Inspection on 31/01/07 for St Marys View

This inspection was carried out on 31st January 2007.

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

Other inspections for this house

St Marys View 27/01/09

St Marys View 10/01/06

St Marys View 24/11/05

St Marys View 12/01/05

St Marys View 14/07/04

St Marys View 20/02/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

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 St Marys View Brook Street Whitley Bay Tyne & Wear NE26 1AF Lead Inspector Allan Helmrich Key Unannounced Inspection 31 January and 1st February 2007 10:00 st St Marys View DS0000033192.V302849.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 St Marys View DS0000033192.V302849.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. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marys View Address Brook Street Whitley Bay Tyne & Wear NE26 1AF 0191 2513630 0191 2513630 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) Lifestyles - Care & Support Ltd Vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: St Mary’s View was originally a large terrace house and is converted to provide a home for up to ten people who have a learning disability. The Home is a short walk away from the sea front in Whitley Bay, and is convenient for the town centre with its’ range of shops and leisure facilities, as well as good transport services. There is a communal lounge, a dining room and another small lounge on the ground floor. The kitchen is a good size and there is a separate laundry. There are two bathrooms, a shower and two toilets. There are ten bedrooms with wash hand basins fitted and one on the ground floor has an en-suite shower and toilet. The home does not have a passenger lift to assist anyone with a physical disability. St Mary’s is part of the Lifestyles - Care and Support organisation. Inspection reports and information about the home are readily available. The home’s fees are in the range £355 - £629 per week. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s annual unannounced key inspection visit. The inspection was done over two days and took 7 1/2 hours. Time was spent talking to the manager, two care staff and several residents. Some of the home’s care records were reviewed and the systems that maintain residents safety. Also as part of the inspection the care plans for three residents were inspected against the actual care provided. This is called ‘case tracking. The communal areas of the home were inspected and the laundry area. Permission was obtained from residents to look at bedrooms. Questionnaires were provided for residents and visitors to the home and the information provided was used in the production of the report. Six responses were received from residents and one from a visitor. All of the responses were positive about the home and no issues were raised. The parents of one resident were complimentary about the staff team and how the home has managed the first three months transition from home into care for their relative. What the service does well: The management and staff support residents to live an active life in the community. Each resident is supported and encouraged to choose what to do and where to go. All residents in the home enjoy living there and feel well supported by the staff. The home is comfortable and homely. The management team are very able and support residents in a professional way. Staff are well-trained and all have either achieved a NVQ in care or are working towards this qualification. The home is safe. No hazards were seen that would affect the well being of the residents. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Marys View DS0000033192.V302849.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 St Marys View DS0000033192.V302849.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process reduces the possibility of admitting someone whose needs cannot be met. EVIDENCE: The manager ensures the home can meet the needs of any referral before a placement is made. Full information is obtained about the person and relevant professionals are involved in the process. Three case records were reviewed and each contained a good standard of information obtained before a place was made permanent. The family of a new resident stated in a questionnaire that the home asked numerous questions about any special needs and that they are satisfied with the introduction programme. Two newer residents looked very ‘at home’ and one said he enjoys living in the home and that the support he receives is good. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 9 The three residents care plans reviewed contained plans of how to provide appropriate care. Plans to develop the person (goal plans) were in place and these were regularly reviewed. Any restrictions placed on residents, such as limiting the use of the kitchen, were detailed with the reasons. The manager stated that this restriction of movement was reviewed and withdrawn, as it did not respect the residents’ freedom of movement around the home. Residents have now been requested not to use the kitchen when the main meal is being cooked. St Marys View DS0000033192.V302849.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, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have good plans in place for daily living. Residents are involved in making lifestyle decisions. Residents are encouraged to be independent. EVIDENCE: Three care plans reviewed were well detailed, easy to understand and regularly reviewed. The plans contained details of how staff work with healthcare and other professionals. There was direction for staff as to how to provide good support for the resident. Each record included details of family and friends, a lifestyle plan is in place containing details of the support each resident needs to encourage their independence. There were goal plans to St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 11 stimulate the resident and a record identifying the range of activities each resident is involved in. Residents spoken to during the inspection made it very clear that they decide what to do. Staff were seen throughout the inspection asking residents to choose what to do and where to go. Although little encouragement is necessary, staff were observed throughout the inspection encouraging residents to be independent and risk assessments are in place that support independent living principles. All residents are encouraged to manage their own finances, some with family support. The local authority is involved for one resident. The home maintains a record of the personal allowances allocated to each resident and maintains a system to record any monies held for residents. This system does not identify the current balance, did not always record the transactions with two signatures or identify the items purchased. St Marys View DS0000033192.V302849.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, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to live a normal life within the community. A range of meals is provided but these do not encourage healthy eating. EVIDENCE: Residents are very much part of the local community. They were seen coming and going during the day with staff support. On the first day of the inspection, six residents went out for lunch supported by staff. This is a regular weekly activity. On the second day of the inspection, a resident was being escorted to visit her friend in another home in Northumberland. The friend of another resident St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 13 visited the home and they went out for the day supported by a member of staff from the visitors home. Two residents spoken to said they regularly use community facilities, visiting nearby shops and other services. One resident said he chose not to go with other residents for lunch. He chooses when to go out and where. The care plans showed that each resident’s care is individual and different. Some residents attend day centres; others go to college for drama, art and cookery. Two residents attend church. One is Church of England and the other a Jehovah Witness. Details of each resident’s family contacts and friends are recorded in the individual case records. Some residents have no family support but those that have are assisted to maintain regular contact. The last house meeting was in August 2006. A range of topics were discussed, the manager talked about complaints and residents were reminded about their right to complain. The home’s menus were provided prior to the inspection. These show that a range of different meals is provided, but that these meals do not encouraged a healthy lifestyle. Every resident spoken to said that they enjoy the meals provided in the home. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 14 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, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to live their chosen lifestyle. An experienced staff team addresses their physical and emotional needs. The home’s systems for dealing with medication are satisfactory although some procedures could be improved to protect the people who live there. EVIDENCE: Throughout the day residents were seen talking to staff. Staff always took the time to talk through any issue mentioned by a resident. Residents said how good and supportive the staff team are. Care plans describe the needs of each resident and how they should be addressed. All healthcare appointments are recorded and the case records that were reviewed showed that regular healthcare is obtained to maintain the good health of the residents. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 15 Currently residents are receiving little support from outside professionals but the records show that when required, support is requested and any information provided to assist in the health and wellbeing of the resident is recorded. The homes system for recording and administering medicines is appropriate to the size and style of the home. Staff are trained in handling medicines and further refresher training is planned. Procedures for handling ‘alerts’ sent by the Medical Device Agency are not sufficient to ensure the wellbeing of the residents. Staff do have access to a medical reference book but this is old and should be replaced. All handwritten entries in the medical administration records should be checked and signed. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 16 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, 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A good complaints process supports residents and they are protected from abuse by a staff team that are aware of vulnerable adult procedures. EVIDENCE: Two residents were asked about the complaints procedure in the home and they said they would speak to any of the staff. The manager said that all complaints are recorded and addressed. Two complaints made since the last inspection were recorded in the homes log with how they were concluded. At the last house meeting with residents, they were reminded of their right to complain. Two staff spoke confidently about how they ensure residents are kept safe. Every member of the staff team has received training related to the protection of vulnerable adults, the proprietors have experience of dealing with this type of issue and have provided the staff team with appropriate supporting information. Training in reducing the effects of challenging behaviour has been provided for staff by the local authority learning disability team and management strategies are in place where a risk is identified. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 17 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, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. St Mary’s View is clean, comfortable and safe. External decoration is poor and some improvements could be made to improve the standard of the internal facilities and appointment for residents. EVIDENCE: The home was clean and safe. All of the residents spoken to said they like living there. The homes bathrooms and toilets could be improved for the benefit of the residents. A plan to improve these facilities is in place. The kitchen contains appropriate equipment and is a good size for the home. The bench tops have been renewed but some of the cupboard doors are peeling making it difficult to maintain good standards of hygiene. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 18 The main communal area on the ground floor is in three parts. Two lounge areas and a dining area. These areas although well used by the residents throughout the inspection were clean and reasonably well maintained. The laundry has access from the lounge. It contained domestic type washing and drying equipment that met disinfection standards. The laundry needs refurbishment to maintain good standards of hygiene. The manager stated that plans are agreed to improve this facility. Inside and outside, the home shows some signs of disrepair. The laminate is coming off kitchen unit doors, walls and ceilings in some areas are cracked and externally woodwork requires painting and generally the house is not appealing. Although improvement works are planned, a long-term plan showing the full extent of the likely improvements is not available for inspection. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 19 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, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A well-trained and competent staff group supports residents. The homes recruitment process does not meet the Commissions requirements to ensure residents are safe. EVIDENCE: Staff said that requests for training are always considered. One member of staff, who is also currently studying at a local college, said she was well supported by the home’s management. Another member of staff is currently on her induction. She is well supported and is aware of her duties in the home. 80 of the staff team have a NVQ in care. A good standard of training is provided but the manager does not have a training plan in place or a composite training record to identify gaps in training. Staffing was recently been increased to meet the needs of one resident. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 20 During this unannounced inspection, additional staff came on duty to support a group of residents who visit a pub for lunch each week. Two company homes are in close proximity and have residents and staff who are very close. The manager uses this closeness to be flexible with staffing to be able to meet individual needs of residents when they request joint activities or support. The company has a recruitment process that includes obtaining references and criminal records bureau checks. This system however does not meet the specifics of Regulations 17(2) and 19, designed to enable checks to be made by The Commission to ensure residents are safe and well protected. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 21 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, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is operating without an experienced registered manager. She and the residents are however well supported by an experienced team of managers. The quality of care provided is not supported by a formal quality monitoring system involving residents and their supporters. A good standard of health and safety is maintained for the benefit of residents. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager has worked with people with a learning disability for 1½ years and has been a trainee manager for 14 months. She is working towards NVQ level 3 in care and demonstrated good values. Her limitations are in management and the company are providing support for her in this area. In addition to the NVQ, the manager has done training courses in; challenging behaviour, protection of vulnerable adults, future strategies, first aid, dementia and diabetes. The manager received a lot of praise from residents and staff during the inspection. She is working, with other members of the management team, to improve the care practices to ensure each resident is given the opportunity to be as independent as they are able. The home is well run and systems are continually being improved. Other company managers visit the service to audit systems and the proprietors visit regularly to ensure the care provided meets the standard they expect. Residents made positive comments about the service provided throughout the inspection and everyone spoken to felt the home met their needs. A formal monitoring of the service together with future development plans were not available. The home is safe and no hazards were seen. All staff receive health and safety training. Fire training is provided and the fire log showed that regular checks are done. The certificate to confirm the servicing of the home’s gas system is in place but the certificate for internal wiring was not available for inspection so this is to be redone. St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 23 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 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 4 23 4 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 24 No 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(2) Requirement The manager must comply with pharmacy guidance; • Produce procedures to ensure Medical Device Agency alerts are appropriately dealt. • Ensure a medical reference book is available in the home for staff use. • Handwritten entries in the Medical Administration Records (MAR) should be checked and signed. The homes recruitment process must be in accordance with the regulations and take account of the need for inspectors to review this information as part of the inspection process. An application must be made to The Commission to register a manager for the home. Timescale for action 28/02/07 2. YA34 17(2) and 19 31/03/07 3. YA37 8 and 9 31/03/07 St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 25 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. 3. Refer to Standard YA7 Good Practice Recommendations The home’s financial recording should be reviewed to ensure all transactions are detailed, with a balance, evidenced by two signatures and regularly audited. Respecting residents’ rights of choice, menus should be reviewed to promote healthy eating with the provision of regular vegetables and fruit. The proprietors should monitor the condition of the premises and undertake any necessary repairs or refurbishment. A programme of improvement should be produced in line with the assessment of a quality service. The proprietors should continue improving the system that monitors the quality of care provided in the home. All issues identified during quality reviews should be costed and have a timescale for implementation. Questionnaires should be used to obtain the views of people who use the service. YA17 YA24 YA30 4. YA39 St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 St Marys View DS0000033192.V302849.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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