CARE HOME ADULTS 18-65
Hallgate, 28 28 Hallgate Hexham Northumberland NE46 1XD Lead Inspector
Karena M Reed Unannounced Inspection 31st January 2006 14:45p Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 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 Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 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. Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Hallgate, 28 Address 28 Hallgate Hexham Northumberland NE46 1XD 01434-600465 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) hallgate@hexham28.fsnet.co.uk At Home in the Community Mr Ian Thomas James Duthie Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th October 2005 Brief Description of the Service: Hallgate is a small home, registered to provide personal care and support to five adults with learning disabilities. Nursing care is not provided. It is situated in the Northumbrian market town of Hexham and is conveniently placed for local amenities, such as shopping, restaurants and leisure centres as well as transport links to other parts of the North East such as Newcastle and the Coast. The home is not recognisable as a care home from the outside. The premises are a grade 2 listed building with access gained from the front street, and an enclosed terrace type garden to the rear of the building. There is a large dining room and lounge. Bedrooms are all for single use and there are sufficient lavatories and bathrooms. Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 1and a half hours. A partial tour of the premises took place and a sample of records were inspected which included: 1 care plan, the fire log, accident book, admission/discharge register, complaints record, staff communication book, staff meeting minutes, service user meeting minutes. I spoke to two support workers and one service user who was on the premises at the time of inspection. What the service does well: What has improved since the last inspection? What they could do better:
The Organization to carry out requirements and recommendations from previous inspections within the stipulated time scales .
Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 6 The Statement of Purpose and service user guide must be made available and accessible to service users. Information to be in an accessible format for service users . To include within the policy about confidentiality when information about a service user may be shared with a third party. A formal quality assurance system to be established. More regular supervision for staff at least every two months to be carried out. 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. Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 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 Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5 Information is not currently made available from the home to potential service users to make them aware of the service the home provides. A contract is not available between the home and the service user detailing the services provided by the home to the individual service user. EVIDENCE: A Statement of Purpose was not available detailing the services provided by the home, although the Organization has drafted a Statement of Purpose for all its services that will need to be localized. The service user guide is also currently in draft form and needs to include more information to tell people who may wish to live at the home about the services provided. Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 Service users know that information about them is handled appropriately, and that their confidences are kept. EVIDENCE: The policies and procedures manual contains an up to date policy about confidentiality, this should include when information about a service user may be shared with a third party. Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 11 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): These standards were not assessed at this inspection. EVIDENCE: Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 13 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): These standards were not assessed at this inspection. EVIDENCE: Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 14 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): 31,32,35,36 Staff benefit from clarity of staff roles and responsibilities. Service users’ individual and joint needs are met by appropriately trained staff. A system is available to ensure the staff team are supervised within the home . EVIDENCE: All Staff receive a written job description that outlines the duties and responsibilities of their role. Staff records and discussion with staff confirmed that they receive induction training. New members of staff follow LDAF, Learning Disability Award Framework in order to give people more insight into the needs of people with a learning disability. Recent training for staff members includes person centred planning , epilepsy awareness, management training and the necessary statutory training. A system for staff supervision is in place within the home, however supervisions take place six monthly currently. Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 A quality assurance system has not been formed to gather the views of service users and other stake holders . EVIDENCE: The home does not have a formal quality assurance programme, which includes seeking the views of residents, relatives and other interested parties, to feedback on the quality of care provided on an annual basis. Service users meetings and staff meetings take place regularly. Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 16 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 2 2 x 3 x 4 x 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 3 32 x 33 x 34 x 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x x x 2 x x x x Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 17 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. 2. 3. 5. Standard YA1 YA5 YA36 YA39 Regulation Reg 4(1) Sch1 5 18(2) 24 Requirement A Statement of Purpose and service user guide must be devized. An accessible contract must be provided between the service user and the home. To establish a regular supervision system for managers of the Organization. To form a quality assurance system. Timescale for action 01/04/06 01/04/06 01/04/06 01/04/06 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 Refer to Standard YA6 YA10 Good Practice Recommendations To make care plans accessible to all service users where possible. To include within the confidentiality policy when information may be shared with a third party on behalf of a service user. Hallgate, 28 DS0000000672.V275917.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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