Inspection on 24/01/06 for Third Row, 11-12

This inspection was carried out on 24th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Third Row, 11-12 27/06/07

Third Row, 11-12 07/06/06

Third Row, 11-12 07/11/05

Third Row, 11-12 19/03/05

Third Row, 11-12 19/01/05

Third Row, 11-12 16/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Third Row, 11-12 11-12 Third Row Linton Morpeth Northumberland NE61 5SB Lead Inspector Carole McKay Announced Inspection 24th January 2006 09:30 Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 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 Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 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. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Third Row, 11-12 Address 11-12 Third Row Linton Morpeth Northumberland NE61 5SB 01670 861417 01670 862342 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) Mr John Thomas Cole Mrs Delia Cole Mrs Linda Algar Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Linton is a small village situated in a rural ex coal mining area of Northumberland. The village is a small close-knit community comprising of rows of attractive terrace houses. The village has a small shop, which is run by the local community as a co-operative, and a local pub. 11/12 Third Row, Linton is a four bedroom terraced house created from two converted houses. The house has a large private garden. Three men live at the house. Their ages range from mid 40’s to mid 60’s. Linda Algar manages the home, under the supervision of Mr Cole. A small team of experienced staff are employed. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The manager was interviewed and the inspector met two of the service users. Satisfaction surveys were sent out to service users and their representatives. What the service does well: What has improved since the last inspection? No requirements or recommendations were made at the last inspection. The home continues to provide a well maintained home for people living there, with an emphasis on individual care. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Although admissions to the home are very infrequent, the home has produced information useful to prospective service users. The home has a satisfactory process for assessing prospective service users. EVIDENCE: The service has a statement of purpose and a service users guide. No service users have been admitted to the home in the past three years. The assessments for the existing service users have been assessed at earlier inspections and were found to be satisfactory. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Service users are allowed to make decisions about how they live. Where this presents risks these are assessed and monitored, in order that the choice of the service users can be safely respected. EVIDENCE: The right of a service user to control his food intake is respected by staff. A standard risk assessment is used to address all risks. The inspector advised that a specific nutritional risk assessment should be adopted in this instance. A copy of an example risk assessment has been forwarded to the manager of the home. Food intake is monitored and recorded where risks are apparent. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 The rights of service users to make their own decisions are respected. The service provides a balanced diet through home cooking and taking into account service users’ wishes, likes and dislikes. Service users enjoy the meals. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 11 EVIDENCE: The home does not have a designated cook. All care staff share the responsibility of preparing and cooking food. The manager said that the menus are planned around service users’ likes and dislikes. Service users are able to make choices and to make their wishes known. Service users who responded to the survey indicated that they liked the food. The menus show that meals are mainly home cooked and fresh ingredients are used as much as possible. One service user has particular diet needs and the manager of the service said that a dietician had been consulted about this some time ago. One service user chooses to have his food presented in a certain manner. This choice is respected, though it is a social restriction. The manager said that medical advice had been taken. There is no medical reason for the arrangements that are made. As stated above the inspector has advised that a nutritional risk assessment is adopted. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20 Service users are provided with personal support in the way they prefer, however these arrangements must be reviewed more regularly. The people living at the service are encouraged to be independent in managing their own medication where possible. Their ability to continue to do so should be monitored more closely. Procedures for staff to administer medication are satisfactory, however records to do with medicines leaving the home need to be improved. EVIDENCE: One of the service users is very particular about the way in which certain parts of his care are provided. This is respected by the service and documented in the care plan. Medical advice is taken as necessary, however where care staff undertake heath care tasks the staff have not had their ability to do so reviewed since their initial training was provided. The manager said that this was approximately three years ago. The home’s medication procedures have recently been revised. These now reflect good practice. All three service users are taking medicines on a regular basis, to varying degrees. Records are kept of medicines administered to service users by the care staff. These are up date and accurate. One of the service users is, in part, self-medicating. No risk assessment or care plan for Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 13 this arrangement is available. However consent of the service user to allow the service to hold medications on his behalf has been recorded and the service user signs the record. This is good practice and should be extended to all service users who are consenting to having their medicines administered by staff. For some service users daytime medications are sent to the day care services to be administered to service users by staff at the day services. A record of the name, strength and quantity of medication going out of the home in this way is not maintained. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The home has a complaints procedure and a complaints record. Service users and their representatives are informed of local procedures. The home has staff guidance and procedures in place to protect vulnerable adults from abuse. Local procedures and national guidance documents should also be available to the manager and her staff. EVIDENCE: The home’s complaints procedure is available in the home and is also included in the Service User Guide. The service users hold copies of this. The manager said that no complaints have ever been received by the service. None are recorded in the complaints record. The home’s procedure includes the contact details of The Commission for Social Care Inspection (CSCI). No complaints about the service have been received by CSCI since the last inspection. Service users and representatives who responded to the survey recorded that they knew who to speak to if they were unhappy with the service and were aware of the home’s complaints procedures. The home has written guidance and procedures for the staff to do with the protection of vulnerable adults (POVA). The manager said that all of the staff have received awareness training in this subject. The manager did not have copies of the local POVA procedures or a copy of the Government guidance document; “ No Secrets”. All surveys returned from relatives showed that people were aware of the complaints procedures. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 These standards were examined at the last inspection and were found to be satisfactory. They will be examined again at the next inspection. EVIDENCE: Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 A team of seven long –serving staff supports Service users. The staff are trained to meet the needs of individual service users. There are areas of care that staff have not received recent or properly accredited training in. Service users have special needs that have not been identified as training needs for the staff team. Staff records must be available for inspection at all times. EVIDENCE: The manager has undertaken NVQ in care to level 3. The manager said that all other staff hold NVQ in care level 2 and that new staff undergo induction training in the Learning Disability Framework. Staff competency to do with undertaking health care procedures, including medication, nutrition and diet, continence and catheter care, should be reviewed. Training must be updated as necessary. Staff should be provided with training in fragile x syndrome. Staff records are not kept at the home so the Inspector was not able to verify the level of training achieved and the recruitment procedures adopted at the home. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 Service users and their representatives are satisfied with the way the service is run. The service is stable. Staff turnover is low. Service users are comfortable in expressing an opinion about the service they receive. EVIDENCE: The registered manager does not hold NVQ level 4 in management and care. It has been agreed that this is not essential as other managers in the group do hold relevant qualifications. The Manager said that during the absence of the registered owners, Mr and Mrs Cole, a manager from another service nearby oversees the running of the home and that this arrangement works well for all staff in the organisation. Because staff records are not available in the services run by Eldron Care the Inspector was not able to verify the qualifications of the manager overseeing the service. Service users and representatives returned positive surveys about the home. One comment was included form service users; Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 18 “ The staff from managers down over are the best around. You would not get better staff in any other homes you went around. They all deserve a certificate saying the best staff around.” One comment was included from representative surveys: “ I’m very happy with were and how my brother’s care is handled.” Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 2 x x x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x 2 x 2 1 x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Third Row, 11-12 Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x x x DS0000000652.V273358.R01.S.doc Version 5.0 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 Requirement The registered manager must maintain a record of all medicine leaving the home to include; the name, strength, and quantity of medicines and the name of the service user whose property the medicine is. The registered manager must ensure that where service users are self-medicating, the risks are first assessed and measures, in the form of a care plan, are put in place to ensure the safety of the service user. The registered person must ensure that the manager and her staff are issued with copies of the local POVA procedures and a copy of the DOH guidance “ No Secrets” The registered persons must develop a training programme to provide accredited training in administering medicines, up dated training in health related tasks, awareness training in fragile x syndrome The registered person must keep in the care home the records of all persons employed at the care DS0000000652.V273358.R01.S.doc Timescale for action 30/04/06 2 YA20 13 30/04/06 3 YA23 13 30/04/06 4 YA35YA32 18 31/05/06 5 YA34 19,17, Schedule 4 30/04/06 Third Row, 11-12 Version 5.0 Page 21 home, including in respect of each person so employed – a) his full name, address, date of birth, qualifications and experience; b) a copy of each reference obtained in respect of him; c) the dates on which he commences and ceases to be employed d) the position he holds at the care home, the work he performs and the number of hours for which he is employed each week e) correspondence, reports, records of disciplinary action and any other records in relation to his employment. 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 YA17YA7 YA20 Good Practice Recommendations The service should use a nutritional risk assessment for service users who have special dietary needs or restrictive diets. Consent to treatment should be sought from all service users and recorded, where staff are undertaking to provide health care tasks. Third Row, 11-12 DS0000000652.V273358.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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