want and need easily and articulately. Where people have a greater level of need (for example where their speech isn’t clear) staff will have to interpret their choices, to understand the meaning of their behaviour, and to be ‘tuned in’ to how they speak. This is the case when developing care plans and in responding to day to day situations. Major life changing decisions (in particular when people move home) appear to be less well supported and for both cases looked at this was done in a very short space of time. Nevertheless, staff were able to demonstrate their skill in communication during the inspection, and were observed to discuss and explain routines and activities with service users, irrespective of their communication needs. Service users are therefore asked and allowed to make decisions affecting day to day choices and about the activities they participate in. They are also encouraged to undertake and help with chores in the home. Where asked, service users are able to give examples of how they make decisions affecting day to day choices and decisions, and the way the home is run. Service users and staff will discuss routines in the home, and service users have been able to make choices about décor schemes, trips out, personal purchases and holidays. There are regular house meetings between staff and service users. One person living here regularly meets up with his advocate (a person who will help him to speak up for himself). The way people communicate is also outlined within each person’s care plan. Care planning can also offer an opportunity for staff to ask, and for service users to state, how they wish their needs to be met. For the people living here, all have a care plan file in place. These follow a standardised format. This includes an overview or summary of each person’s needs, strengths and areas of risk. These are person centred, that is they relate specifically to each persons individual needs. However, each service user has numerous care needs identified in individual plans of care. For one person there were 34. Each of these has monitoring, evaluation and review notes written up. There is also reference made to teaching and training plans, although no clear plans or goals have been set. Closely linked to care planning arrangements are risk assessments. Again, these have been developed by a key worker. Areas of risk are therefore documented within each person’s care file, including assessments relating to activities out of the home and behaviours that may challenge the service. This can contribute to staff having guidance to enable the people living here to access community facilities without being placed at undue risk of harm. A model is used, whereby each risk area is identified, who or what may be harmed is noted, current and additional control measures are documented, and Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 13 this is then reviewed. For one of the service users case tracked, these had not been reviewed since 2003. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Service users are assisted to lead active and fulfilling lifestyles by having a regular community presence and by accessing a range of community facilities. This will assist in them leading a full and enjoyable life. The people living here are supported to maintain their personal relationships and friendships, which helps them to keep in touch, and be involved in family life. The rights of service users are respected, and routines in the home are, within reason, flexible. This can help to promote service users’ choices and preferences. A varied, menu has been developed. This can contribute to the general health and wellbeing of the people who live here. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 15 EVIDENCE: The people living here lead an active life, and often go out and about, usually with staff help. The activities participated in include swimming, light aerobics, trips to the shops and the pub. During the inspection service users were being supported on various activities including shopping in the town centre, spending time with friends or attending day services operated by the local Council. As well as going out and about, contact with friends and relatives can affect the quality of life enjoyed by people. Although contact with relatives varies for the people living here, due to their individual circumstances, staff in the home will assist service users to ‘keep in touch’ by sending cards, helping with visits, and making phone calls. Each person’s relationships are outlined within care plans, and should there be any concerns or needs in this area, plans of care have been developed to guide staffs’ practice. Service users have a range of dietary needs, which are outlined within their care plans. There is a record kept of the meals planned and provided. Meals are normally taken within the lounge / dining room, which is often at the centre of activity in the home, particularly now that one of the lounges has been converted to a bedroom. Staff have yet to receive externally accredited training on food hygiene, which is needed as they prepare and handle food on a daily basis. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and support is offered flexibly, discreetly and with sensitivity. This can help to ensure each person’s privacy and dignity is respected. The health care needs of the people living here are clearly identified and promoted. Medication arrangements are appropriate for the needs of service users, and are managed in a generally safe manner. EVIDENCE: The service users living at Eastbourne Avenue have their personal and healthcare needs outlined within their case files. Their needs are supported and met, where appropriate, in private, and they are encouraged to cater for their own needs. Specialist support is sought where necessary, and multidisciplinary input (for example from the Occupational Therapist, Speech and Language Therapist and Consultant Psychiatrist) are made available. Each Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 17 time someone gets health care (such as a visit to the GP or dentist) this is recorded within each service users’ care file. Linked to health and personal care arrangements, is the support given with medication. Due to their levels of need, the people living here are not able to administer their own medicines, and staff therefore assist in this area. None have yet undergone accredited training in relation to medication administration (the safer handling of medication course), but this is scheduled for November and December for some staff. Some staff have received in house training on this topic. Locked storage has been installed for service users’ medications, but internal and external medicines are not stored separately from one another, which can compromise good hygiene practice. Printed administration records are kept to indicate who has received their medication, and when. There were three recording omissions found for one service user. A sample stock check was concluded successfully, with no errors found. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ views are listened to and acted upon to a good level. This can help contribute to a service user centred service. Steps are taken to help ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: A clear complaints procedure exists within the home. There have been no complaints reported within the past twelve months. As noted above, service users have varying communication needs, which make it difficult for some to directly express their views and opinions on the service they receive. Staff therefore have to be mindful of service users’ behaviours as a means to gauge their feelings. Staff have, in the past, received training from the local Adult Protection Coordinator, which will help to explain the role of adult protection, and to offer guidance to staff. Both the home’s own and the local authorities adult protection procedures are available in the home, should staff need guidance in this area. During the last random inspection a requirement was made to tell social services staff about an incident of abuse (common assault) that had occurred in the home. This report was sent to social services. There has been no information received from social services about what decision was made or what, if any, action taken. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from well maintained, clean, homely, and largely safe and accommodation. This can help promote a positive image for service users, and ensure they remain comfortable and safe. Service users bedrooms are furnished to generally suit their needs. This can contribute to their comfort during their stay at the home. EVIDENCE: Eastbourne Avenue is an adapted terraced property, and provides accommodation across two floors. Access into the home and between the floors is by stairs, making the home unsuitable for service users with a physical disability. Communal areas consist of one lounge area, and a separate dining room. A former lounge has recently been converted to a bedroom, reducing the amount of shared space available, whilst at the same time increasing the Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 20 number of people living here. To compensate for this there are plans to add a conservatory area to increase the amount of shared space. Domestic style furnishings and fittings are provided, and decoration schemes have been developed in consultation with service users. Bedrooms have been decorated and furnished in a domestic manner and a regular, planned cycle of cleaning is implemented. Two have en-suite bathrooms. The new bedroom does not have an en-suite toilet and shower fitted, but an additional bathroom is being provided, again to compensate for this. Domestic type laundry facilities are provided, and a shared bath is available on the ground floor. A small number of health and safety matters were identified around the building. See the ‘Conduct and Management of the Home’ section below. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff team have received little training over the past year. Regular training can help ensure that service users are supported in a safe manner by staff who have an understanding of their needs. Service users are protected by the home’s recruitment policy and practices, which can help ensure unsuitable candidates do not gain employment in the home. Staff are given few opportunities to formally meet to discuss issues and their performance on a one to one basis. Regular, structured supervision sessions are important for the management of the staff team, and in allowing views and issues to be shared and discussed. EVIDENCE: Staffing levels are maintained to a level where there is never less than two care staff working at any one time during the day (8:00am to 9:00pm and 10:00am to 9:00pm at weekends). The home is funded to provide two staff to Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 22 one service user staff support for two recently placed service users. This level of additional staffing cover is only sustained for short periods during the day. Staff are paid from 7:00am during weekdays and 9:00am at the weekends. Staff often work between a number of homes operated by Ashdown Care Homes Limited. Some of the staff working here are therefore managed from a different home. The examination of a sample of staff records and confirmation by the manager indicated that staff are only employed in the home after the receipt of sufficient background checks having been carried out, which help determine their suitability to carry out their role. These checks include the receipt of a Criminal Records Bureau ‘disclosure’, two written references, and confirmation of physical fitness. Where the manager obtains verbal confirmation regarding references received this is now documented, as recommendation in the last inspection report. Once recruited to the home, staff need to receive a range of training, relevant to the needs of service users, health and safety, and to care in general. There has been little in the way of training offered and arranged for staff over the past twelve months. Some staff have had no training over this period. Two out of the 11 care staff working here have undertaken and achieved an NVQ in care, at level 2 or higher. Training and attaining qualifications in care are one of the issues that can be discussed at staff supervision and appraisal sessions. However, these are infrequently arranged or carried out. Two staff members have had none over the past year. Where these have been carried out there is evidence that these are a two way process, where improvements can be suggested by the care worker, as well as issues being raised by the manager and her deputy. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has relevant qualifications and experience to carry out her role. The quality of the service is regularly checked. This can help ensure the service remains focused on their needs and aspirations. The home is generally free from hazards to service users. This can contribute to the health, welfare and security of service users. EVIDENCE: There is a clear management structure within the home. There is a manager, a deputy manager and a team of care workers. The owner provides periodic oversight, and carries out monthly inspection visits. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 24 The registered manager is qualified to NVQ level 4 in management, and to level 4 in care. Since the last inspection she has attended training relevant to her post and the needs of service users. Courses attended have been: • • • ‘health and safety / risk assessment’, none abusive physical and psychological interventions (nappi)’ and ‘emotional freedom techniques’. As well as ensuring her own knowledge and practice remains up to date, the registered manager undertakes a number of quality checks and audits to see what standard of care is being offered. An annual questionnaire survey is also conducted to gain the views of service users’ relatives and independent representatives. However, due to the communication needs of some of the service users living at the home, it is not always easy to gain a clear understanding of service users’ views. Just as the quality of the care provided is checked, so are matters affecting health and safety. Therefore regular checks on the building are carried out, water and fridge / freezer temperatures are monitored, and working practices that could present a risk are looked at. During the inspection the following health and safety matters were identified: • • • Missing lock from chemical cupboard. Chemical and hazardous products without safety data sheets or risk assessments. Fire door held open with door wedge. Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 25 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 X 2 1 3 X 4 1 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 1 32 1 33 X 34 3 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X X 1 Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 26 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 YA2 Regulation 14(1)(a to d) Requirement All prospective service users must have their needs assessed (and a copy of the assessment obtained by the registered manager) before they move to the home. A letter from the manager confirming that on the basis of the assessment the service users needs can be met here must be sent to the service user and those acting on their behalf. This is to ensure the manager has sufficient information on which to develop a plan of care, and to ensure this home is suitable for the person concerned. This is a new requirement. A copy of the contract agreed between the home’s owners and the placing authority (in this case Gateshead Council) must be kept at the home. This is so the service users and those acting for them know what has been agreed to on their Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 27 Timescale for action 21/12/07 2 YA5 5(3) 21/12/07 3 YA17 behalf. This is a new requirement. 18(1)(c)(i) All staff who prepare or handle food on behalf of service users must attend externally accredited training on, and be deemed competent in food hygiene (to at least foundation level). This is to ensure that they are aware of and can practice good food handling and hygiene techniques. This is a new requirement. 18(1)(c)(i) All staff who administer medication must attend and successfully achieve an accredited award in the safe handling of medication. This is so they are aware of current practice and safeguard the health and welfare of service users. This is a new requirement. Internal and external medication stocks must be stored separated to ensure good hygiene practice. This is a new requirement. The reason for medicines being omitted must be recorded on the medication administration record. 21/05/08 4 YA20 21/05/08 5 YA20 13(2) 21/12/07 6 YA20 13(2) 21/12/07 7 YA31 18(1)(a) This is to make it clear why a medicine has not been administered. This is a new requirement. 30/11/07 The registered person must review staffing levels to ensure that they remain at least adequate to ensure the welfare of service users and the safety of both service users and staff. The previous action plan date for this overdue requirement was 12/01/07. DS0000069991.V350666.R01.S.doc Version 5.2 Page 28 Eastbourne Avenue 8 YA31 17(2) The staffing rota must only include the working hours for staff working at this home. 21/12/07 9 YA35 This is to make it clear who has worked here and when. This is a new requirement. 18(1)(c)(i) Staff must receive regular training, relevant to their job role and the purpose of the home. This is to ensure they are aware of good practice in meeting service users needs, health and safety matters, food hygiene, and so on. This is a new requirement All staff must received regular, structured supervision and performance appraisals. This is to ensure they are well managed and have the opportunity to share their views and discuss issues that affect both service users and staff. This is a new requirement. The following health and safety matters must be attended to, to ensure the health, safety and welfare of service users and staff: Missing lock from chemical cupboard. • Chemical and hazardous products without safety data sheets or risk assessments. • Fire door held open with door wedge. This is a new requirement. • 21/05/08 10 YA36 18(2) 21/12/07 11 YA41 13(4)(a to c) 30/11/08 Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 29 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 YA5 Good Practice Recommendations The registered person should review and amend the residency agreement to: • Accurately reflect the respective responsibilities for payment of fees. • The point at which fees no longer become payable following the death of the service user. This is a repeated recommendation. The registered person should prioritise care plans and ensure that these are regularly monitored, evaluated and reviewed in consultation with service users. This is a repeated recommendation. Risk assessments should be reviewed at regular intervals to ensure they remain up to date and relevant. This is a new recommendation. 2 YA6 3 YA9 Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Eastbourne Avenue DS0000069991.V350666.R01.S.doc Version 5.2 Page 31 - 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. 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