Inspection on 22/12/05 for Saltshouse Road

This inspection was carried out on 22nd December 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Saltshouse Road 27/02/09

Saltshouse Road 11/12/06

Saltshouse Road 07/07/05

Saltshouse Road 25/01/05

Saltshouse Road 12/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Saltshouse Road 199a 201a 203a Saltshouse Road Hull East Yorkshire HU8 9HG Lead Inspector Christina Bettison Unannounced Inspection 22nd December 2005 09:30 Saltshouse Road DS0000000911.V275387.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 Saltshouse Road DS0000000911.V275387.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. Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Saltshouse Road Address 199a 201a 203a Saltshouse Road Hull East Yorkshire HU8 9HG 01482 618096 01482 329337 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) Avocet Trust Carol Ann Osbourne Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: The service at 199a-203a Saltshouse Road is managed by Avocet Trust who rent the premises from Sanctuary Housing. It is one of a small number of similar services that Avocet provides. Avocet Trust is a registered charity. 199a-203a Saltshouse Road consists of three separate units registered to provide care for 8 service users with a learning disability. The property is set back from the main road in the corner of a new residential estate, built in the old grounds of Tilworth Grange Hospital. 199a has three bedrooms one upstairs; all other accommodation is at ground floor level. 201a has two bedrooms and 203a has three. All bedrooms are singles four of which have ensuite facilities. Each unit has its own lounge, dining room, laundry room and shared bathroom. All units have their own front door and separate garden areas to the rear. The properties adjoin each other and share a large communal patio / garden at the front. Nearby there is a range of local shops, pubs, and health services. Public transport to various parts of the city is easily accessible and in addition some of the service users have leased their own cars; arranged through their mobility benefits. Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4 hours and was an unannounced inspection. A tour of the premises took place; staff files and training records were examined. 4 of the staff, the registered manager and the service users that were at home were spoken to. Care practices and interactions were observed during the inspection. This report should be read in conjunction with the previous inspection report as the majority of national minimum standards were assessed at the previous inspection. What the service does well: What has improved since the last inspection? A contract / statement of terms and conditions that meets the requirements of this standard has been developed and has now been agreed with service users and / or their representatives. All staff have got an individual training profile, thereby ensuring that their training needs are highlighted to ensure that they are able to meet the needs of the service users. The manager has completed a training audit for the home to enable her to identify staff training needs and develop a training plan. Recruitment practices have improved; all staff now have ID as required by regulations, this means service users are protected from harm. The majority of staff have completed in house protection of vulnerable adults training to ensure that service users are protected from harm. The policy/procedure for the use of restrictive physical interventions had been produced to ensure that staff are aware of their responsibilities and are able to protect service users from harm. Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 Page 6 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. Saltshouse Road DS0000000911.V275387.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 Saltshouse Road DS0000000911.V275387.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): 5 All service users are provided with a statement of terms and conditions that has been agreed with service users and / or their representatives. EVIDENCE: There had been no new service users (who would have had their needs assessed) come to stay at Saltshouse Rd since the previous inspection; therefore the majority of these standards were not assessed. A contract / statement of terms and conditions that meets the requirements of this standard had been developed and has now been agreed with service users and / or their representatives. Saltshouse Road DS0000000911.V275387.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): EVIDENCE: All of these NMS were assessed at the previous inspection and met therefore they were not assessed at this inspection. Saltshouse Road DS0000000911.V275387.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): 14, 17 All service users enjoy a healthy and varied diet and a variety of leisure activities. EVIDENCE: NMS 11-16 were assessed at the previous inspection and met therefore they were not assessed at this inspection, apart from NMS 14. The manager showed the inspector a model that they use at Saltshouse Rd to ensure that all service users have active community involvement and participation in activities and events. In this case it was particularly related to Christmas. The model consisted of a plan of Christmas events that a particular service user likes to undertake, all presented in a pictorial format with dates attached as to when the event would take place and who would be supporting the service user. Examples of what is included in the plan are; attending the pantomime, Christmas parties, visits to friends, visits to family to deliver Christmas presents, Christmas shopping and putting up the Christmas decorations. This provided a good plan that all staff could follow, assisted Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 Page 11 service users to be involved in the preparation of the plan and was good evidence as to what had taken place. The manager and staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. Breakfast consists of a variety of cereals, porridge, toast, tea, coffee and juice, with a full cooked breakfast on a weekend. Lunch is a choice of sandwiches, soup, toasted sandwiches, beans or egg on toast. Options on the menu for dinner included chicken, mince, pizza, pasta, fish, all served with fresh vegetables and the manager confirmed that there is always plenty of fresh fruit available. Any restrictions are clearly documented in the care plan and agreed to by the service user. Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The service users physical and emotional needs are met, by the provision of a wide range of healthcare professionals and outside agencies, however the inadequate medication training compromises this. EVIDENCE: NMS 18 and 19 were assessed at the previous inspection and met therefore they were not assessed at this inspection. The home has policies and procedures for the administration of medication and staff had commenced the medication training. They have not yet completed module 3 that includes a competency check or a workbook to complete at the end to ensure staff understand their responsibilities. Therefore this remains an outstanding requirement from the previous inspection. Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The staff team are aware of the Protection of Vulnerable Adults policies and procedures and their responsibility within these, thereby service users are protected from abuse, neglect and harm. EVIDENCE: Since the previous inspection the manager has provided in house briefings for all staff to inform them about the Protection Of Vulnerable Adults Policies and Procedures and their responsibilities within this. Staff members have to complete a questionnaire following the training to demonstrate their understanding. If the manager has any concerns with regard to any staffs understanding she will ask then to undertake the training again or pick it up in supervision. The inspector examined both the training pack and individual questionnaires, which evidenced good practice and linked in with the multi agency guidelines. Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 On the whole service users are provided with homely, comfortable and safe environment in which to live however attention must be given to providing en suite facilities to a specified service user in which to protect her dignity. EVIDENCE: All of these NMS were assessed at the previous inspection and met therefore the majority were not assessed at this inspection. However the home had received a letter from a relative of one of the service users living in the house highlighting the lack of privacy and dignity afforded to the service user when using the WC. The inspector discussed this with the manager and staff of the house. The house has only one bathroom without a WC and a separate WC facility for service users and staff in the house. The particular service user prefers to take her time and leave the door open, which opens directly onto the corridor and therefore does not protect her privacy and dignity. The service user must be provided with an en suite WC and there must be another WC installed for the other service users and staff use. Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Service users are cared for by a staff group, which is sufficient in numbers to meet their needs, however inadequate training does not ensure that service users needs can be met. EVIDENCE: NMS 31,33 and 36 were assessed and met at the previous inspection; therefore they were not assessed at this inspection. The inspector was informed that the home still only has 7 out of 31 care staff that are NVQ qualified, she is hoping to register 4 staff in January 2006. Therefore this remains an outstanding requirement. Recruitment practices have greatly improved; all staff now have 2 written references and CRB clearances this means service users are protected from harm. The manager has completed staff individual profiles and a staff training audit which evidences were there are gaps in staff skills, she has requested places on training courses to meet these skills gaps and staff have attended some Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 Page 16 training; all staff have completed modules of the medication training provided by the local authority and all staff have had an in house POVA briefing. All certificates for training completed are now being held on site. The manager still needs to provide a training plan for the home and ensure that all staff are up to date with mandatory training, to include infection control. Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 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): 40 Service users live in a safe environment however all staff need to be up to date with mandatory training to ensure that the health, safety and welfare of service users is promoted. The policies and procedures are out of date and do not reflect current practices in the home. EVIDENCE: NMS 37-39 and 41-43 were assessed and met at the previous inspection; therefore they were not assessed at this inspection. The registered manager presented herself as friendly and approachable throughout the inspection, she had a clear sense of direction and aims for the home and was making good progress towards meeting requirements previously made. The manager is approved and registered with the CSCI. Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 Page 18 It was evident throughout the inspection that the service is centred around the service users. The Manager supported staff to ensure this was the case. Policies and procedures were examined as part of the previous inspection since then some have been updated, one of these being the use of physical interventions. The quality assurance manager is making steady progress in reviewing and amending the policies and procedures in line with changes in legislation and best practice guidance and the timescale for completion has been agreed at 31/1/06. Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 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 x 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 3 ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 2 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 2 36 x 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 4 15 x 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 x x x x 2 x x x Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Requirement The registered person must ensure that all staff complete their training in the safe handling of medication and are assessed as competent. (Timescale of 30/09/05 not met) The registered person must provide en suite WC facilities for a specified service user to protect their privacy/dignity. The registered person must ensure that at least 50 of staff are qualified to NVQ level 2 and new staff need to be registered for LDAF induction (Timescale of 1/12/05 not met) The registered person must ensure that all staff are up to date with mandatory training and this must include infection control. (Timescale of 30/09/05 not met) The registered person must ensure that a training plan is developed for the staff team in the home. The registered person must ensure that Avocets policies and procedures are updated and amended in line with legislation DS0000000911.V275387.R01.S.doc Timescale for action 31/03/06 2 YA27 23 (2j) 12 (4a) 18 31/03/06 3. YA32 30/06/06 4. YA35 18 31/03/06 5. YA35 18 31/03/06 6. YA40 24 31/01/06 Saltshouse Road Version 5.1 Page 21 and best practice guidance. 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 should complete the registered managers award by the 31st March 2006 Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. Extracts may not be used or reproduced without the express permission of CSCI Saltshouse Road DS0000000911.V275387.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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