Inspection on 11/08/09 for Sydenham Terrace

This inspection was carried out on 11th August 2009.

CQC found this care home to be providing an Adequate 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sydenham Terrace 09/09/08

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 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Sydenham Terrace 3 Sydenham Terrace South Shields Tyne And Wear NE33 2RY Lead Inspector Clifford Renwick Key Unannounced Inspection 11th August 2009 09:00 Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sydenham Terrace Address 3 Sydenham Terrace South Shields Tyne And Wear NE33 2RY 01914545383 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) Potensial Limited Miss Wendy Cairns (currently on extended leave) Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only -code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning disability - Code LD, maximum number of places 6 The maximum number of service users who can be accommodated is: 6 9th September 2008 Date of last inspection Brief Description of the Service: Sydenham Terrace provides ordinary housing for six people who have a learning disability. The home is registered to provide personal care. Nursing care cannot be provided but district-nursing services can be used as required. The home is a large three storey terraced house and comprises six single rooms. There is a lounge and a spacious kitchen/dining area. There are two bathrooms and two toilets and these are located on the first floor, close to bedrooms. As access to the first and second floor is via a flight of stairs the home would not be suitable for people who use a wheelchair. The home is situated within walking distance of the town centre of South Shields close to a number of local amenities such as shops, public houses, and places of worship, parks and the beach. There are bus stops nearby. Information about the fees payable was not available during this visit. Sydenham Terrace DS0000071689.V376440.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 1 star. This means that the people who use this service experience Adequate quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspections may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future if a requirement is repeated, it is likely that enforcement action will be taken. The last inspection of this service was carried out in September 2008. In line with current CQC policy on ‘Proportionality’ the inspection focused upon a number of key standard outcomes for service users. And also what actions had been taken with regards to the requirements and recommendations that were made at the last key inspection in September 2008. Before the Visit. We looked at. Information we have received since our last visit. How the service has dealt with any complaints or concerns. Any safeguarding issues. Any changes to how the service is run. The providers view of how well they care for people from information they provided in the annual quality assurance document (AQQA) that they sent to us. The Visit. An unannounced visit was made on the 11th August 2009. During the visits we. Met with the people who live in the home. Spoke with the staff that were on duty. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 6 Held discussion with the deputy manager who was present during our visits and who is currently responsible for the management of the service in the absence of the manager. Observed staff working practices. Looked at information about the people who are receiving support and how well their needs are met. Looked at other records which must be kept in relation to health and safety and staffing. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the home to make sure it was accessible, well maintained, safe and free of any hazards. We also gathered information from looking at, care records to assess how staff supports people with their assessed needs. We also focused upon looking at the records for 2 people who live in the home we refer to this as case tracking. And this involves looking at all of the records for a named individual. We told the deputy manager and staff what we had found. What the service does well: The building is well maintained and safe which ensures that service users have a safe and well managed home to live in. People are continued to be supported to attend day services so that they can follow their own interests and maintain contact with friends. Service users are encouraged to be involved in planning menus and this ensures they receive meals that they enjoy and which are well balanced and address any health needs they may have. The staff is committed to undergoing updated training so that they can increase their knowledge and skills. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Each person who lives at the service must be issued with an up to date contract so that they understand their rights and responsibilities. Provide all staff with training on how to develop and implement the service user plans so that people enjoy more individualised care and support with their assessed social needs. Ensure that all staff receive training in the homes polices and procedures so that service users receive consistent care and support. All staff must receive training in safeguarding adults. When recruiting staff a full check on their employment history must be carried out before appointing someone. Any gaps in employment must be explored with a written reason being kept in the file. To continue to review the staffing rotas so that they are designed to meet the needs of the service users, so that they receive support when they most need it and can plan more individualised routines. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 8 This should take into account accessing community activities in the evening as a way of meeting a person’s social needs and interests. Make sure that all records are up to date and kept in good order. Steps should be taken to look at how written and other administrative records can be stored in a better way. When submitting the annual quality assurance assessment ensure that is clearly identifies what evidence is available to demonstrate where improvements have been made. Appoint a manager who is qualified and experienced and ensure that staff and service users have some input into the recruitment processes within the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 9 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 Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at the service have had their needs assessed, but they do not have a written contract with the current provider. EVIDENCE: In discussion with staff it was confirmed that service user’s needs are assessed and kept under review. The assessment is then used to determine how staff will support people. At the last inspection a requirement was made that all service users must be issued with a contract that included their terms and conditions of residence. As the people living at the home had a written contract with the original providers of the service. Copies of which were included in their files. The current providers took the home over in March 2008, but had not yet issued contracts to service users. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 11 We looked at all of the files for the 6 people living in the home and though contracts had been issued by the provider these were not fully completed. For example the contracts did not include, • • • • • • the date of when they were issued they had not been signed by the service user or the provider they did not specify what fees had to be paid or the rooms to be occupied the contract is only available in written format In addition to this on page 1 of the contract reference is made to the National Care Standards Commission and on page 2 references are made to the Commission for Social Care Inspection. Neither of these organisations continues to exist. Staff were unsure when the contracts had been issued but were able to tell us that the manager of the home had been requesting that the area manager issue up to date and fully completed contracts for all service users. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are supporting people with their assessed needs but this is not fully recorded in the individual care plans. Risks to do with safety are assessed and managed. EVIDENCE: During this visit we looked at the service user plans that staff use to demonstrate how they are meeting assessed needs. As a recommendation was made at the last inspection was for the service user plans to be developed further with particular reference to the social care needs of service users. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 13 We looked at two service user plans but it was evident that these are still under development as they were incomplete in parts. For one person records confirmed that the service user plan had been updated in March of this year but the service user plan could not be located by staff. Therefore it was difficult to determine what had been reviewed and why. The staff confirmed that service user plans are evaluated 3 monthly. For another service user plan that we looked at assessments were up to date and the deputy manager had begun work on a document called “My care plan” which was almost complete. However the other member of staff was unaware of this document and stated that he had not seen this document before despite this being the way in which staff were to set out the service users plans. The deputy manager stated that she was currently working on developing the service user plans and initially started with one service user due them displaying behaviours that challenge. Similarly the carer who was on duty stated that he had also begun working on a care plan for another person who also had behaviours that challenge. Though the service user plan and risk assessments could not be located. It was evident from discussion with staff that they have built up a good knowledge of the service users and as such have implemented an up to date “pen picture” of each person. Records are also available of individual service users like and dislikes though these are not reflected in the care plans as fully as they could be. This information that staff have collated is good as it gives people a better understanding of the person and also their background and previous lifestyle. In addition to this staff is aware of the individual behaviours of service users some of which they described as obsessive and requires different levels of intervention. This is good as it will ensure that when the service user plans are further developed they will be person centred. At present however this information is not fully recorded in the care plan so it was difficult to assess the level of support staff is offering to people. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 14 Though staff holds all of this knowledge, developments with the individual service users plans is slow and little progress has been made since the last inspection visit. How records are stored and staffs level of understanding of these records indicates that staff needs training in how to put together a service user plan using the documents that have been issued by the provider. Service user’s files are not well organised making the retrieval of information difficult and this needs to be addressed. A lot of information in respect of service user plans and assessments are those which were carried out over a year ago using the previous providers documentation. Information provided in the annual quality assurance assessment (AQAA) submitted by the deputy manager. States that service users are involved at consulted at every stage of the production of their service user plan. Evidence is not currently available to show how this achieved. The AQAA also states that improvements with the care plan (service user plan) that are to take place in the next 12 months are to include more information about communication. And the methods to be used with each service user. Some of this development work can be evidenced in the pen picture that staff is currently compiling. Discussions held with people who live in the home and observations made confirmed that they are satisfied with the home. And as stated in other sections of this report good relationships exist between staff and the service users. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 15 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): This is what people staying in this care home experience: 12, 13, 15, 16 17 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are supported to follow individualised lifestyles and are receiving support with their personal development. And this should continue to be developed. EVIDENCE: At the time of our visit four people were out attending day centres and two people were in the house. We met with these four people later in the evening as they returned from day centres. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 16 One person is supported to help with housework and shopping as part of their involvement in the house and this is written in their activity plan. Two service users have taken up knitting as a hobby and one person also does sewing. In discussion with the staff they stated that no one is able to go out to the town independently. Though one person does walk to the day centre independently and another person goes to the local corner shop to purchase items for themselves. It was confirmed that some of the service users have bus passes that enables them to travel on public transport free of charge. Staff stated that they try hard to take people out but there are restrictions on going out as none of the staff have transport they can use. Therefore they are dependent on using public transport or taxis. In addition to this as staff finish their working day at 7.30pm leaving only one staff member on duty there are insufficient staff to take part in regular supported evening community activities. The staff said that they are flexible and will at times adjust the rotas so that they are able to take people to planned activities such as the theatre. Staff was of the opinion that if it was not for this flexibility then people would be limited to what activities within the community they could take part in. It was positive to note that 2 of the service users had spent a 2 day holiday in Scotland and in discussion with staff they confirmed that service users had enjoyed this. Service users have recently acquired 2 pet budgies and a large cage and these now reside in the front lounge. In discussion with service users they stated that they were hoping to teach the budgies to talk. They also went on to say that they were pleased that they now had some pets. Three of the service users have started to grow plants in the back yard and each person ahs their own pot that they take responsibility for watering. Menus were not looked at during this visit But staff confirmed that service users are involved in menu planning and also the shopping. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 17 Staff said that the menus are reviewed and changed every three months in order to reflect service user’s choices and preferences. In addition to this staff stated that they also take into account any nutritional and health needs. Staff confirmed for one person they received support from a health professional regarding their diet and weight management. They said that they now had a better understanding of this persons needs following the health support. In addition to this 3 staff has also undergone an online training course on food, diet and hydration and this too has increased their knowledge. Lunch was taken with the two service users and consisted of pie and beans and also a choice of desserts. The service users said that they like the food that is provided and started to talk about their favourite meals on the menus. There was also some friendly banter about who was the better cook among the staff. Service users have free access to the kitchen and it was good to see that they are involved in making snacks and drinks for themselves. The staff support service users to maintain contact with friends and families though they said that this varies as some people have no or minimal contact with their relatives. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users receive support from staff to ensure their physical, emotional and health needs are met. And procedures are in place to ensure that service users can access all health services. Though this information is not always fully documented in the care plan. EVIDENCE: In discussion with staff it was confirmed that care plans are currently being reviewed and updated as previously stated in sections 6 – 10 of this report. Staff was able to provide examples where they had reassessed the equipment that was needed to support someone to bathe safely. And in discussion they were very clear about what actions they took to support this person in order to maintain their safety whilst at the same time promoting their independence in managing their hygiene. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 19 However these actions were not fully documented either in the risk assessment or the individual written plan of care. Individual health records are maintained for each person and these are updated on a regular basis. And these confirmed that good arrangements are in place between the home and the health professionals. This ensured that service users were able to receive support for any medical conditions. Service users are able to access a wide range of health services within the community. Where people have identified that someone may be at nutritional risk staff have looked at diet and nutrition and implemented an appropriate course of action to assist someone with managing their diet. Regular weight checks are carried out monthly and staff confirmed that they would use this information as part of the care process when they support people. Now that staff have received training in diet and nutrition it ensures that they are clearer about the kind of support people may need with nutrition. We looked at medication records that demonstrate how service users are supported by staff to take their prescribed medicines. The records were being maintained correctly by staff. In discussion with the deputy manager it was confirmed that all but one staff member has received training in the safe handling of medicines. And one person is currently undergoing this training as part of their NVQ Level 3 training. 2 recommendations made at the last inspection were for the manager to ensure that the existing medication procedures in the home were supported by updated policies and procedures. This has been achieved. The other recommendation was for the manager to periodically assess the competencies of staff in administering medication. There was no evidence to confirm whether the manager had put systems in place to do this. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has procedures in place to deal with complaints though no one has been issued with an updated complaints procedure. And furthermore staffs lack of training in safeguarding adults means that the systems are not robust enough to protect people. EVIDENCE: As noted at the last inspection the home has a pictorial booklet to help service users to think about the support they need. Some completed and signed examples of these were available. The complaints procedure is user friendly with pictures and easy to read type. A requirement of the last inspection was that the provider must provide an up to date and accessible complaints procedure to each service user. There was insufficient evidence to demonstrate that this requirement had been met. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 21 The complaints booklet in use is the same as noted at the previous inspection visit. It refers to the previous owners and also to an inspector who no longer visits the service as being people who a complaint can be made to. In discussion with the staff they were unsure if a new complaints procedure had been issued by the company. In looking at the homes policy and procedure file staff were unable to locate a current copy of the providers complaint policy or procedures. In discussion with staff they were able to explain how a person would be encouraged to make a complaint if they were unhappy with the service. In addition to this staff stated that they had built up a good knowledge base of each individual. As a result of this they would observe for any changes in behaviour or anything out of the ordinary that may suggest someone was unhappy. Staff also said that there were some people who would also be able to tell them if they were not satisfied. The staff confirmed that they would always respond to any concerns expressed by service users. Staff showed us a complaints and compliments book and this noted some recent positive comments that had been received about the service. A further requirement made at the previous inspection was for the provider to issue staff with up to date guidance. To support them in safeguarding service users from abuse and handling safeguarding referrals. And a recommendation was made to obtain a copy of the Local Authority guidance on safeguarding adults. The staff has a copy of the South Tyneside Local Authority policies and procedures and guidance on safeguarding adults. And this meets the recommendation made at the last inspection. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 22 However in discussion with staff that were on duty it appeared that they were not clear about these procedures. Neither were they aware of whom the contacts were in the Local Authority should they need to make a referral. The service has safeguarding procedures, including whistle blowing, which were drawn up by the previous owners and staff were aware of these. However they were unsure about what safeguarding policies and procedures had been implemented by the current provider. We were unable to view any policies and procedures on safeguarding adults that relate to the current provider. And in looking at the providers policies and procedures file none were available during our visit. During discussion with staff they were clear of what constituted abuse and what to report within their own organisation and who to report to. In discussion the staff confirmed that they had made arrangements for refresher training on safeguarding adults to be carried out by an external training agency. And 2 staff is to complete this refresher training. The commission are aware that a safeguarding referral has been dealt with previously by the area manager and the manager of another service. And this was dealt with in accordance with the appropriate guidelines. Records of personal finances (referred to by staff as pocket monies) held on behalf of service users were looked at. Monies belonging to service users are held in a lockable cash box and individual amounts kept in wallets with envelopes of receipts that are numbered. The records were in good order and provided an audit trail of each transaction that was made on behalf of service users. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, comfortable and clean home. And works has been carried out to ensure their ongoing safety. EVIDENCE: During this visit we looked at all areas of the home and this included service users bedrooms. Bathrooms and toilets have soap dispensers and paper disposable towels installed to prevent cross infection. Care staff is responsible for the cleaning schedules in the home and the home is clean and smells fresh. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 24 Staff have had training in infection control. Staff were able to inform us of the changes that were taking place and these include obtaining new bedroom furniture and carpets for some service users. And plans are in place to change the vinyl floor covering in one of the bathrooms. Some decoration is required in this bathroom and the loose bath panels need to be re-fixed to the bath. Service users have personalised their bedrooms and this made each room different. Bedrooms were clean and free of any noticeable hazards. The kitchen area is also used for dining by the service users and in this area a large notice board is being used to display a range of information for employees. Notices such as what to do if you contract swine flu, safeguarding and abuse information for staff and other similar information leaflets are on display. This detracts from the homeliness of the room and the information leaflets could be kept in a different way. Better use could then be made of this notice board by service users to display information that is more personal to them, such as menus, postcards and activities etc. Similarly in the lounge there is an area set aside with a computer that is used by staff for maintaining documentation within the home. The adjacent coffee table was being used to store a number of ring binder folders that contained a range of the homes policy and procedure files. Again these would be better if stored in the filing cabinet as this detracts upon service users living environment. Staff were also using a large white notice board in the lounge to leave messages for staff some of which were seen to be impersonal. Some of the messages that were recorded on this board related to reminding staff to carry out tasks in service users rooms. This style of communicating is impersonal and staff was asked to remove this board from the lounge. To the rear of the home is a small yard area in which staff and service users have planted some wallflowers and also some plants in large pots. This provides a nice area to sit in when the weather is good. One thing that is noticeable about the home is that it is the only house in the street that has no number on the front door. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 25 When this was discussed with staff they stated that the home had never had a number on the door. This does not appear to bother the service users who know that they live at No.3, though consideration should be given to having a number on the door. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are supported by staffs that have a range of experience and skills and the staffing levels ensure that the basic needs of service user are met. Though the current staffing numbers could places limitations on service users being able to access community activities on a regular basis. The homes recruitment practices are not sufficiently robust to ensure that service users are protected. EVIDENCE: A recommendation made at the last inspection was for all staff to be issued with an up to date job description. In discussion with staff that was present during our visit, a carer and the deputy manager, they were uncertain as to whether they had been issued with a job description. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 27 The carer after further discussion confirmed that he believed he had received a job description with the deputy manager confirming that she had not received an updated job description. A requirement made at the last inspection instructed the provider to review the staffing numbers and deployment of staff in order to meet service user’s needs and support the development of the service. The staffing arrangements in place whereby staff worked between this home and another home that is owned by the provider have changed. Staff now solely works in this home, though the staffing arrangements that are in place meet minimum standards. The manager is on maternity leave and this position is currently being covered by the deputy manager who works 37 hours a week. The management arrangements are discussed more fully in sections 37 – 43. There are 2 carers who work 37 hours a week one of whom has been on sick leave and is currently on holiday. These people’s hours are being covered by existing staff as extra shifts. There is also one person who works one shift a week. And the 37 hours that have been left vacant by the absence of the manager are being covered by a person referred to as a “bank” worker. The staff confirmed that as a last resort they are able to use agency staff if they need to cover any hours. The staffing roster showed that there are 2 staff on duty each day working what is termed a “long day” (7.30am – 7.30pm). One person then remains in the building on a sleep over shift. There is also an arrangement where one long day is split between 2 staff whereby they work ½ day each. And this is an improvement from the previous inspection where staff was working a number of split shifts. In discussion with the staff they thought that the new shift arrangements were better and enabled them to offer consistent support to people who lived in the home. However though shift arrangements had changed there has been no increase in staffing numbers. There are no domestic, kitchen or administrative staff and the care staff undertake all of these duties. Staff no longer undertake any driving duties Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 28 associated with taking people who live at the home to day services. As there are no designated drivers in the home. Due to the current minimum staffing arrangements staff confirmed that the rota’s have to be adjusted in order to be able to support service users who wish to go out in the evening. For example staff had adjusted the rotas in order that they could take people to a musical show that was being held at the theatre in the evening later in the week. However there are potential limitations should it be that service users wish to access a range of activities that take place in the evening on a more regular basis. As this would require the staffing rota to be reviewed and amended. In addition to this as none of the staff are designated drivers service users are dependent upon the use of taxis or public transport when they go out. A requirement made at the last inspection was for staff to receive thorough induction training. This has been achieved and the induction record the person most recently employed in the home was signed and dated. Discussion was held with staff about training and what developments had taken place since the last inspection visit. It was confirmed that at present training is being provided in a number of ways by making use of an external agency and also by staff accessing online training using the homes computer. The training file confirmed that three of the staff has completed a course on diet and nutrition and two staff is still undergoing this training. Training has been organised for all staff on the Mental Capacity Act and this is to take place in August and October with the training to be provided by the Local Authority. In discussion with staff they confirmed that the online learning courses which are organised though the NHS are good as it enables staff to learn at their own pace. At the end of the training staff sit a test and then receive their certificates of competency. One staff member is currently undergoing NVQ Level 2 training in health and social care. And 4 staff completed an in house training course on First Aid that was provided by the Newcastle Ambulance Society. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 29 The staff that were on duty have worked in the home for a number of years and as such have built up a good relationship with the service users. They have developed a range of skills that enables them to support the service users assessed needs. And from discussion and observation of practices it was evident that they had established a good rapport with the people who live in the home. The staffing file for the “bank” worker was looked at and this confirmed that appropriate checks had been carried out as part of the recruitment process and this had included obtaining a satisfactory criminal record check. However a full application form had not been completed in that there were substantial gaps in the employment history, there were no dates linked to education or further education. And there was insufficient evidence to demonstrate that these gaps in employment had been explored with a written reason being recorded in their personnel file. Information provided by the deputy manager in the Annual quality assurance assessment document confirmed that staff receives regular supervisions and appraisals Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 30 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The deputy manager has sufficient experience to ensure that the service is managed safely for staff and service users, though their lack of management experience makes it difficult to develop the service further. EVIDENCE: The registered manager is on maternity leave and has been since April and in her absence the day to day management of the service is being carried out by the deputy manager. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 31 They stated that when the manager initially went on leave an acting manager had been appointed but this person left after a couple of weeks. However during this time staff believed that the acting manager had left staff confused by changing things around in the home particularly the records systems. The deputy manager has a range of experience and is working hard to maintain standards within the home. And also attempting to gain a better understanding of the providers polices and procedures. A requirement of the last inspection was for the provider to ensure that all staff is trained in and understand their employer’s policies and procedures. It was evident from discussion that staff is still unclear about some of the homes policies and procedures. And there was no evidence to confirm that they had received training on the provider’s policies and procedures. We looked at the policy and procedures file and it was noted that the policies are not filed in a structured way. Some of the policies were dated and a number of the policies and procedures were undated. Therefore it was not possible to identify when these policies had been implemented or when they had been reviewed. A copy of the provider’s complaints policy and procedure was stored in this file but did not contain sufficient detail. In discussion with staff they stated that a lot of the homes/providers policies and procedures get sent to the home from head office. However in the past these have been filed away before staff have had an opportunity to read and discuss them. This is in conflict with information provided by the deputy manager in the annual quality assurance form that stated the manager is responsible for supporting staff. And taking the lead for implementing any new policies and procedures. During our visit the deputy manager showed us service development plans which outlined how improvements were to be made in the service. And it was confirmed that staff had input into this development plan. However parts of the plan were not dated and it did not address how any requirements or recommendations made in the last inspection report were to be addressed as part of the ongoing development. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 32 As discussed previously in the environment section of this report there are some issues relating to records and documents storage and this was discussed with the deputy manager. There was insufficient evidence to ascertain whether quality assurance systems had been established. Though it could be confirmed that monthly monitoring visits are carried out by a representative of the organisation. The deputy manager also confirmed in the annual quality assurance assessment document that the home was aiming to develop and implement a user friendly quality assurance system. Records of these were viewed and part of these reports identified actions to be taken as a result of the visit. Discussion held with staff and evidence available in the home confirmed that appropriate fire safety procedures are in place. And this includes staff taking part in regular fire drills and fire instruction. Staff stated that records are kept of any accidents that occur in the home and this also lists any actions carried out by staff. The deputy manager confirmed that as part of the ongoing training programme staff would be receiving health and safety training that was necessary for their work. As previously stated in this report staff have undergone updated training in first aid. One service user is dependent upon the use of a new bath chair to assist with getting in and out of the bath. And in discussion with staff about the potential risks associated with this. They were able to confirm that they had a set procedure in place to support this person whilst using the chair and the bath. This needs to be documented more fully as part of the care plan and associated risk assessment. In discussion with the deputy manager it was confirmed that the provider had appointed a temporary manager but would not be commencing work until all satisfactory employment checks had been completed. Not all of the staff has met this person and it was unclear as to whether service users had had the opportunity to meet this person. The deputy manager had only met this person briefly when she had showed them around the house prior to this person binge offered the post as temporary manager. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 33 There was no evidence available to confirm that service users are actively supported to be involved in staff selection. And a major change such as employing a new manager in the home should be discussed with them. Overall though the deputy manager has assumed responsibility for the day to day management of the service it was evident that her level of management experience is limited. In terms of dealing with policies and procedures and other procedural matters. However there are no doubt her hands on caring skills are excellent and she is also able to supervise staff effectively to ensure that service users are supported appropriately. A requirement made at the last inspection was for the provider to review the manager’s job description and learning and development plan to ensure their competency. This could not be assessed in the absence of the manager and staff were unaware and unsure of whether this had been done. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 34 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 2 3 x 4 x 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 2 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 2 x 2 2 x 3 x Version 5.2 Page 35 Sydenham Terrace DS0000071689.V376440.R01.S.doc 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 YA5 Regulation 5 Requirement The registered provider must issue to each service user the terms and conditions in respect of the accommodation provided. OUTSTANDING PREVIOUS TIMESCALE (30/11/08) NOT MET The registered provider must provide an up to date and accessible complaints procedure to each service user. OUTSTANDING PREVIOUS TIMESCALE (31/12/08) NOT MET The registered provider must ensure staff receives up to date training to do with safeguarding service users from abuse and handling safeguarding referrals. The registered provider must continue to review the staffing numbers and staffing deployment to ensure that shift patterns support service development and service user’ needs. Timescale for action 31/10/09 2. YA22 22 31/10/09 3. YA23 13(6) 30/11/09 4. YA33 18 31/12/09 Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 36 5. YA34 6. YA37 7, 9 & 19 and Schedule 2. 9 When recruiting staff a full employment history of the applicant must be obtained as part of the recruitment process. The provider must review the manager’s job description and learning and development plan to ensure that she is competent to act and be accountable in line with her registration with CSCI. OUTSTANDING PREVIOUS TIMESCALE (31/12/08) NOT MET The registered manager must ensure that staff are trained in and understand their employers’ policies and procedures. OUTSTANDING PREVIOUS TIMESCALE (31/03/09) NOT MET 11/08/09 31/10/09 7. YA37 18(1)(i) 31/10/09 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 YA6 YA12 Good Practice Recommendations The staff should receive training and support in order to continue developing the service user plans. The service should continue developing more individualised programmes of social, vocational, educational activity and domestic routines with the people who use the service. Staff should be issued with up to date job descriptions. This recommendation remains outstanding since the last inspection. A suitably experienced and qualified person should be DS0000071689.V376440.R01.S.doc Version 5.2 Page 37 3. YA31 4. YA37 Sydenham Terrace 5. YA41 identified to manage the service. The registered provider should ensure that all records that are required to be kept are in good order up to date and accurate. Sydenham Terrace DS0000071689.V376440.R01.S.doc Version 5.2 Page 38 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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