Inspection on 25/02/08 for The Alan Shearer Centre

This inspection was carried out on 25th February 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

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

CARE HOME ADULTS 18-65 The Alan Shearer Centre West Denton Hall West Denton Newcastle upon Tyne NE15 7LT Lead Inspector Elaine Malloy Key Unannounced Inspection 25 February to 4th March 2008 09:30 th The Alan Shearer Centre DS0000070728.V354535.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 The Alan Shearer Centre DS0000070728.V354535.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. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Alan Shearer Centre Address West Denton Hall West Denton Newcastle upon Tyne NE15 7LT 0191 267 8118 0191 267 5540 jane.percy@stcuthbertscare.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) St Cuthbert’s Care Vacant Care Home 8 Category(ies) of Learning disability (8), Physical disability (4), registration, with number Sensory impairment (8) of places The Alan Shearer Centre DS0000070728.V354535.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 categories: Learning Disability, Code LD, maximum number of places 8 Physical Disability, Code PD, maximum number of places 4 2. 3. Sensory Impairment, Code SI, maximum number of places 8 The maximum number of service users who can be accommodated is: 8 Should a service user aged 16 or 17 years of age be admitted, an upper age limit of 25 years will apply for anyone else using the service at the same time. Not applicable Date of last inspection Brief Description of the Service: The Alan Shearer Centre is a new service for people with disabilities and their carers that is situated in the West End of Newcastle upon Tyne. The centre was created within West Denton Hall, a former manor house set in its’ own grounds. There are extensive activity facilities including sensory rooms, hydrotherapy pool, cinema, ball pool, craft room, internet café, a sensory garden, and outdoors play and walk areas. The centre provides a short break service to adults and children, who stay at different times. Services for children are registered with OFSTED and inspected separately. The short break service is on the upper floor of the centre and can be accessed by a passenger lift. The accommodation consists of a lounge and dining area, small kitchen, eight bedrooms each with en-suite facilities, bath and shower rooms, and a laundry and sluice. A guide to the centre’s services is available. The cost for staying at the centre is £180 a night during the week and £200 a night at weekends. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection was carried out by: • Looking at information received since the service was registered in October 2007. • Getting the provider’s view of the service and how well they care for and support people. • Two inspectors visiting the centre on 25th February 2008. • Talking to the management and staff about the service. • Looking at records about the people who use the service and how well their needs are met. • Looking at a range of other records that must be kept. • Checking that staff have the knowledge, skills and training to meet the needs of the people they support. • Attempting to get the views of people who use the service, their relatives, and staff. One feedback survey from a relative was received. People using the service are called guests of the centre, and are referred to as such throughout this report. What the service does well: People who are considering having a short break, and their relatives are invited to visit the centre and are provided with a guide to the service before they come to stay. This is so they have enough information before deciding whether to use the service. Each person has an assessment of their needs and the information is used to record individual care plans. This is to make sure staff know what they have to do to support the person to meet their needs. The service aims to provide a holiday for guests whilst their parents/carers take a break from the caring role. They are encouraged to make choices and decisions and take part in a wide range of stimulating activities within the centre and in the community. A relative told us, “They take a genuine interest. My son has complex needs and the staff have quickly worked to settle him into their care. He needs to feel secure and must constantly receive reassurance or else he will become very anxious. Having gained his trust so quickly they will be able to get the best out of him. I feel this to be the case”. Guests are offered flexible support that is tailored to meeting their personal and health care needs, and taking medication. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 6 Clear systems are in place to make complaints and protect vulnerable people from being harmed. The accommodation is to a good standard and is well equipped so it is can be accessed by people with physical disabilities. Guests can use all of the activity facilities within the centre, and at certain times they have exclusive use. Staff who are properly recruited and trained support people to meet their diverse individual needs. An experienced and qualified manager runs the service in the best interests of guests and their carers. What has improved since the last inspection? What they could do better: Some recording systems need to be improved. These are the frequency of evaluating care plans, to show how effective they are in meeting people’s needs; developing plans so they clearly set out how risks in supporting people are managed; and keeping full details of meals to show guests receive a varied and nutritional diet. The service is to get a medical history for each guest to enable staff to be more aware of people’s health needs. Consent to give medication is to be introduced to uphold people’s rights and choices. The pipe-work in toilets on the unit needs to be boxed in, to stop this being a potential hazard. The size of the kitchen, and storage space are to be reviewed to make sure the facilities are suitable for the people using the service. More staff are to study for nationally approved care qualifications to improve their skills and knowledge about the people they care for. A plan is to be drawn up to show how the quality of the service will be monitored that includes how people’s views will be listened to and acted upon. All relevant policies and procedures need to be put in place to guide staff practice. Staff must be provided with regular instruction so they know what to do in the event of a fire and how to keep people safe. Please contact the provider for advice of actions taken in response to this The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 7 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. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 8 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 The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 9 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 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person has their needs thoroughly assessed, and can visit the centre before they use the service. This is to make sure the individual care and support they require can be provided. EVIDENCE: The manager explained that when a new person is referred to the centre their care manager is given a referral/assessment form to complete with the person and their family. This assesses their needs in the following areas: personal details, family, communication, eating, toileting, night-time, sleeping, health needs, mobility, personal hygiene, dressing, activities, and typical routine. This was verified by looking at the care records of current guests. A separate assessment of risks is also completed. An example was seen of a risk assessment for a guest who needs to have bed-rails fitted to their bed for their safety during their stay. People are only offered short break stays when the manager is certain the service will be able to meet their needs, as identified from the assessments. If staff require further training to support a person then this is carried out before they come to stay. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 10 People considering using the service can have a gradual introduction by visiting the centre, with their relatives if they wish, until they feel able to have overnight stays. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Guests have their care well planned and are supported to make decisions, though records do not always fully reflect how risks are managed to ensure their welfare. EVIDENCE: Each guest has individual plans to show how their assessed needs will be met during their stay. These were generally well recorded and addressed personal care and hygiene, health care, moving and handling, diet, safety and wellbeing and social activities. The manager agreed to revise some plans that needed more specific information. The frequency of evaluating plans was discussed, as this was stated as being six monthly. The inspector recommended staff record evaluations with greater frequency. For example, during or at the end of a guest’s stay to show whether the plans have been effective in meeting the person’s needs. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 12 Detailed day and night reports are recorded and separate records of activities, health, and, where appropriate, food and fluid intake are maintained. Guests are encouraged to make choices and decisions about what they want to do whilst staying at the centre. Parents/carers advocate on the person’s behalf where he/she is unable to communicate their needs and wishes. A relative said, “My son’s stay is all about his needs and wants. They are very obliging in ensuring that he gets as much as possible from his stay”. The manager said there is information about advocacy services available and she is booked to attend a training course on working with advocates. Guests bring in cash for personal spending and are encouraged to manage this independently. They can keep money in a lockable cabinet in their bedroom or put it in the safe. Communication needs are assessed and details of the best ways to understand and communicate with the person are described in support plans. Where used, people will bring in their own communication aids. Some guests do not use the spoken word and therefore staff need to observe and interpret gestures, body language and behaviour. For example, one support plan described how the person makes noises when they are feeling happy. A relative told us, “The staff are very interested in my son, ensuring that his stay is a happy one. They have asked and continually ask about certain mannerisms that he portrays. Their interest in him is extremely beneficial as he gains his trust and security from people who genuinely care”. The service has a ‘Risk Management Panel’ that monitors and reviews medium to high risks activities. There is a risk policy that focuses on how to assess and manage risks to increase independence whilst keeping people safe. Each guest has an individual ‘evacuation plan’, in the event of needing to be supported to leave the building in an emergency. The manager said that guests are provided with a range of opportunities that are risk assessed, and that positive risk-taking is encouraged. This was not always fully reflected in care records. Examples were seen of assessments and the action to be taken to manage or minimise identified risks. The standard of recording was variable and in some instances the strategies to reduce risks were not clearly recorded. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are offered flexible support to maintain their usual routines, and enhance their lifestyle through new experiences and stimulating activities. EVIDENCE: During their stay guests are supported to continue with their usual routines and interests, and attend schools, centres and clubs. The centre has an extensive range of activity facilities that are available to the public on a booking system. Guests have exclusive access to these outside of opening hours in the early mornings and evenings. All activities have moving and handling equipment to aid people with disabilities. The facilities include a ball pool, hydrotherapy pool, craft room, three different sensory rooms and a sensory cave, and an Internet café. There are also external play areas, a sensory garden and walkways. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 14 There are shops, a public house, hairdressers and post office within walking distance, and good public transport links. Most of the guests who have stayed to date have not used community facilities, as they have preferred to enjoy the activities at the centre. The service can provide flexible staff support to enable people to be involved in community activities. The manager said that one guest went out shopping with staff support. Taxi services are currently used for transport. A minibus is on order that will be based at the centre and able to be used by guests. This will have wheelchair access. The service has an open visiting policy. People wishing to visit in the evenings are asked to telephone in advance due to the main gates to the centre being closed at this time. Parents/carers usually maintain contact by telephone as they are having a break from the caring role and/or taking holidays. Staff telephone parents/carers to inform them of any significant issues affecting their relative. Records of contact are kept. A relative told us that they get enough information about the service to help them make decisions and said, “My son cant talk but I am certain they would contact me if he displayed behaviour that might indicate hed be better off at home”. Staff will support people to maintain and develop relationships. The service has policies and procedures on people’s rights to form relationships. The manager agreed to clarify issues relating to intimate and sexual relationships, with senior management. Each person’s usual routine is identified as part of the assessment process. The information helps staff to provide individualised support according to the guest’s preferred times of getting up, going to bed, taking meals etc. This is balanced with offering the guests new activities and creating a holiday atmosphere. All personal care and any medical examination/treatment are carried out in private. Guests are offered keys to their bedroom and have a lockable piece of furniture in their bedroom to keep personal possessions in. A key ‘fob’ system is used within the building and guests have unrestricted access to all areas. The manager agreed to make sure that information is made available to guests about the service’s procedures on smoking, alcohol and drugs. Each person has an assessment of their needs that covers diet, likes/dislikes, and aids and support with eating. The initial intention when the service opened was that guests would have meals provided by the café in the centre. The manager said this has not proved to be practical and meals are now prepared and cooked in the small kitchen on the unit. This is appropriate at present whilst there are only a few guests staying however this will be more difficult when the service is running at full capacity. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 15 All staff have had food hygiene training and guests can be involved in preparing food if they wish. The menu is changed every week. Staff need to make sure they record all food provided to show that people are receiving a nutritional and varied diet. The times of meals are flexible to suit individuals. The main meal is served in the evening, with the exception of Sunday lunch. Guests can also take meals, drinks and snacks at the centre’s café. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are well supported to meet their health and personal care needs and take medication safely. EVIDENCE: The extent of support that each person requires with meeting their personal care needs is assessed and set out in individual care plans. Staff ensure consistency with routines at home where this is required. The service provides a wide range of aids and equipment to assist people with disabilities. These include overhead tracking, a mobile hoist, two adjustable beds, grab rails, bathing and toileting aids, and aids to promote independent eating and drinking. Guests also bring in their own equipment such as wheelchairs and moving and handling slings. A relative told us that the service gives the care and support agreed and said, “The care staff have ensured that they know as much as possible about my son’s complex needs and they continually ask questions. They talk about him with affection and through their views I feel he is well settled in their care”. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 17 The service gets details of each person’s doctor and other professionals involved in their health care. The inspector suggested that a medical history also be obtained. This will help staff to be aware of the person’s past and current health care conditions that may affect their welfare. Wherever possible guests keeps their own medical professionals for advice and visits for the duration of their stay. Arrangements have been made with a local GP practice to temporarily register people as patients if needed. For example if they live outside of the area and their own GP is unable to visit at the centre. A ‘health diary record’ is maintained for each guest where staff record information such as if the person has been poorly, and any contact with health care professionals. The manager said that staff would accompany guests to attend health care appointments that occur during their stay. The service has a medication policy and procedures. All staff have completed safe handling of medication training. If a guest wishes to administer their own prescribed medication then the risks involved in doing so would be assessed. A list of the person’s current medication is obtained during their initial assessment and this is updated if they have further stays. Charts of current medication, form, dosage, how taken and times of administration are kept. Consent to give medication is not recorded at present, and is to be introduced. There is a cupboard and fridge for storing medication. A new cupboard has been ordered that incorporates a facility for storing controlled drugs. Staff keep records of medication received and returned. The manager agreed to make sure that this is clearly recorded, for example the volume of liquid medicine. Medication is given directly from boxes and bottles that are prescribed for the individual and labelled with directions by a pharmacist. Administration was appropriately recorded and two staff sign to verify medication has been given. Advice was sought from a Pharmacist Inspector on specific medication issues and relayed to the manager following the visit to the service. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are protected from harm by clear complaints and safeguarding procedures. EVIDENCE: The service has a complaints procedure that is provided to guests and their relatives. The procedure is available in an ‘easy read’ format with pictures to aid understanding. No complaints have been made about the service since it was registered. A relative told us that they know how to make a complaint about the care provided by the service if they need to, and indicated they are confident this would be responded to appropriately. There are policies and procedures on protecting vulnerable adults (POVA), prevention of abuse and ‘whistle blowing’ (informing on bad practice). A copy of Newcastle Local Authority’s Safeguarding Adults Inter Agency Policy has been obtained. All staff have received training in ‘No Secrets’. In the period since registration there have been no allegations of abuse. The service has procedures on working with people who have challenging behaviours. A physical intervention record is kept. The book is currently used to record interventions with both adults and children. The manager agreed to introduce separate books and record details in line with Department of Health guidance. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests stay in a safe, clean and comfortable building with extensive facilities. EVIDENCE: The accommodation is self-contained on the upper floor of the centre and can be reached by a passenger lift. It is accessed by a ‘fob key’ system. CCTV is installed, however this is not used. All areas of the unit are accessible to guests and a good range of equipment and aids is provided for people with disabilities. There are eight en-suite bedrooms, each with appropriate furnishings and equipped with flat screen television and DVD player. The manager has purchased pictures and other items to make the rooms look more homely. All bedrooms have individual temperature control, however one of the rooms is consistently cold. The heating has been checked but the cause has not yet been determined, and this bedroom is not being used. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 20 There is a communal lounge/dining room with views over the gardens. Space may be limited here when the service is running at full capacity. As previously stated the kitchen facility is small and may not be suitable for catering for up to eight guests. A bathroom with shower, and a separate shower room are provided. These are equipped for use by people with physical disabilities. There is a laundry/utility room, and a separate sluice room. Piping around toilets needs to be boxed in. The unit lacks sufficient storage space and this needs to be reviewed. The back stairway was partially blocked by a portable hoist, shower chair, two boxes and a roll of carpet on the landing, and in the utility room items were on the stairs. An internal health and safety audit had previously identified the laundry as crowded and untidy. There are policies and procedures for control of infection. Suitable hand washing facilities with liquid soap and paper hand towels are provided. Disposable gloves and aprons are available for staff use. The health and safety training that staff undertake includes elements of infection control. Arrangements are in place to dispose of clinical waste. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient, well-trained staff to meet the needs of people who use the service. EVIDENCE: Staffing levels are flexible and determined according to the number and needs of the people staying. The manager’s hours are in addition to these levels. Agency staffing from the Primary Care Trust is currently being used whilst new staff are being recruited. 17 domestic hours are provided weekly. Staff demonstrated they are aware of the aims of the service and were able to describe key procedures, for example what to do in the event of a fire, and how to report safeguarding issues. They said there is a good staffing ratio and they have regular individual supervision. Staff have job descriptions and receive a copy of the standards of conduct and practice set by the General Social Care Council. Each guest is allocated a member of staff as their ‘key worker’. Staff meetings have been taking place monthly. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 22 A relative told us they feel the staff they have met have the right skills and experience to look after people properly. She said, “The staff are very open and friendly. They would contact me as I would them. My son is new to the Alan Shearer Centre. We are totally at ease with him staying there and he has settled exceptionally well, very much enjoying his time there. He cant talk but I can tell by his relaxed and happy mood when he returns from a visit that he has had a great time”. A sample of three staff recruitment files was examined. These contained appropriate information including application forms and references from suitable sources. One file did not have a photograph of the staff member. Arrangements are in place for all staff to be employed subject to Criminal Records Bureau checks. Individual records of staff training are maintained. Each file viewed had a signed copy of the staff member’s induction training. Records of mandatory training, for example safe working practices, adult protection and medication training indicated that staff were up to date. Specialist training, specific to the needs of people using the service is organised before they come to stay. An example of this was staff being trained by a nurse in the techniques of using a Percutaneous Endoscopic Gastrostomy (PEG) tube to give nutritional feeds and medication. Two staff have achieved National Vocational Qualifications (NVQ) and the service is aiming to have further staff study for these care qualifications. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests stay in a well-managed centre that is run in their best interests and promotes their health and safety, though some aspects of fire safety are to be improved. EVIDENCE: Mrs Carol Harrison has recently taken up post as the manager of the short break service and is applying to the Commission to become the Registered Manager. She was previously registered as the manager of another St Cuthbert’s Care service. She has worked for the organisation for eight years and has three and a half years experience in a senior and management capacity. Prior to this she has worked in education for children with disabilities and childminding. Mrs Harrison has achieved the Registered Manager Award The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 24 qualification in children’s services and NVQ Level 3 in caring for children and young people. She is currently studying NVQ Level 4 in care of children and adults. She is up to date with all safe working practices training. St Cuthbert’s Care senior management and departments for training, human resources and finance support the manager. Mrs Harrison’s hours are additional to the staffing levels to allow her to concentrate on the management of the service. She currently manages a team of one senior care officer and six full time care officers. Further staff are in the process of being recruited for day and night duty, including another senior. The manager is looking to arrange an on-call system that she and the seniors will operate on a rota basis, should staff need advice out-of-hours. A system of monitoring the quality of the service is in the process of being developed. Surveys for guests and relatives are being introduced and some audits, for example health and safety are taking place. A senior manager visits and reports on the conduct of the service each month. An annual development plan with measurable methods of quality assurance has not yet been devised. The manager is to make sure that all policies and procedures relevant to the service are in place to guide practice. A relative said she could not give any suggestions as to how the service could improve and said, “At this stage I am very happy with the care they provide for my son”. There is a health and safety policy and a range of associated procedures. All staff receive training in health and safety and safe working practices. The manager said that any issues highlighted by the fire brigade are always implemented. Fire safety records are maintained. Records of fire drills were evident however there was no record of in-house fire instructions being given to staff. Systems are in place for the reporting and recording of accidents and incidents. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 2 2 X 3 X 2 X X 2 X The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 26 N/A 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. 2. Standard YA27 YA42 Regulation 13(4)(a) 23(4) Requirement Pipe-work in toilets must be boxed in to prevent potential hazards. All staff must be given in-house fire instructions at the required intervals. Timescale for action 25/05/08 25/02/08 The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 27 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. 4. 5. 6. 7. 8. Refer to Standard YA6 YA9 YA17 YA19 YA20 YA28 YA35 YA39 Good Practice Recommendations Guests individual care plans should be evaluated, as a minimum, at the end of each stay. The standard of recording of risk management strategies/plans should be further developed. All food provided should be recorded in the menus. A medical history should be obtained for each guest. Recorded consent to give medication should be introduced. The size of the kitchen facility and storage space should be reviewed. The ratio of staff with NVQ qualifications should continue to be improved. (a) An annual development plan for quality assurance should be introduced. (b) All policies and procedures relevant to the service should be put in place. The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 28 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 The Alan Shearer Centre DS0000070728.V354535.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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