Inspection on 31/01/06 for Sovereign Court

This inspection was carried out on 31st January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sovereign Court 01/10/09

Sovereign Court 27/11/08

Sovereign Court 07/12/06

Sovereign Court 05/10/05

Sovereign Court 02/02/05

Sovereign Court 18/08/04

Sovereign Court 15/03/04

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

CARE HOME ADULTS 18-65 Sovereign Court Newbiggin Lane Westerhope Newcastle Upon Tyne Tyne & Wear NE5 1NA Lead Inspector Alan Baxter Unannounced Inspection 31st January 2006 13.30 Sovereign Court DS0000000495.V275988.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 Sovereign Court DS0000000495.V275988.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. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sovereign Court Address Newbiggin Lane Westerhope Newcastle Upon Tyne Tyne & Wear NE5 1NA 0191 271 6151 0191 271 6151 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 Jennifer Houghton Ms Susan Gray Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may not admit any person under the age of 40, or over the age of 65, without the prior agreement of the CSCI. The home may not take any emergency admissions without the agreement of the CSCI. 5th October 2005 Date of last inspection Brief Description of the Service: This is a relatively new, purpose-built care home that opened for its current client group (persons with acquired brain injury and Huntington’s syndrome, aged between 40 and 65 years) in May 2005. It is a single storey building, with twelve single bedrooms, all en-suite, lounge, smoking lounge and dining room. It is situated on the outskirts of Newcastle upon Tyne, on a bus route, and fairly close to local shops. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Sovereign Court care home took place in January 2006. It took approximately four hours. The main focus of this inspection was to check that the home had met the requirements and recommendations of the last inspection report. Therefore, not all standards were assessed on this occasion, and reference should also be made to the report of the last inspection of the home (dated 5th October 2005). Time was spent with the home’s deputy manager studying care records and other relevant documentation. Parts of the building were toured. Residents were engaged in conversation and asked for their views of the home. Those able to give an opinion were highly complimentary about the home, and the service they are receiving. What the service does well: The home conducts full assessments of the needs of all residents, and draws up detailed care plans to meet those needs. Care plans are regularly reviewed and kept up to date. Residents’ physical and mental health needs, including specialist needs, are fully met. Residents are protected by the home’s policies and practices for the storing and administration of medicines. No complaints have been received since the home opened. There are proper policies for the prevention of abuse of residents. The home gives a comfortable, homely and safe environment for its residents. Specialist equipment is provided, where necessary. The home is clean and hygienic. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 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. Sovereign Court DS0000000495.V275988.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 Sovereign Court DS0000000495.V275988.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): These standards were not assessed on this inspection. (Standards 3,4 & 5 were met at the last inspection.) EVIDENCE: Sovereign Court DS0000000495.V275988.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): 6 6) Residents’ assessed needs are reflected in their care plans, which are updated as necessary. EVIDENCE: 6) Care plans were generally in line with the assessed needs of those residents whose care records were sampled. Care plans are reasonably detailed and are holistic, including separate social care plans. Care plans are drawn up on the day of admission to the home: this is good practice. Care plans are evaluated monthly, and there was clear evidence of the care plans being updated in the light of these evaluations. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this inspection. (Standards 11,12,13,14,15 and 17 were met on the last inspection.) EVIDENCE: Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20. 19) Residents’ physical and emotional health needs are met. 20) Residents are protected by the home’s policy and practices on giving medicines. EVIDENCE: 19) Study of residents’ care records confirmed that their health needs are assessed in good detail, and that individual care plans are drawn up to meet these needs. These care plans are evaluated every month and are kept up to date. There was also evidence of full reviews of care, including health care needs, taking place every six months. Good support is received from the Hartside unit of St Nicholas’ Hospital (from where most residents were admitted) in the form of quick response to emergencies, and by re-assessment, if required. There is also an occasional ‘ward round’ where the consultant, social worker and Huntingdon’s specialist nurse from the Hartside unit visit the home. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 12 There was evidence of the regular checking of hearing, eyesight and teeth. It was a recommendation of the last inspection report that the home should seriously consider the emotional benefits for residents of having a house pet, such as a cat. This recommendation has not been implemented, and is repeated in this inspection report. 20) Due to the medical condition of the residents, none have been assessed as being able to self-medicate. Therefore, the home takes responsibility for the safe recording, storage and administration of all medicines on behalf of its residents. The home uses the ‘Nomad’ system of medications. The home has drawn up a clear cross-reference of staff names against the staff initials used in the ‘Medication Administration Record’ (MAR). The home has also ensured that there is a photograph of each resident in the relevant section of the MAR; and that all hand written entries are signed and dated. Medications are administered only by senior staff, but all care staff have now attended a ‘Safe Medication’ course. This is good practice. Sovereign Court DS0000000495.V275988.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): 22,23. 22) The home listens to its residents, but must also have a recording system for logging complaints and other feedback. 23) Residents are protected from abuse, neglect and self-harm. EVIDENCE: 22) No complaints have been received, either by the home or by the C.S.C.I. The home has no system for recording complaints, other than an ‘incidents and events’ file. The deputy manager said that the home seeks to avoid formal complaints, by listening to its residents and their families and ‘nipping concerns in the bud’. Nevertheless, a book or log must be introduced to record all complaints, concerns and compliments received. 23) Staff have had ‘in-house’ training in the Protection of Vulnerable Adults (PoVA). External training had been planned, but this had fallen through when the training company went out of business. All care staff have started their NVQ level 2 in care, and Adult Protection forms one module of this training. The deputy manager was able to describe the steps to be taken by the management in response to any allegation of abuse that might be brought to its attention. Care records showed that any risks that may affect residents are properly assessed and acted upon. Sovereign Court DS0000000495.V275988.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): 24,29,30. 24) Residents live in a homely, comfortable and safe environment. 29) Residents have the specialist equipment they need to be as independent as possible. 30) The home is clean and hygienic. EVIDENCE: 24) The building was toured. No significant problems were noted, although a few small items, such as a missing bin lid, were noted for immediate attention by the home. Those residents able to give their opinions said that they were comfortable in the home. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 15 29) The home has been fully assessed within the past year to ensure that it provides a safe and suitable environment for its residents. Care records confirmed that specialist needs and equipment are fully assessed and actioned. Examples include the ‘Stand-Aid’ recently obtained through local social services. 30) The building was partly toured. All areas seen were clean and hygienic, and the home was free of any offensive odours. There is a regular carpet cleaning programme. The home has two new washing machines. Any washing that requires sluicing is put in yellow bags and taken to the neighbouring care home. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 16 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): 32,33,34,35,36. 32) The home is in the process of getting all of its care staff qualified. 33) The home was not able to fully demonstrate that there are sufficient staff hours to meet all the assessed needs of the current resident group. 34) Residents are supported and protected by the home’s recruitment practices. 35) Not all staff have been given the full range of training required. 36) Staff are not receiving formal supervision as often as they should. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 17 EVIDENCE: 32) It was a recommendation of the last inspection report that at least 50 of care staff should hold N.V.Q. level two in social care by the end of 2005. This has not been fully implemented, largely because the home has not been open long enough to get all care staff trained. However, 40 of care staff do hold NVQ level two; and all other carers are currently studying for this qualification. 33) Staff rotas were inspected. The minimum staffing level is two carers on duty at all times, with a supernumerary manager. In addition, each new resident has an individually-contracted number of staff hours, agreed at the assessment stage, to make sure all the resident’s needs can be fully met. Currently, it was stated that there is a total of 210 additional hours each week. It is not clear from the staff rota, however, the way in which these extra hours are allocated. It was agreed that the registered manager, who was away from the home on the day of this inspection, will provide a breakdown of how these hours are allocated in practice. In practice, at the time of this inspection, staffing levels are: manager, one senior and three carers between 8am and 4pm; one senior and three carers between 4 and 5pm; one senior and two carers between 5 and 8pm; and one senior and two carers overnight. 34) It was a requirement of the last inspection report that Criminal Record Bureau (CRB) checks on staff must be held in the home and made available for inspection (after which they may be removed). The company keeps such information at its head office, but was able to produce the necessary documents at short notice, by bringing them to the home during the inspection. This was acceptable. All staff have had a satisfactory CRB check undertaken on them. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 18 35) The records of statutory staff training were examined. Of the four staff files chosen at random, three had no certification for fire safety training or infection control training; two had not had health & safety training; and one lacked food hygiene and first aid training. Such training should have been given as part of the staff induction process, prior to the home opening, and must now be seen as a high priority. 36) The records of staff supervision were examined. The home was not able to demonstrate that it is giving formal staff supervision at the required rate of at least six sessions each year. Although there was some evidence of the forward planning of supervision, it was advised that a year planner is used to ensure that all staff receive supervision at the required frequency. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 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): These standards were not assessed on this inspection. (Standards 37,39 and 42 were met at the last inspection.) EVIDENCE: Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 20 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X X X X X X X X Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 21 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 YA22 Regulation 17(2) Requirement The home must introduce a book or log for the recording of complaints, concerns, compliments and other feedback from residents and other interested persons. The home must supply the CSCI with a breakdown of the extra staff hours assessed as being required for each resident. The staff rota must clearly show which member of staff is allocated to provide ‘one to one’ support to individual residents. 3. YA35 18(1) All staff must be given the full range of training required by statute. All care staff must be given formal supervision at least six times per year. 30/04/06 Timescale for action 31/03/06 2. YA33 18(1) 31/03/06 4. YA36 18(2) 31/03/06 Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 22 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 YA32 YA19 Good Practice Recommendations At least 50 of care staff should hold N.V.Q. level two in social care by the end of 2005. The home should seriously consider the emotional benefits for residents of having a house pet, such as a cat. Sovereign Court DS0000000495.V275988.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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