Inspection on 07/01/08 for Serlby Close (11)

This inspection was carried out on 7th January 2008.

CSCI found this care home to be providing an Good service.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Serlby Close (11) 02/10/06

Serlby Close (11) 01/11/05

Serlby Close (11) 18/05/05

Serlby Close (11) 01/12/04

Serlby Close (11) 12/05/04

Similar services:

22 Sandown Road

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Dilston College Of Further Education

West View House

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Park View (15)

Craigmore House

1 Lanark Close

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 7 and 18 January 2008 10:00a th th Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 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.V352899.R01.S.doc Version 5.2 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.V352899.R01.S.doc Version 5.2 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 4162 fiona.beattie@nhs.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Northumberland, Tyne & Wear NHS Trust ** Post Vacant *** Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd October 2006 Brief Description of the Service: The house at 11 Serlby Close provides accommodation and care for 8 younger adults with Autism. Northumberland Tyne & Wear 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 a central 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 registered manager transferred to another management post within the Trust. Over the past 15 months there have been several temporary management arrangements. The home does not currently have a registered manager. The fee for a placement at 11 Serlby Close is £864.16 to £1,012.88 per week. (The people who live here contribute £63.95 towards the weekly fee.) Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Before the visit: We looked at: • information we have received since the last visit on 4th October 2006 • how the service dealt with any complaints & concerns since the last visit • any changes to how the home is run • the provider’s view of how well they care for people • the views of people who use the service & their relatives, staff & other professionals The Visit: An unannounced visit was made on date 7th January 2008. Another visit was made on 18th January 2008 to talk to the temporary manager. During the visits we: • talked with people who use the service, staff and the manager • joined residents for two meals and looked at how staff support the people who live here • looked at information about the people who use the service & how well their needs are met • looked at other records which must be kept • checked that staff had the knowledge, skills & training to meet the needs of the people they care for • looked around parts of the building to make sure it was clean, safe & comfortable • checked what improvements had been made since the last visit We told the manager what we found. What the service does well: The home makes sure that it is still the right place for people to live in. The people who live here make their own choices about activities, clothes, and holidays. They enjoy lots of activities every day. There are enough staff to help people go out when they want. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 6 Staff help the people who live here to go to local shops, pubs, and sports centres. People have made their bedrooms look like they want. People said that they liked their bedrooms. One person said, “It’s my room - I chose the colours and I like it”. Another person said, “My room is very nice.” The home makes sure that people get help from health services when they need it. 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. The summary of this inspection report can be made available in other formats on request. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 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.V352899.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. People who use the service experience adequate quality outcomes in this area. A full assessment of peoples’ needs means that the home can be sure that the service is right for them, but residents are not well-informed about the service because of the out-of-date information they get. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Each resident has an Information Pack in their bedroom and this includes information about menus, activities, fire procedure and complaints procedure. However much of the content is out of date, including activities timetables, menus and who to contact with a complaint, so it is misleading. This incorrect information is particularly confusing for the people here as they have Autism Spectrum Disorder. The Information Pack is written in a mixture of pictures and plain English. However much of the information in stick figures is very difficult to understand and confusing. Some residents find photographic or standard pictorial symbols easier to read. This was reported at the last inspection, but the information has not been updated. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 9 Before any of the 8 men moved into this home, their needs were assessed by a range of health and social care professionals. Each resident and their relatives or representatives were involve in the assessments. In this way the Trust ensures that only people whose needs can be met move into this home. It is also good practice that any changing needs of residents are reassessed. The home holds on-going reviews, with other professional where necessary, to ensure that it can continue to support any change in a residents needs. For example, the home arranged for two residents to be assessed by relevant health professionals following an increase in their behavioural needs. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience adequate quality outcomes in this area. Residents have opportunities to make decisions about their own lifestyles, but their progress is not recorded so it is not clear if residents are supported to achieve their personal goals. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: There are support plans in place for each of the people who live here. These include appropriate goals and support needs such as health eating, safety awareness, communication and mental health. There have been some improvements to how care records are filed so that they are easily accessible. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 11 Some areas of the care plans have not been kept up to date. For example, most of the care plans examined were set in April 2007, but there have been no reviews to show whether there is any progress or change in need. Another goal for one resident to make his own sandwich had not been reviewed since September 2006. There are key worker meetings with each resident to set their own short-term goals such as choosing furniture, and arranging holidays. However these meetings have been very infrequent, not monthly as planned. In the sample examined there had been only two in the past year, so there is no follow-up to show whether the residents have been supported to achieve their own goals. It is likely that the many changes in management arrangements have had an impact on this. The acting manager confirmed that the priority had been to get care files in working order, and that reviews and monthly key worker meetings will now be put in place. The long-term support plans are written in a form that residents could not understand. There is currently no indication in the care files whether residents have been involved in their own care planning, or the reasons why not. 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. In this way residents are encouraged to make daily decisions. The young men who live here are supported to take part in their choice of activities that may incur an element of responsible risk, for example, sports and using public transport. There are risk assessment records in place to demonstrate whether risks have been considered acceptable and to show the actions staff take to support residents in these areas. For example, risk assessments showing why someone could not manage their own bedroom key, and other assessments to show that they can manage trampolining. Some have not been reviewed for over 18 months. Some others simply had a date recorded, but no written review to state whether the risk assessment was still appropriate. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. Residents are supported to lead their own preferred lifestyle that respects their rights to individuality, choice, and privacy. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The people who live here have access to a good range of age-appropriate activities every day. These are mainly sporting or leisure activities. For example, on the morning of this visit some people went for a walk to the bank or Post Office, or went out on the bus for a ride. In the afternoon, some people went 10-pin bowling, or used the sensory room. This evening some people went to the local pub. In this way everyone has daily opportunities to go out. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 13 Support staff provide all the support for each persons activities programme (and one person also has a separate part-time ‘enabler’ to assist him with daytime activities). The home also has a suitable activities budget in order to fund many of the daytime activities. These are mainly community-based activities that include horse-riding, hydro pool, bowling, cinema, cycling, gym and trips out. Only one person attends any structured occupations outside of the home, that is college courses of their choice twice a week. At this time none of the people who live here have paid or unpaid employment. (For at least one person this is at their choice.) The acting manager discussed her plans to broaden the residents’ opportunities for purposeful activities e.g. creating a vegetable garden and using the produce for cooking. The people who live here make good use of many local community facilities, including shops, pubs, library, bowing club, sports centres, and local transport. The home is in a modern housing estate that was built 10 years ago. It is inkeeping with the other properties in the area, and residents have good relations with neighbours. In this way, they are part of the local community and there are currently no limitations or barriers to their involvement in local community facilities. Most residents have good contact with relatives. Some people go to their family home for short breaks and weekends. Other relatives visit the residents at Serlby Close. 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 support 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 rights and responsibilities are respected. At this time it is not known if residents’ names are included in the electoral register, so the acting manager is to look into this. Some people go grocery shopping with staff. Other people cannot tolerate large, noisy environments but do have opportunities to go shopping at local grocery shops. All the residents are asked for their meal suggestions for the 4 weekly menus. It was clear from discussions with some residents that their favourite dishes are included in the menus. Everyone chooses their own breakfast. There is a menu in each kitchen for the lunch and teatime choices (and other alternatives can be made.) The teatime meal choices on this day were jacket potatoes with various fillings or spicy burgers. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 14 The menus include healthy options, as well as occasional take-away meals and meals out. Both units have their own dining room where residents and staff can dine together. At least one person can make their own drinks and snacks independently and some people are sometimes supported to be involved in preparing their own sandwiches. In discussions, the acting manager and staff are aware that some people could be supported to learn to be more independent in this area, and that this is an area for development. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. Residents receive support in the right way so their physical, emotional, and health care needs are met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The young men who live are physically fit and so can manage their own personal care needs with verbal prompts and guidance from staff. None of the residents require physical support. It is good that there are now more male staff in the team to provide genderappropriate support and positive role-models for the 8 men who live here. Staff were encouraging and patient while supporting people, and residents were relaxed and engaged in staff’s company. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 16 There was one occasion when a staff provided too much support for a resident, even thought he was fully able to manage the self-care task himself (that is, wiping his face.) This practice was unintentionally disabling for the person and treated them as if they were a child. There was also continence equipment left on display in a shower room that did not support residents’ dignity. If it is necessary to have it to hand, this could be kept discreetly in a bathroom cupboard. There are clear health care records which show that the home ensures that residents have regular access to the right health care services when required. For example, psychiatrists, opticians, chiropodists and dentists. It was also clear from health records that parents are now kept informed of forthcoming healthcare appointments and outcomes. None of the people who live here have been assessed as able to manage their own medication. However it is possible that, with lots of support, in time at least one person could manage all or part of their medication independently. Medication is managed by the home using a standard monitored dosage system. This means most medication is delivered by a pharmacist to the home in blister packs. The home has arranged for some people’s medication to be provided in liquid form as they find this easier to take. The storage and administration of medication is appropriate, and all records of medication were in good order. All staff who administer medication have had training in Safe Handling of Medication. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. The home’s procedures and staff training make sure that people are protected from abuse. We have made this judgement using a range of evidence, including a visit to the service. 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 that each resident keeps in their own bedroom. However the contact details are now out of date. Residents are also asked at Residents Meetings if they are unhappy with any aspect of the service they get at this home, and records are kept of residents comments. There are also Complaints Records, which are regularly audited by a representative of the Trust. There have been no formal complaints about this service over the past 3 years. All staff have training in the local authority protection of vulnerable adults procedures. They also receive brief annual refresher training in safeguarding guarding adults. This means that staff would know how to report bad practices or suspected abuse. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 18 All staff have had training in physical interventions, so that they can safely support the challenging behaviour of residents. Staff receive annual training in this area. There is clear guidance to show how and when staff should intervene to support someone with their behaviour. There are also clear records to show when and why this has been necessary. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30. People who use the service experience good quality outcomes in this area. Overall the standard of decoration and furnishing in the home is satisfactory so that residents enjoy comfortable, warm and safe accommodation. We have made this judgement using a range of evidence, including a visit to the service. 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 in most areas. At the time of this visit the hallways and stairways are in need of redecoration. The current acting manager commented that due to the many temporary management arrangements over the past year, no-one had taken responsibility for redecoration. As a result it has not been kept up to the usual Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 20 good standard in some areas of the home. However this is now being addressed and the hallways are to be redecorated in the near future. Also the worn carpet in one bedroom is to be replaced soon. Repair work has been carried out to address damp in one shower room, which has also resulted in a large plaster area in the adjacent lounge that now requires decoration. Both shower rooms are also in need of redecoration. The shower fittings in both shower rooms are not high enough for comfortable use by the men who live here. Both kitchen ceilings have flaking or patchy paintwork, and the lighting in one kitchen is broken. However most other communal areas of the home and the bedrooms remain bright, well decorated and comfortable. Some people have redecorated their bedrooms in their own preferred colour schemes. Some people showed me their rooms and said, “It’s my room - I chose the colours and I like it”, and “My room is very nice.” Residents appear to have a great sense of ownership of their bedrooms as these have been highly personalised with pictures, bedding, and home-entertainment equipment. There is good freedom of movement around this home. Resident spend their time as they choose either in the comfortable lounges or in the privacy of their own bedrooms. Cleaning is mainly carried out by staff, although residents are encouraged and prompted to participate in some household tasks such as clearing dishes after meals and hoovering. The home was generally clean and hygienic. The light pull cords to all communal WCs (including the staff WC) are still rather grubby, and may present a possibility of cross-infection. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People who use the service experience good quality outcomes in this area. The home provides competent, well-trained staff in sufficient numbers to ensure that the needs and choices of residents are met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The minimum staffing levels for this home were previously 4 support staff and 2 enabler staff on duty through the day. (Enabler staff had specific duties in relation to occupational and leisure activities for the people who live here.) However, since the last inspection the home no longer employs enabler staff. The staff rota shows that there are instead between 5 and 6 support staff on duty. This staffing level includes additional support provided for one resident for activities. (There is a separate arrangement where a part-time enabler is provided by Social Services Department for another resident.) Since the last inspection 8 staff have left or have been transferred to other services by the Trust. Another staff is on maternity leave. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 22 There have been 7 ‘new’ staff to start work here. The Trust operates robust recruitment and selection procedures that includes all necessary checks and clearances, to make sure that only suitable staff are employed. However all 7 changes are the result of staff being transferred here from other care services operated by the Trust. Staff turnover over the past year represents more than a third of the staff team. Such a high staff turnover could have compromised the continuity of care of the people who live here, especially during a time of management instability. However the turnover has also resulted in some positive changes. There are now more male staff working here, and this has a beneficial impact on the men who live here. The acting manager also commented that there is good teamworking amongst the current staff team. This supports a consist approach, especially towards behaviours, which in turn has helped residents to feel confident about the way that staff support them. Staff stated that they have “good” opportunities for training. There is an individual learning plan for each member of staff that identifies any training that they need. The home also has a record of all training courses already attended by each staff. Of 20 staff in the team, two staff are registered nurses and at least 15 have achieved or are about to complete NVQ level 2, which is a care qualification. In this way the majority of staff have had suitable training in care. However, the acting manager confirmed that it is likely that some ‘new’ staff (who have transferred here from other services) may not have any training in Autism Awareness, which is specific training to help them understand the needs of the people who live here. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good quality outcomes in this area. Overall the home is satisfactorily managed on a day-to day basis, but the many change in management arrangements may compromise the continuity of care of the people who live here. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: About 13 months ago the registered manager transferred to another similar service run by the Trust. In that period there have been 4 different management arrangements at this home. At this time, another former manager has returned to the home to manage it until a long-term decision is Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 24 made. (She was formerly the registered manager of the home a couple of years ago, so is a suitable person to be temporarily managing the service.) However it is not known by the acting manager how long this ‘temporary’ management arrangement will be in place, and the Provider has not informed CSCI about the proposed future management of this service. In discussions staff commented how unsettling the various ‘temporary’ management arrangements have been. Staff stated that each ‘manager’ has had their own distinct style, and feel that the home’s management is currently in a state of ‘limbo’. The Trust uses a number of quality monitoring tools to audit the service at this home. These include monthly visits by a representative of the Trust to the home to check on its operations, and to talk with residents and staff for their views. However there have only been 7 recorded visits in the past 12 months. Residents views of the service they receive are sought at Residents Meetings, which have been held about 3 monthly. The acting manager stated that these are now to be held monthly. Due to the nature of Autistic Spectrum Disorder most residents would find it difficult to complete satisfaction questionnaires independently. Staff receive mandatory training in health & safety matters on an annual basis through the Trust. The records of safety checks that were examined were up to date. Since the last inspection staff took appropriate action to support two residents to Accident and Emergency for advice and treatment following accidents during activities. However CSCI did not receive the required notifications about these two events. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 25 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 3 X X 3 X Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 5(1) & (2) Requirement The Information pack must be brought up to date, including the complaints procedure, and the information provided in suitable formats to meet the communication needs of the people who live here. Timescale for action 01/04/08 2. YA6 15 3. YA24 23(2)(d) This is to ensure that residents have clear information about the service they use. (Previous timescale of 01/01/07 not met.) Residents’ support plans must be 01/04/08 kept under review to show any progress towards goals or any change in need. The hallways, stairwells and both 01/04/08 shower rooms require redecoration; the flaking paintwork to both kitchens needs attention; the broken light to the kitchen needs fixing; the shower fittings need to be raised so that they can be comfortably used by residents; and the bare plastered area in East lounge needs decoration. This is to ensure that the Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 27 4. YA37 39 residents live in a home that is reasonably decorated. The Provider must keep CSCI informed about changes to the management arrangements of this service and ensure that an application for a registered manager is in progress. This is to ensure CSCI is aware of who is managing the service and that the person is ‘fit’ to be in charge. The Provider must carry out and report on Regulation 26 visits at least monthly. This is to ensure that the Provider is fully aware of the home’s operations. 01/03/08 5. YA39 26 01/03/08 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 YA16 YA18 Good Practice Recommendations The home should check to see if residents’ names are included in the electoral register and, if not, support them to do so. Staff should not carry out care tasks for residents that they can manage themselves, and should help people to store personal equipment in a discreet way to protect their dignity. The medication procedures should make clear the issue of capacity, where only health care professionals can make decisions about a residents health care needs. Light pull cords should be replaced with cleanable cords. Any new staff who have not had specific training in ‘Autism Awareness’ should be provided with such training to support them to understand the needs of the people who live here. Staff are reminded that the home must notify CSCI about any accidents to residents that require medical DS0000015765.V352899.R01.S.doc Version 5.2 Page 28 3. 4. 5. YA20 YA30 YA35 6. YA42 Serlby Close (11) intervention. Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Serlby Close (11) DS0000015765.V352899.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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