Inspection on 01/11/05 for Serlby Close (11)

This inspection was carried out on 1st 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Serlby Close (11) 07/01/08

Serlby Close (11) 02/10/06

Serlby Close (11) 18/05/05

Serlby Close (11) 01/12/04

Serlby Close (11) 12/05/04

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Craigmore House

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

CARE HOME ADULTS 18-65 Serlby Close (11) Coach Road Usworth Washington Tyne And Wear NE37 1EN Lead Inspector Miss Andrea Goodall Unannounced Inspection 1st November 2005 10:00 Serlby Close (11) DS0000015765.V253359.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 Serlby Close (11) DS0000015765.V253359.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. Serlby Close (11) DS0000015765.V253359.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Serlby Close (11) Address Coach Road Usworth Washington Tyne And Wear NE37 1EN 0191 419 4162 0191 419 4172 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) Northgate & Prudhoe NHS Trust Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Serlby Close (11) DS0000015765.V253359.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2005 Brief Description of the Service: The house at 11 Serlby Close provides accommodation and care for 8 younger adults with Autism. Northgate & Prudhoe NHS Trust operates the care service. The home is a modern, 2 storey, purpose-built house owned by Three Rivers Housing Association, which remains responsible for repairs and maintenance to the property. The house divides into two units that are accessed through the middle communal area containing an activities room, staff room and laundry room. Each unit contains a lounge, a dining room, a fully fitted kitchen, 4 good-sized bedrooms, a bathroom, and a shower room. The house is not intended for use by people with a physical disability. However there is level access into both units, and there are toilet/shower facilities and one bedroom on the ground floor in both units. Access around the ground floor would be suitable for any visitor with mobility needs. The house is close to local village facilities such as small shops and pubs. There is a home vehicle for residents use, and there are local public transport routes to Sunderland and Washington centres. Since the last inspection the Manager has taken up a new post within the Trust. The Assistant Home Leader has applied for registration as the Manager, and her application is currently being processed by CSCI. Serlby Close (11) DS0000015765.V253359.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day. The Inspector spent time with all of the young men who live here. Some people here find it difficult to express their views but others talked about the house, their activities and the food. Time was spent in their company, observing their interaction with staff and looking at their bedrooms with them. Time was also spent with the staff on duty discussing the progress of the service. Some records were examined, including care records, medication systems and health & safety records. About half of the homes premises were examined. What the service does well: What has improved since the last inspection? Care files are much easier to follow. Lots of old information has been stored, so now the files have up to date information for staff to follow. This helps them find information about how to help residents much quicker. The new support plans also include goals about what the residents want to do, such as decorating their bedroom. More bedrooms have now been repainted in the colours chosen by the residents. This makes them seem like they belong to the residents. Serlby Close (11) DS0000015765.V253359.R01.S.doc Version 5.0 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. Serlby Close (11) DS0000015765.V253359.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 Serlby Close (11) DS0000015765.V253359.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): 5. Each resident has had a written contract, which includes a statement of terms and conditions of their residence at Serlby Close. EVIDENCE: Most of the men have lived here since the home opened over 7 years ago, and one person moved here over 2 years ago. They each had a copy of a contract that outlined the terms and conditions of their residence, which is written in plain English with some pictorial symbols. The contracts are now archived in residents individual files. There is also some detail of the cost of their placement and funding arrangements, although again these are stored in files so are not easily accessible to residents. However each resident has an Information Pack in their bedrooms and this includes much of the information that would be included in the contract. The information pack is written in a mix of pictorial symbols and plain English. In this way some information is made as accessible as possible for residents. Serlby Close (11) DS0000015765.V253359.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, 7 & 10. Residents needs and personal goals are reflected in their care plan, but these do not always include changes in needs. Residents are supported to make daily decisions and choices. Residents have had information about how to access their own files. EVIDENCE: There have been some improvements to care plans. These have been streamlined and now include only the pertinent, individual goals of each person. In this way care plans are now an informative tool that guide staff in their support of the people who live here. The files are easier to manage and information can be more readily extracted. However, some long-term goals have not been reviewed for well over a year. As a result some areas where significant changes have occurred have not been recorded e.g. weight loss or new equipment. For short-term goals the date and timescales have not been recorded so it not possible to see where progress has been made. Serlby Close (11) DS0000015765.V253359.R01.S.doc Version 5.0 Page 10 The care plans have not been signed by residents so there is no demonstration that residents have been involved in drawing up the care plans. The nature of Autism Spectrum Disorder can make it difficult for people to cope with too many choices. From discussions and observations it is clear that the residents are involved in making their own decisions from a small number of familiar options such as what to wear, what to eat, and what activities to take part in. Every daily task involves the residents in a discussion about how they would like to be supported and by whom. In this way residents are encouraged to make daily decisions. There is a now a statement about residents rights to access their own records that is in easy language and some symbols. This has been verbally explained to residents but the actual statement has been put away in their files, where they will rarely see it, and not in their Information Pack. Serlby Close (11) DS0000015765.V253359.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): 16 & 17. Residents rights are respected, and their responsibilities promoted. Residents are offered a balanced menu that suits their lifestyle and dietary needs. EVIDENCE: Residents were seen to make choices about how to spend their day and when to spend time in the privacy of their own rooms. All bedroom and bathroom doors are lockable by residents, and residents rights to privacy are respected. Staff supported residents to be involved in the daily household tasks as far as their capabilities allow, and include them in all discussions about the home. In this way residents were included in the running of their home. Residents said that they like the meals. Some people were able to describe how they are involved in shopping and preparing meals cooking with staff support. All the residents are asked for their meal suggestions for the 4 weekly menu. Residents go shopping twice a week with staff to local supermarkets and more often to local grocery shops. Serlby Close (11) DS0000015765.V253359.R01.S.doc Version 5.0 Page 12 The menus include healthy options, and the range of choices has recently broadened as 2 people are now supported with a low cholesterol diet. Residents also have take away meals and occasional meals out. Both of the units has its own dining room where residents and staff can dine together. Serlby Close (11) DS0000015765.V253359.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): 18 & 20. Residents receive supervision to manage their own personal care needs. The staff manage medication on behalf of residents but the method of carrying medication around the home needs to be reviewed. EVIDENCE: The 8 people who live here do not need physical support to manage their personal care, e.g. washing, shaving and brushing teeth. Staff provide support through prompts and encouragement for this area of care. Some people do need staff supervision when having a bath to ensure their safety. There are 4 male staff on the staff team to make sure that residents are supported when using public changing rooms in the community. At this time none of the residents has been assessed as able to manage their own medication, so staff manage this for them. Medication systems and storage are in place, and most staff have had training in Safe Handling of Medication. Medication is delivered to the home in Monitored Dosage blister packs for administration by staff. However during this visit staff carried medication for 4 different people in one dosette box (rather than their own individual blister packs). This is secondary dispensing and is not best practice. The Royal Pharmaceutical guidelines states, The best way of administering medicines to a service user is directly from the dispensed container. Serlby Close (11) DS0000015765.V253359.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 & 23. Residents have information about how to make a complaint if they are not happy with the service. There are clear adult protection procedures in place but these have not always been followed by some staff, which does not support the protection of the residents. EVIDENCE: The Trust has a clear Complaints Procedure for the people who live here. It is in plain English and in pictorial symbols, and is in the Information Pack, which each resident keeps in their own bedroom. In this way it is as accessible as possible for the people who live here. Residents are also asked at Residents Meetings if they are unhappy with any aspect of the service they get at this home. As with all care services for adults in the City of Sunderland, the Trust has adopted the MAPPVA (Multi-Agency Panel for the Protection of Vulnerable Adults) policy and procedures. These are robust procedures for dealing with suspected abuse. Most of the staff have training in MAPPVA procedures so they should know what to do in the event of suspected abuse. The Trust is currently investigating an incident that was reported by staff. This matter is not yet concluded. However there was a significant delay between the alleged incident and the time it was reported. In this way some staff are either not aware of, or failed to follow, their duty of care under the General Social Care Council Code of Practice, the MAPPVA procedures, and the Trusts own protocols. Serlby Close (11) DS0000015765.V253359.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 & 26. Residents live in a comfortable, safe and homely environment. Bedrooms promote their independence, choice and privacy. EVIDENCE: The house is a modern building that is split into two units of accommodation. It is suitable in design for the people who currently live here, and is bright, comfortable, well furnished and decorated to a good standard. The home also benefits from an out building, which has additional activity space for the people who live here. There is also a large back garden, which residents enjoy for games and barbecues. There have been improvements to the homes décor since the last inspection. A rolling programme of decoration means that some bedrooms and both lounges have been repainted. A new carpet has been fitted to the hallway and stairs of one unit. Serlby Close (11) DS0000015765.V253359.R01.S.doc Version 5.0 Page 16 The bathrooms are now very ready for attention, particularly in the East unit. Also the door to the shower room in the East unit is sticking and so it is difficult to pull shut. Residents have all chosen their own colour schemes for their own bedrooms. Bedrooms are becoming more personalised by residents and there is a good sense of ownership of each room by the people who live here. Residents showed the Inspector their rooms and some said that they like their room. Residents were seen to spend time in their own rooms when they want. Bedrooms are all lockable from the inside. Staff said that currently no-one can manage a key to their room. Serlby Close (11) DS0000015765.V253359.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): 33, 34 & 35. Staffing level currently meet the needs of the people who live here. Residents are protected by the homes recruitment procedures. Staff are appropriately trained to meet the specific needs of people with Autism. EVIDENCE: The minimum staffing levels for this home are 4 Support staff on duty throughout the day (2 staff per unit) and 2 staff on night duty (one of whom is on waking duty). In addition, there are also Enabler staff who have specific duties in relation to occupational and leisure activities for the people who live here. At the time of this visit there were 4 Support staff on duty and 1 Enabler. The Trust operates robust recruitment and selection procedure that includes all necessary checks and clearances. In this way the appointment of new staff ensures the protection of the people who live here. All staff have ID cards that they can use as proof of their role when supporting residents in communitybased activities. There have been few changes to staff over the past year. However recent changes to the daily management team will mean that there will be vacant Support Worker post. Serlby Close (11) DS0000015765.V253359.R01.S.doc Version 5.0 Page 18 Training records could not be accessed during this unannounced visit, as the Acting Manager was not on duty. However, staff confirmed that they receive Autism Awareness training as part of their induction training when starting to work at this home. Over half the staff team have achieved NVQ level 2 or above, and several other staff are undergoing this training. Serlby Close (11) DS0000015765.V253359.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 & 42. There has been a change in the running of the home. Overall the health and safety of residents is promoted. EVIDENCE: Since the last inspection the Manager has taken up another post within the Trust. The Assistant Home Leader has been appointed as the Manager, subject to registration, which provides some continuity of daily management of the care for the residents. The Applicant Manager is supported by a line manager and there is a clear plan of accountability within the Trust. All staff receive mandatory training in health & safety. The Trust carries out full health & safety audits of the home and procedures for health & safety practices are in place. There were no health and safety issues noted within the premises during this visit. Serlby Close (11) DS0000015765.V253359.R01.S.doc Version 5.0 Page 20 The fire log records showed that fire alarm tests and tests of Dorguard closures were slightly overdue. Fire instruction records could not be found during this inspection. At the last inspection it was stated that staff receive fire instruction during supervision. However staff did not know if there is a demonstrable, accessible record of such instruction. Serlby Close (11) DS0000015765.V253359.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 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x x 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 4 x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Serlby Close (11) Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x DS0000015765.V253359.R01.S.doc Version 5.0 Page 22 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 YA6 Regulation 15 Requirement Support plans must demonstrate how residents have been involved in their own care planning. Any significant change in goals/needs must be reflected in the support plan. Support plans must be reviewed at the given timescales. Medication must not be secondary dispensed, and must be administered to a resident directly from the original container. All staff must be re-instructed in the procedures for reporting suspected abuse, and reminded of their duty of care in line with the General Social Care Council Code of Practice. The redecoration of both bathrooms must be included in the programme of decoration; and the door to the East unit shower room must be attended to. A record must be kept of the inhouse fire instruction detailing each member of staff, their signature, the date and content of instruction, and the name of DS0000015765.V253359.R01.S.doc Timescale for action 01/01/06 2. YA20 13(2) 01/12/05 3. YA23 13(6) 01/12/05 4. YA24 23(2)(d) 01/01/06 5. YA42 23(4)d 01/12/05 Serlby Close (11) Version 5.0 Page 23 the instructor.(Previous timescale of 01/08/05 not met.) 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 YA10 Good Practice Recommendations Consideration should be given to including the new Access to Information statement in the residents Information Pack. 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