Inspection on 15/11/05 for Finchley House

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Finchley House 15/09/06

Finchley House 14/06/05

Finchley House 26/01/05

Finchley House 03/06/04

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 Finchley House 57 Brandling Street Roker Sunderland SR6 0LP Lead Inspector Mrs Elsie Allnutt Announced Inspection 15th November 2005 09:00 Finchley House DS0000015744.V253577.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 Finchley House DS0000015744.V253577.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. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Finchley House Address 57 Brandling Street Roker Sunderland SR6 0LP 0191 510 8448 0191 510 8448 finchleyhouse@c-i-c.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) Community Integrated Care Jaqueline Gannon Care Home 6 Category(ies) of Learning disability (6), Physical disability (3) registration, with number of places Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 Brief Description of the Service: Finchley House was purpose-built as a Residential Care Home in 1993. The property is owned and maintained by Three Rivers Housing and Community Integrated Care delivers the service. The home is built in a residential area in the Roker area of Sunderland and is amongst other housing which pre-dates the home. It is within walking distance of the sea front, shops and local amenities, such as a post office, hairdresser and pubs. The home is currently registered to provide care for 6 adults under 65 years who have learning disabilities and additional physical disabilities. The age range is 28 to 60years. Four of the service users rely on the use of wheelchairs for mobility and are encouraged to be independently mobile around the house. A team of staff support the service users to live a full and active lifestyle and a mini bus owned by the home is available to access the local community. The security of the building has been enhanced through the installing of security lighting. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took 6.25 hours over one day in November 2005. The views of five service users and six members of staff were sought. As all service users have communication needs their satisfaction of the service was interpreted not only through speech but the observations of body language, interaction with staff, discussions with staff and the examination of records. This process demonstrated that all were satisfied with the service and the care and support given by staff. Service users were able to give an explicit account of their life in the home and a relative who was visiting the home at the time of the inspection also gave their views of the home. As part of the inspection process a tour of the building took place and the service users’ care files and a sample of the homes records were examined. What the service does well: This service provides accommodation of a good standard. It is well maintained and as a result of effective cleaning routines offers a clean and hygienic environment. As found at the previous inspection the friendly interaction of service users and staff create a warm and welcoming atmosphere in the home. By observing life in the home it was evident that service users are supported to live a full and active lifestyle. Staff were observed working with respect and skill and involved service users in making their own choices about what they preferred to do. Service users are encouraged to communicate effectively and were observed to be a positive part of conversation and discussions with staff relating to issues regarding the home and the service delivered. Two service users were included in the time spent with the manager examining records as part of the inspection process. Care plans are well documented, up to date and relevant. There is evidence that the home attempts to make them accessible to service users by using pictures to illustrate what is being recorded. Recent meetings have been carried out by the home where service users, their families and other people involved in their care were invited to discuss the service users needs and progress. A relative visiting at the time confirmed this. The way the record of the meeting is presented proves that the meeting was lead by the service user. Simple language and photographs assisted the service user to demonstrate their opinion about life at Finchley House. Good care practices reflect, a good staff training programme, and strong leadership lead by a qualified management team. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? The refurbishment programme carried out throughout the home is now almost complete. The standard of accommodation has been improved for all service users. As well as the communal areas of the home being redecorated and refurbished, this now includes individual bedrooms. After considering advice and the preferences of service users and their families, the home has now replaced all service users’ bedroom furniture and small furnishings with good quality furniture and furnishings that coordinate with the décor. The call cords that were cut off during the refurbishment process in the bathrooms have now been replaced making the new comfortable environment a safer facility to use. Concerns and complaints are addressed seriously by the home and these are recorded appropriately following the homes Complaints Procedure. Staff have acted as advocates for service users when they felt that the behaviour or expression indicated dissatisfaction with the service or someone else’s behaviour, this was then logged as the service user’s complaint and dealt with accordingly. Observation of the interaction between service users and service users and staff proved that the communication skills of the service users have developed further since the last inspection. As a result, service users are becoming more confident and taking a greater part in the development of their own lives and the running of the home. This is a credit to the way staff are consistently working with individual service users, addressing their needs and encouraging further development. Small lockers have been provided by the home to be used by staff so that their personal property is kept safe when working at the home. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 7 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. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 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 Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users needs are assessed prior to admission in order to determine that their needs can be met by the home. EVIDENCE: One service user moved into the home last year from another service. The manager explained that, prior to moving in, the home requested information regarding their needs and also carried out their own assessment to ensure that the home could meet their needs. The assessment and care plan from the referring agency is comprehensive and includes important and relevant information about the service user, including a description of their behaviours and risks that are related to them. The home’s records and the service user’s relative, who was visiting on the day of the inspection, confirmed that the service user had visited the home prior to admission. Records of a six-week review confirmed that the home had stated that they were able to meet the service users needs. The home’s care plan reflects the needs identified in the assessment and has risk assessments in place in relation to the risks identified, for example there are risk management plans with guidelines for staff to follow regarding challenging behaviour. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 10 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 Service users assessed needs are reflected within their individual plans of care, which provide guidance for staffs’ care practice. EVIDENCE: Care plans reflect that service users assessed needs are met and their rights and independence are promoted. To ensure a consistent approach to the care of individual service users, all are allocated a key worker who is responsible for the monitoring of the care plan. Although all of the service users living at this home have different needs, service users’ individual difficulties are evident and recorded appropriately. The guidelines, that were evident in the care plan for staff to follow in relation to these, maintain a consistent approach. Information in the care plans demonstrate that service users are supported to take part in as normal a life as possible and the risks that may be involved in doing this are addressed and risk management plans put in place. These are an integral part of the care plan. Service users’ changing needs are addressed and recorded, for example one service user has recently progressed with their independent mobility and guidance from the physiotherapist is recorded to guide staff to be consistent in their approach. This reflects the progress made. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 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): 15,16,17 Service users are supported to take part in a variety of leisure and community based activities, and as a result live a valued lifestyle, while at the same time are successfully supported to maintain personal and family relationships. To also maintain a balanced and healthy lifestyle varied, wholesome food is provided by the home. EVIDENCE: During the inspection a family member who was visiting the home confirmed that they are always made to feel welcome when they visit and are included “like part of the family.” A service user discussed with delight how staff had supported them to visit their family members even though they lived in a different town. Records also confirmed this. Records and photographs confirmed that the different venues and holiday destinations taken this year had reflected the aspirations and choices of the service users. Service users, supported by staff, discussed with enthusiasm the experience of flying and spending time in a different country. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 12 During the day service users were engaged in different activities including attending day centres and college, shopping in town and taking part in activities at home. Two service users shared their excitement about going to a drama group early that evening. Individual records confirmed a regular and full activity programme for all service users. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 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): 20 Staff follow the home’s safe and comprehensive policies and procedures when administrating medication to service users, service users are therefore protected from harm. EVIDENCE: Prior to the last inspection mistakes had been made in relation to the administration of medication. The manager stated that such errors have now stopped and staff realise that the process merits their full concentration and attention. Staff confirmed that all staff have now received training in relation to the administration of medication and the home’s guidelines are followed. Staff emphasised that they do not allow themselves, when involved in the process, to be distracted in any way. The home has a sound policy and comprehensive procedures in relation to the administration of medication and medicines are stored appropriately and safely. There were no discrepancies found in the medication records. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Arrangements are in place to seriously address complaints and concerns about the service, however staff must ensure that their personal concerns and any concerns communicated by service users, but advocated by them, are identified separately, so that it is clear where the complaint is coming from. EVIDENCE: The home has a complaints procedure that is comprehensive and in picture format so that service users have access to it. A visiting relative confirmed that they were aware of the procedure and would have no hesitation to make a complaint if needed. The complaints Book confirmed that complaints and concerns are taken seriously, recorded and satisfactorily addressed. However the manager agreed that further discussion would take place with staff in relation to issues surrounding the logging of complaints and the understanding by staff in relation to advocating for service users. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,30 Service users live in a homely safe and comfortable environment that provides adequate facilities that meets their individual needs, personality and preferred lifestyle. However ineffective cleaning routines of the new shower appliances could put service users at risk of cross infection. EVIDENCE: The refurbishment of the home is now almost complete. This includes all of the living areas and individual bedrooms that have been refurbished with new furniture as well as décor and small furnishings. Service users showed their delight in these areas. The toilets are in the final stages of refurbishment having had new toilet and sink units fitted. New non-slip flooring has recently been fitted and the paintwork is planned to take place in the near future. The refitting of the call cords in the bathrooms have now provided a safe place to bathe and the extension of the curtain rail around the shower area now provides an area that promotes the privacy and dignity of service users. Service users, staff and relatives, who were visiting at the time, demonstrated their satisfaction and appreciation of the comfortable surroundings. The manager discussed the plans to refurbish the laundry room and the plans still to be actioned, by the owners of the building Three Rivers Housing, in relation to the added security needed for the carport. Finchley House DS0000015744.V253577.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): 35 A well-trained and competent workforce, that receives appropriate training opportunities in relation to their individually assessed training profiles, supports the service users living at this home. EVIDENCE: Staff discussed the needs of the service users with respect and understanding. When observing staffs’ social interaction with service users, their response, and the way they addressed service users’ needs, it was evident that positive relationships continue to develop between them. Service users and relatives spoke positively about staff and one relative described them as a “dedicated team who are good at what they do”. Staff training profiles demonstrates individual training needs, training completed and the training to be done. There was evidence that there is good progress being made in relation to NVQ training and the manager is confident that the home will reach the target of 50 of staff qualified by December 2005. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The manager, who is well supported by a senior member of staff and the staff team, provides good leadership and runs a service that has effective monitoring systems and is focussed on the best interests of the service users. EVIDENCE: The Registered Manager is now fully qualified having achieved the Registered Managers Award and NVQ 4 in Care. The manager confirmed that she has enough time to carry out her managerial duties by not always being included in the duty rota. A senior member of staff effectively assists the manager with the managerial role. An examination of the staff rotas confirmed this. The manager was however, observed working with the staff team when necessary and guiding them discreetly and competently. Staff and service users were observed responding effectively and showing respect towards their manager. Service users receive an effective service as a result of effective policies and procedures being in place. Records proved that they are regularly monitored Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 18 and reviewed. A discussion took place with the manager in relation to the monitoring systems. Although the home has good monitoring systems in place these are all recorded in different files. It was suggested to the manager that the quality monitoring of systems might be more effective and easier to access if they are kept in one file that was referred to as the Quality Assurance File. The manager was receptive to this idea. Staff were aware of health and safety issues and carried out their roles accordingly. The fire log and accident book were examined and were satisfactory. As there has been no inspection carried out by the Fire Department since 1997 the manager was advised to contact them to request a visit, so that the fire service could advise if necessary. A recent visit from the Environmental Health proved positive with some very positive feedback in relation to recent improvements made in the home. A recommendation made by them in relation to recording the temperature of food when tested with a probe is now being carried out. Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Finchley House Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000015744.V253577.R01.S.doc Version 5.0 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 YA42YA30 Regulation 13(3) Requirement So that service users are not put at risk of cross infection staff must be aware of how the new shower chair dismantles so that it can be cleaned thoroughly after each use. Timescale for action 30/11/05 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 YA22 Good Practice Recommendations Further discussion should take place with staff in relation to issues surrounding the logging of complaints and, in relation to this, the understanding by staff in relation to advocating for service users. The plans to extend the carport should go ahead. The plans to refurbish the laundry should go ahead. The home should meet the target of 50 of staff qualified in NVQ by December 2005. It is recommended that the quality monitoring systems are brought together as one Quality Assurance System to ensure that the service is monitored and developed in relation to the views of the service users. 2 3 4 5 YA24 YA24 YA32 YA39 Finchley House DS0000015744.V253577.R01.S.doc Version 5.0 Page 21 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. 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