Inspection on 06/06/07 for Eastholme

This inspection was carried out on 6th June 2007.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Eastholme 29/11/05

Eastholme 16/05/05

Eastholme 10/08/04

Eastholme 20/05/04

Eastholme 03/12/03

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 Eastholme Denehouse Road Seaham Durham SR7 7BQ Lead Inspector Mrs Tanya Newton Unannounced Inspection 6th June 2007 10:30 Eastholme DS0000007468.V342726.R02.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 Eastholme DS0000007468.V342726.R02.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. Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastholme Address Denehouse Road Seaham Durham SR7 7BQ 0191 5812656 F/P 0191 5812656 denise.grufferty@autismnorth.co.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) Autism North Limited Monica Catherine Hindson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Eastholme DS0000007468.V342726.R02.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: 4 The maximum number of service users who can be accommodated is: 4 29th November 2005 Date of last inspection Brief Description of the Service: Eastholme is registered for four adults with learning disabilities between the ages of 18 and 65 years. It is a specialist service, which provides care for people with autism. Currently four young women live in the home, which is a spacious semi-detached house in a quiet cul-de-sac. The house has four single bedrooms, generous communal space and garden and it is close to Seaham town centre, the beach and train services to other towns. Autism North manages Eastholme. Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. Records were looked at and the inspector spent time talking to staff. A visitor also provided feedback during the inspection. People living at the home have limited communication so the inspector spent time watching the way in which staff interacted with them. The home also sent some information to The Commission prior to the inspection, which provided the inspector with information about the home. What the service does well: What has improved since the last inspection? What they could do better: The amount of fruit and vegetables should also be recorded so that peoples dietary needs can be monitored. Quality assurance systems should be developed further to gain the views of relatives and other professionals visiting the home. The fire risk assessment should be reviewed to ensure that it complies with recent changes to fire legislation. The range of fees charged must be included within the homes information and made available for CSCI to publish within their reports, so that people can be given greater choice about the services they receive. This follows on from the report published by the Office of Fair Trading. (OFT) Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 Page 6 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. Eastholme DS0000007468.V342726.R02.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 Eastholme DS0000007468.V342726.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are well managed by the home. EVIDENCE: All people living at the home had been there for a long period of time so there were no recent admissions to gather information on. The home does have an admissions procedure, which is detailed. One of the relatives said how well the home had managed the admission of their daughter and how excellent the support from staff was. Each person is provided with a contract and staff read through the statement of purpose with each individual person, recording their ability to understand this. Copies of these documents are also given to the parents. Feedback from all relatives confirmed that the home was meeting people’s needs appropriately. Eastholme DS0000007468.V342726.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans continue to reflect individuals changing needs in a detailed manner. People are encouraged to participate in all aspects of life within the home. EVIDENCE: The standard of care planning was very high with particular regard given to risk management demonstrating that staff had a clear understanding of each person’s individual needs. Although all people living at the home have very limited communication, the care plans demonstrate a deep understanding of the additional ways that people communicate non-verbally and through signing. Decision-making is encouraged at all times and the way in which staff support people to do this is recorded in peoples files. Observations made throughout the inspection found that staff interacted well with all people living at the home. Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 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. 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 using available evidence including a visit to this service. There are a variety of social opportunities available, which all people living at the home participate in. Staff respect peoples rights and respond to their wishes. Mealtimes are a relaxed social occasion. EVIDENCE: It is clear that the home provides a range of activities which people living in the home enjoy. The home has a choice and consultation file with pictures to assist people when choosing where to go or what to do. These are completed after each activity and followed up by comments and an outcome of how successful the trip was. People living at the home have autism and very limited communication. They are able to let staff know what they want very effectively. Staff are skilled in determining what people are saying, either by behaviour or gesture. This enables them to respond to choices people are Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 Page 11 making. There are policies in place to guide staff and these include choice and consultation and sexuality. One of the relatives said that she was always made welcome to the home and had great respect for all of the staff working there. The home has a menu file, which includes weekly menus, individual service users likes and dislikes and individual eating guidelines. Weight loss programmes are put in place where required. The menus did not include 5 portions of fruit and vegetables each day. Two of the people living at the home do not eat vegetables, a dietician has been involved and both are on vitamin supplements. This should be recorded within the care plan. All people have access to fruit at any time the home should try to record daily fruit intake as well so that records are more up to date. Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were clearly being looked after in a way that supported them as individuals and clearly met their needs. Medication systems continue to be safe. EVIDENCE: People’s personal and healthcare needs were well documented within care plans with reviews taking place on a regular basis. Each person’s individual needs are catered for. Feedback from relatives in this area was excellent. People are encouraged to be as self-managing as possible. One of the relatives said that their daughter had developed an excellent range of skills since being admitted to the home. Medication systems were safe. All staff administering medication had undergone training first. Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has taken reasonable steps to make it possible for people to complain. Policies and practices within the home protect people from the risk of abuse. EVIDENCE: The home has clear policies for complaints and adult protection which include pictorial versions to make them more accessible to people living at the home. Staff have received training in adult protection, they also receive training in restraint, however this is seldom used. Staff have attempted to go through the complaints procedure with people and this is then recorded within their care file. There is a lot of recorded info about people’s ability to communicate and how staff can tell if there is a problem. Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is safe, well maintained and comfortable for the people who live there. EVIDENCE: The environment is well decorated and maintained. All rooms are individually furnished and decorated to suit individual needs and choices. Standards throughout the home were high. The home is clean and well maintained. Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 Page 15 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): 32, 34 & 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staffing levels meet people’s needs and are determined by what people are doing. Staff are recruited in a manner, which protects people. Staff training is of a high standard. EVIDENCE: Staffing levels are higher during weekdays so that residents can take part in activities, which need a lot of support from staff to be safe. Three or four staff on duty is usual and this can rise to five or six on some shifts. At weekends for much of the time two staff are on duty. However the manager tries to make sure that for some part of the weekend that this number is increased so that residents can go out more easily. One of the staff takes particular responsibility for the housekeeping role and prepares meals, which ensures a consistently high standard. 11 of the staff have now achieved NVQ 2 in care. New staff carry out the LDAF-accredited induction training, which is recommended for staff in homes for people with learning disabilities. There is a programme to make sure that Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 Page 16 all staff receive training in core areas such as first aid and food hygiene as well as in specialist areas such as understanding autism and restraint. The manager uses supervision sessions to deliver training on particular topics to all staff. The home has established procedures for recruitment, which include obtaining references and doing CRB/POVA checks. Checks of personnel files showed that these procedures were followed. There are some vacancies, which are being filled. People have been interviewed but the home is waiting for CRB checks. Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 Page 17 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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements in the home are satisfactory. Systems to monitor quality standards within the home should be further improved. Health and Safety systems are sound and protect people. EVIDENCE: The previous registered manager has moved to a different service, the home now has a new manager who is registered with CSCI. Staff were very positive about the recent changes to the management arrangements. Quality assurance systems were also viewed, most of the information was outdated, particularly questionnaires. The home should develop further systems to gain feedback from relatives and other stakeholders. Maintenance checks were up to date. The fire risk assessment needs to be updated to comply with recent Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 Page 18 changes to fire legislation. The senior in charge was not sure whether or not this had been done. Health and Safety systems protect people and keep them safe. Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 Page 19 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 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Eastholme DS0000007468.V342726.R02.S.doc Version 5.2 Page 20 NO 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 YA5 Regulation 5b Requirement The home must provide information regarding the level of fees charged. Timescale for action 31/07/07 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 2 3 Refer to Standard YA17 YA39 YA42 Good Practice Recommendations A record of all fruit and vegetables should be included within menus. Further quality assurance systems should be implemented to seek the views of relatives and other professionals. The fire risk assessment should be reviewed to see if it complies with recent changes to fire safety. 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