Inspection on 09/09/09 for Belfry Gardens

This is the latest available inspection report for this service, carried out on 9th September 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

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Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Belfry Gardens 2 Belfry Gardens Doncaster S Yorkshire DN4 6TS     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Shirley Samuels     Date: 0 9 0 9 2 0 0 9 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 25 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 Homes for Adults (18-65 years) 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. 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 Care Homes for Adults (18-65 years) Page 3 of 25 Information about the care home Name of care home: Address: Belfry Gardens 2 Belfry Gardens Doncaster S Yorkshire DN4 6TS 01302537588 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Active Care Homes Ltd Name of registered manager (if applicable) Mr Chris Laurence Type of registration: Number of places registered: care home 2 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who may be accommodated is 2 The registered person may provide personal care (excluding nursing) and accommodation to service users of both sexes whose primary care needs on admission to the home are within the following category: Learning Disability (Code LD) Date of last inspection Brief description of the care home Belfry gardens is owned and run by active care home LTD. Active care states the philosophy as Service users physical, psychological and spiritual wellbeing is paramount to active care homes. For this reason we provide homes with a relaxed atmosphere that promote individuality, giving each service user the right to dignity, choice, privacy, confidence and independence. Belfry gardens is a care home for a maximum of two people in the category of learning disabilities. The home is staffed 24 hours a day and staff sleep in at night. Care Homes for Adults (18-65 years) Page 4 of 25 Over 65 0 2 Brief description of the care home The home is situated in Doncaster within a residential housing area, close to parks, shops, bus route and other local amenities. The accommodation comprises of three bedrooms, one with an en-suite. The third bedroom is used as an office and sleeping in room for staff. There is also a large bathroom, kitchen/diner, lounge, enclosed garden, to the rear of the property and parking area at the front. The manager confirmed that the weekly range of fees charged for accommodation and care was £1950-£2220. Further information about the service can be obtained by contacting the manager. Care Homes for Adults (18-65 years) Page 5 of 25 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was an announced inspection carried out by Shirley Samuels on the 09/09/09 from 4:45pm-7:45pm. This service was registered with us on the 11/03/09. As part of the visit we sought the views of the people using the service, staff and relatives. We checked a selection of documents regarding peoples care and support, staff records and records that show evidence of compliance with regulations and standards. Before the inspection the manager completed an, Annual Quality Assurance Assessment (AQAA). This information provided by the manager told us what the service did well and what was planned to further develop the service over the next 12 months. Care Homes for Adults (18-65 years) Page 6 of 25 Care Homes for Adults (18-65 years) Page 7 of 25 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Adults (18-65 years) Page 8 of 25 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. Care Homes for Adults (18-65 years) Page 9 of 25 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 25 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this 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 did not move into the home without having their needs assessed. This meant staff had the information they needed to support people in the way they preferred. Evidence: People had their needs assessed before moving into the home. There was evidence that they were consulted and had a say about where they lived. On each file there was information about the conditions of admission. The information detailed what people could expect, what they were entitled to and how the staff would work with them. It was clear from the records and from what people told us, family interest were taken into consideration, subject to the agreement and interest of the person using the service. Care Homes for Adults (18-65 years) Page 11 of 25 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs were detailed in a plan of care and they were supported to take risks. This meant peoples individual needs and choices were met. Evidence: Each person had a plan of care. The plan was developed in consultation with the person, their family representative and other professionals. People using the service, staff and relatives told us, people were encouraged as much as possible to make their own choices. This was supported by our observations on the day of the visit. There were records detailing peoples preferred communication style and the action staff needed to take to promote independence and wellbeing. The information was comprehensive and included peoples goals and aspirations. Details of peoples health care appointments and treatments were recorded. Care plan Care Homes for Adults (18-65 years) Page 12 of 25 Evidence: risk assessments were in place. Care plans and risk assessment were updated on an ongoing basis. Care Homes for Adults (18-65 years) Page 13 of 25 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this 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 had a say about how they lived their life and were supported to achieve goals and aspirations. This meant that people had a lifestyle they were happy with. Evidence: People were supported to develop and maintain skills for life and independent living. The records showed that people were supported to develop their own goals and aspirations. People told us they felt cared for by the staff and told us about activities that staff supported them in. People told us about contact with family and friends. Staff told us that family contact was important to individuals. There was evidence on peoples files that family and friends relationships were encouraged and supported. Care Homes for Adults (18-65 years) Page 14 of 25 Evidence: Relatives told us there was good communication between themselves and the staff at the home. There was evidence from staff practice that they respected peoples rights. People were observed to be treated with dignity, given choices, helped to make decisions and listened to. People told us about their activities, this was supported by written information in their files. Activities were arranged and individuals were supported by staff. The records showed and people told us they were able to take part in activities such as swimming, bowling, ice skating, local walks and attending day centre. There was also the opportunity for spontaneous activities such as playing football, going for walks, relaxing and board games. Relatives commented that some improvement could be made to make sure favourite pastimes and activities were maintained. People were offered a healthy diet and told us they were able to have a say about the meals. There was evidence that people were supported to plan prepare and serve meals. People told us they were offered food they liked and were able to try new things. Care Homes for Adults (18-65 years) Page 15 of 25 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this 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 were supported with their personal needs and were able to access healthcare services. This meant their overall health and personal care needs were met. Evidence: Peoples personal support care needs were recorded in their plan of care. People told us they were happy with the support offered to them by the staff. Staff were able to tell us how on a daily basis they respected peoples rights to privacy and dignity. Personal support was offered to people according to their individual needs and what was recorded in their care plan. Staff promoted peoples independence by encouraging self help and making choices. People had access to health care services. The records showed that staff supported people to attend appointments and visit local health care services. There was evidence that staff received training in relevant health care matters. This meant staff had knowledge to help them support people appropriately. Care Homes for Adults (18-65 years) Page 16 of 25 Evidence: The home had a medication policy in place. Staff responsible for administration of medication were trained. The medication procedures and practice was checked by the manager of the home. This made sure safe practices were maintained. Care Homes for Adults (18-65 years) Page 17 of 25 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this 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 were protected by the homes complaints and safeguarding procedures. Evidence: The home has a complaints procedure. This was provided in writing and explained to people using the service and their relatives at the time of admission. There was a complaints book. There were no complaints recorded and the manager told us there had been no complaints. Staff were able to tell us the action they would take if an allegation of abuse was made or if they had any concerns about how people were being treated. They told us they had received training. This was supported by staff training records. Care Homes for Adults (18-65 years) Page 18 of 25 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean, safe and well maintained. This meant that people lived in a comfortable environment. Evidence: The layout and facilities provided at the home were appropriate for the needs of the people using the service. People told us, they were happy with their bedrooms and showed us what was provided. One of the bedrooms had an en-suite. The other person had access to a bathroom that was near to the bedroom. There was a kitchen dining area and a separate lounge. These areas were clean, well furnished and well maintained. Peoples bedrooms were personalised and they were encouraged to bring personal belongings in with them. Bedrooms reflected peoples hobbies and interest. The shared areas of the home offered the opportunity for people to see visitors in private. Care Homes for Adults (18-65 years) Page 19 of 25 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recruitment procedures were robust and staff were trained. This meant people were supported by competent staff. Evidence: Staff told us they received the training they needed to do their job. The records showed that staff attended essential training. These included, first aid, food safety, fire safety, adult safeguarding, health and safety. Staff also received specialist training which helped them approach the more challenging elements of their job with confidence and competence. These included, autistic spectrum disorder and non violent crisis intervention. The recruitment procedures were safe. Staff files contained evidence of checks being made. They included, criminal record checks, taking up references, interviews and verification of identification. Care Homes for Adults (18-65 years) Page 20 of 25 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well managed. In the main there were procedures in place to promote good working practices. This meant the health safety and welfare of people was promoted and protected. Evidence: The manager was experienced and competent to manage the home. He had a clear understanding of his roles and responsibilities. Staff told us they had confidence in the manager and that the home was run in the best interest of the people using the service. Visits were made to the service by a representative of the organisation. These visits were made to check on the conduct of the service and to obtain the views and comments from people using the service, staff and relatives. The last recorded visit however, was dated 25/03/09. Relatives told us they felt the standard of the service was very good. Care Homes for Adults (18-65 years) Page 21 of 25 Evidence: The records showed, in the main safety checks were carried out. Risk assessments were in place, staff received fire instructions and fire drills were completed. There were records to show that electrical portable appliances were checked. The manager told us the gas supply had been checked, however the certificate was not available for inspection. The records also showed, there were gaps in the weekly fire system checks although these were up to date at the time of the inspection. Care Homes for Adults (18-65 years) Page 22 of 25 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 23 of 25 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 42 13 The fire system must be checked at weekly intervals. This is to make sure the fire system is in good working order. 12/10/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 39 Following visits to check on the conduct of the service. A report should be completed and made available at the home for inspection. The gas certificate issued following a check of the gas supply, should be kept at the home and made available for inspection. 2 42 Care Homes for Adults (18-65 years) Page 24 of 25 Helpline: 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). 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