CARE HOME ADULTS 18-65
Newfield View - 6/8 Gleadless Avenue 6/8 Gleadless Avenue Sheffield South Yorkshire S12 2QH Lead Inspector
Paula Loxley Unannounced Inspection 12:40 7 December 2005
th Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.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 Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.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. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Newfield View - 6/8 Gleadless Avenue Address 6/8 Gleadless Avenue Sheffield South Yorkshire S12 2QH 0114 281 0818 0114 281 0818 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) Mrs Mandy Billard Mr Clifford Anthony Billard Mrs Mandy Billard Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.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: The home is a large domestic style detached house located in an attractive residential area in the south east of the city, situated close to local amenities and public transport. Newfield View is currently registered to provide 24hour care for 8 younger adults with a learning disability. The home has 8 single bedrooms and all rooms have been decorated and furnished to a high standard. Two bedrooms have en-suite facilities provided and one bedroom has an ensuite shower/wet room. All bedrooms have been individually personalised by each service user. Several areas of the home have recently been redecorated and refurbished to a high standard and this has ensured that the home is exceptionally well maintained, welcoming and homely. During the last eighteen months a new heating and fire alarm system have been installed and the home has been completely rewired. In October all external areas of the home were repainted. There is a large, private and attractive rear garden and this is well stocked and maintained. A greenhouse, external lighting, out-door seating with sun parasols in addition to garden ornaments and potted plants have also been provided. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day from 12:40 pm to 16:40 pm. As part of the inspection process the inspector spoke to three service users and three staff, including the manager. A number of records were checked and several areas of the building were inspected. All key standards that had not been assessed on the last inspection in June 2005 were checked in addition to the progress made on any outstanding requirements. Service users appeared relaxed and happy and were obviously comfortable with the manager and staff with whom they had developed positive relationships. The inspector would like to thank service users, the manager and staff for their help with the inspection process. What the service does well:
The service continues to work positively with all service users to ensure that their needs are met. Service users said they enjoyed living at the home where they felt comfortable and well cared for by staff that they referred to as ‘their family’. Service users were encouraged to maintain contact with their family and friends and some service users regularly enjoyed social activities in the local community. The homes minibus provided transport for service users when needed and two staff employed by the home were now approved to drive the bus. Care plans had been developed within a new format and service users and staff had been involved in the development of these to ensure that each individuals needs were clearly identified. The home continues to be exceptionally well maintained and is attractively furnished and decorated. Service users said they were really happy with the work that had been done to the home and the new curtains and carpets that were in their rooms. All areas seen were very clean and service users said that they helped with some of the domestic tasks. Service users were provided with a healthy diet that was varied and nutritious. Service users said they loved the food that was well cooked and that other choices were always provided if they wanted them. They said they sometimes fetched a take-away at weekends and that they enjoyed these too. The appropriate systems were in place for the control and administration of medication and the homes systems were regularly checked by a local pharmacist. Staff continue to undertake training on a regular basis and the manager confirmed that two staff were due to start their NVQ level 2 training in care in the new year. The home is very well managed and the manager is keen to see the service develop further to ensure that a quality service is provided and that the minimum standards are exceeded. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None- please see below. These standards were assessed on the last inspection and scores of 3 and 4 were achieved. This means that at that time the home met or exceeded the required minimum standards for standards 1-5. EVIDENCE: Not applicable. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. Service users individual needs had been assessed and reviewed. Care plans had been updated within a new format and staff confirmed that this ensured they had the relevant information on each individual in their care. Some sections of the plan had not been regularly reviewed and therefore it could not be ensured that service users were fully protected. Service users were supported to take risks however discussions with the manager confirmed that this could be expanded to further encourage and develop each individual’s independent living skills. EVIDENCE: Since the last inspection care plans have been updated within a ‘Person Centred Plan’ (PCP) format and staff had been involved in the development of these with service users. The manager confirmed that she and the staff team had completed training on PCP’s and that further training on care planning and goal setting was planned early in 2006. Two plans checked clearly detailed each individuals needs under several headings including communication, contacts, culture and religion, nutrition, finances, limitations and risks, activities and leisure, routines, new things to learn and the future.
Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 10 Details of the support required by staff had been recorded and daily records included the action taken by staff to support each person with their needs. Detailed healthcare sections confirmed that service users needs had been identified and reviewed. Professional advice had always been sought when staff had identified any health issues or concerns. Inventories had not been updated on a regular basis and several risk assessments, including COSHH, had not been regularly reviewed and reassessed. Information seen recorded in the care plans checked, and discussions with staff, confirmed that service users were supported to take some risks within their everyday routines. Observations of individual routines and discussions with the manager identified areas where some service users could, with the right planning and staff support, further develop their independent living skills. One example of this would be the preparation and cooking of snacks/ meals. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.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 and 17. Service users were well supported by staff to develop and maintain family links and friendships, inside and outside of the home. Service users were provided with varied and nutritious food that they said they enjoyed and that ensured they maintained a healthy diet. EVIDENCE: Service users confirmed that their family and friends were made to feel very welcome at the home and that staff supported them with visits if they wished. One service user said that her sister regularly joined her on her annual holiday away with the home and that this made her very happy. Other service users that had regular contact with family members said the manager and staff encouraged them to maintain contact and that they could see their visitors in private if they wished. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 12 Service users said that they enjoyed the meals at the home. The two-week menu had been discussed at service user meetings and any changes requested had been implemented. Alternatives were available for anyone not wanting the set menu and service users said the meals were varied and well cooked by staff. Service users confirmed that a variety of drinks were available and that they always had enough to eat. One service user said that since she had moved to live at the home staff had helped her to maintain a healthy diet. As a result of this she had lost weight and felt much happier because her health had improved. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.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. The home had the appropriate medication policies and procedures in place to ensure that service users were protected. EVIDENCE: The manager confirmed that service users would be able to administer and control their own medication if this was assessed as being appropriate to the individual service user. All medication received, administered and disposed of by the home had been signed for as required and medication was securely stored. Staff administering medication, had completed accredited training and were aware of safety procedures, recording systems and any possible side effects that specific items of medication may cause. Medication reviews had taken place regularly and it was positive to note that intense monitoring and recording had been undertaken when any particular concerns had been identified by staff. The manager confirmed that a local pharmacist visited the home every three months to audit the homes medication systems. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.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): 23. The home had the appropriate adult protection policies and procedures in place to ensure that service users were protected from abuse, neglect and self-harm. EVIDENCE: Training records checked confirmed that staff had completed training on Adult Protection and staff were aware of the different forms of abuse and of the appropriate procedures for reporting any suspicions or evidence. The policies and procedures included whistle blowing and the Department of Health Guidance ‘No Secrets’. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.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): 25, 27 and 30. Service users were provided with a bedroom that ensured that their individual needs were met. The toilets and bathrooms met each individuals needs and the appropriate locks had been fitted to ensure the privacy of service users. All areas of the home checked were very clean, fresh smelling and exceptionally well maintained. EVIDENCE: All service users were provided with a single room that had been individually decorated and furnished to a high standard. Service users confirmed that they had been involved in choosing their own bedding and curtains and that they were able to personalise their rooms how they wished. Service users said that they were comfortable in their room and happy because they had everything that they needed. Service user meeting minutes confirmed that service users had been involved in discussing any redecoration programmes for the home and that any issues relating to their environment were discussed fully. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 16 Service users were able to easily access the two main bathrooms on the first floor or the shower room on the ground floor. The appropriate fittings had been provided and all areas had recently been redecorated or refurbished. Two bedrooms had an en-suite toilet and sink provided and one bedroom had an en-suite shower/wet room. All areas of the home checked were clean and free from offensive odours. Service users confirmed that they shared some of the household tasks in the home and that they helped to clean their own rooms. Policies and procedures were in place for the control of infection and all equipment was in good working order. The communal areas of the home were attractively decorated and furnished and this created a homely and welcoming atmosphere. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 17 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): 34 and 36. Service users were supported by the homes recruitment policy and practices and this ensured that they were well protected. Staff received the appropriate support and supervision to ensure that service users needs were met. EVIDENCE: The inspector checked the staff recruitment file for one member of staff recently recruited by the home. All of the required documentation was available and copies of references and proof of identity had been retained. Newly recruited staff had been confirmed in post following receipt of a health declaration, two written references and a satisfactory CRB check at the enhanced level. The manager confirmed that service users had been actively involved in the recruitment of new staff and service users said that they were pleased with the staff that cared for them at the home. The staff file also contained a copy of the individual’s job description, dress code, induction programme, training records and personal development plan. The manager had recently introduced a ‘stress guidance’ and ‘staff retention’ policy for staff. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 18 Discussions with staff and the manager, and records checked, confirmed that staff received regular individual supervision and records of this were maintained. Minutes of staff meetings were checked and staff had signed to confirm that these were accurate. Staff meetings had not been held regularly as there had only been two recorded since the last inspection in June of this year. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 19 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, 41 and 42. Service users benefit from a home that is well managed. Records checked were securely stored, well organised and in the main up to date. The manager was committed to ensuring that the rights and best interests of service users were promoted. The appropriate health and safety policies and procedures were in place at the home and staff had completed all of the required statutory training. Written risk assessments had been completed for the home however these had not been reviewed as required and therefore the health and safety of service users could not be fully ensured. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 20 EVIDENCE: The registered manager has successfully completed the registered managers award and is currently undertaking NVQ level 4 in care. She has a wealth of experience of caring for people with a learning disability in a residential care setting. Discussions with the manager and staff confirmed that they are committed to developing the service to ensure that service users needs are met and that each person is supported to become more independent. Since the last inspection the manager had improved the standard of the records retained by the home and any requirements found on the last inspection had been addressed. Rotas detailed the shifts being worked by all staff and service users finance records had been signed as required. The manager had monitored all records and she had signed to confirm this. Any issues found relating to records have been reported on elsewhere in this report under the relevant standard. The accident records checked confirmed that there had been no accidents recorded since the last inspection. New forms for recording accidents had recently been introduced at the home to take into account requirements relating to the 1998 Data Protection Act. The appropriate safety notices were posted throughout the home. Written risk assessments had been completed however these had not always been reviewed as regularly as required. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 21 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 X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score X 4 X 4 X X 4 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 4 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 4 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 4 X Standard No 37 38 39 40 41 42 43 Score 2 X X X 3 2 X Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? NO 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. Standard YA6 YA9 Regulation 17 16 Timescale for action Inventories and risk assessments 28/02/06 in care plans must be regularly updated. All service users must be 31/03/06 provided with the opportunity to develop their independent living skills. Staff meetings must be held 31/01/06 regularly. Written risk assessments must 28/02/06 be regularly reviewed and reassessed. Requirement 3. 4. YA36 YA42 18 13 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 YA37 Good Practice Recommendations The registered manager must complete NVQ level 4 training in management and care, or equivalent by 2005. Newfield View - 6/8 Gleadless Avenue DS0000002988.V268729.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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