Inspection on 12/01/06 for Washington

This inspection was carried out on 12th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Washington 20/03/08

Washington 18/01/07

Washington 03/08/05

Washington 17/02/05

Washington 27/09/04

Washington 02/03/04

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 Briarlea 18a Bede Crescent Washington Village Washington Tyne And Wear NE38 7JA Lead Inspector Sam Doku Unannounced Inspection 12th January 2006 10:00 Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 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 Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 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. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Briarlea Address 18a Bede Crescent Washington Village Washington Tyne And Wear NE38 7JA 0191 419 1867 0191 419 1867 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) Azure Charitable Enterprises Mr Philip Leslie Coverdale Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2005 Brief Description of the Service: Briarlea is a large detached house situated in Washington Village, owned by 3 Rivers Housing Association and run by Azure. The house is home for 6 adults with learning disabilities, 5 male and 1 female, ages ranging between 39 and 75 years. There have been no changes to the service user group since the home opened and their needs have not changed since the last inspection. Each person living in the house has a bedroom of their own with the facility to lock the door for added privacy, as well as a key to their room door. Each person also has a key to the door of the house. Everyone in the house shares the lounge, dining room, kitchen, bathroom and toilets. There are staff available 24 hours a day, seven days a week to support people in their daily lives and to provide waking night cover. A consistent approach to all areas of service users needs is achieved by a key worker system. The aim of the service is to offer the people who live there a good quality of life by promoting independence as far as possible and a valued lifestyle through access to community based activities. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out in the morning and the inspector met with the service users who tend to go out through the day to use other care and community services. All the service users were at home except who had gone out for the day for pre-arranged activities. The inspection process involved talking to service users, sitting in the lounge and observing staff interaction with the service users, discussions with the manager and care staff, tour of the house, examination of health and safety records and service users’ personal file including care plans. What the service does well: The manager provides good leadership and direction for the staff. The manager and his senior staff team provide appropriate supervision for all staff. The company provides good training for the staff to equip them for their roles within a caring environment. The service users confirmed that they are well looked after and the life plans and daily records provided further evidence of the good care practices in the home. The service remains a high quality service, enabling service users to exercise a great deal of choice and independence. It was evident from the records and discussions with the service users. The staff are highly motivated and offer a service that is generally consistent with the expressed wishes of the service users. The service is very much service user centred. The interest and welfare of the service users are at the forefront of the way the service is organised and managed. The service users continue to enjoy active and fulfilling lifestyles. Service users engage in active educational, social and recreational activities of their choice. The service users are supported to exercise as much choice as possible. They continue to be actively involved in the arrangements for their annual holidays. Staff are at the forefront of preparing and supporting the service users in achieving a fulfilled lifestyle. The key worker and life plan meetings are good ways of empowering the service users to be involved in the planning and review of their care. These have recently been reviewed and improved upon. The system is clear and easy to understand and staff who were spoken with have good knowledge of the content of the individual life plans. The home has good induction programme for new staff, which equip them in providing good quality care for the benefit of the service users. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 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 Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 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, 3, 4, 5. Service users are involved in the formulation and evaluation of their care plans. This ensured that the views, wishes and aspirations of the service users are established and incorporated into their plan of care. The home has suitable admission arrangements in place for admission, including pre-admission arrangements. The home has tenancy agreement with each service user but this does not reflect the arrangements between the housing association and the service users. EVIDENCE: The three service users files that were examined contained copies of the service user guide. The guide provides good information to service users and the information is in Widget format to assist service users with understanding the content of the guide. One service user was spoken with he is aware of the guide. Three life plans were examined and these provided good evidence of staff understanding of the needs of the service users. The life plans set out the wishes and aspirations of each service user and they are to be supported to achieve their aims. This ensured a person-centred approach to the provision of care and support in the home. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 9 The manager described the arrangements for admission. It is acknowledged that there had not been an admission to the home for time now. However, the description given by the manager includes arrangements for prospective service users to visit the home and to meet with staff and service users. He described the trail period which would enable the service user have sufficient time to decide on permanent residency. The tenancy agreement with the service users is still being considered by the housing association. The manager confirmed that arrangements are underway to re-issue new tenancy agreements with the service user. This would provide the service users with adequate information regarding their responsibilities. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10. The life plans are formulated with involvement of the service users thus ensuring their participation in the planning of their care and in the running of the home, taking into account their wishes and aspirations. Information held about service users are appropriately stored and kept in accordance with the provider’s policy on data protection. EVIDENCE: Three service users files were examined and these contained details of assessments carried out to identify their care needs. Detailed life plans have been formulated by staff and agreed with the individual service users. The life plans are regularly reviewed and evaluated to take account of the changing needs of the individuals. These clearly set our the details of the individual’s care needs and plans indicating how those care needs are to be provided by the staff. This ensures that the care provided for the service users are relevant to their current needs. The practice of involving the service users in the formulation and evaluation of their life plans ensured that they are involved in decisions about the care they receive. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 11 The service users are encouraged and supported to be involved in the day-today running of the home. Service user meetings and individual life plan meetings are mechanisms for promoting service user involvement. This has created a sense of empowerment amongst the service users. The home adopts responsible risk taking strategies to ensure the safety and wellbeing of the service users. Risk assessments related to daily living activities within the home, as well as activities outside the home. These include accessing the kitchen, independent travelling, seizure episodes and bathing. Risk assessments are regularly reviewed and comments recorded in the daily record sheets. This ensured that service users enjoy fulfilled and independent lifestyle without unnecessary restrictions on their life. Information about the service users are securely kept and in line with the data protection. Keys to the cupboards are kept on the person in charge to ensure safety and security of information relating to the service users. The life plans about the service users are available on floppy disks and stored in the office under lock and key. However, the manager was advised to seek further clarification from the provider on the storage and management of such electronic data to ensure that it is line with the Data Information Act in order to promote the welfare of the service users. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 16, 17. The home promotes personal relationship amongst the service users and provides support for the individuals to experience personal, family and sexual relationship. This recognises and the rights of the individuals. Service users are offered homely and nutritious meals, which promote their health and wellbeing. EVIDENCE: The records and practices observed indicate that the staff team support and promote family links with the service users. Service users are reminded of important events such as birthdays for relatives and friends. This ensures that service users are able to send good wishes cards to their friends and families, thus maintaining contacts with them. Staff also provide support for service users who have established personal relationships. Practices observed indicate that staff enable and support service users to make independent decisions for themselves. It was noted that staff always sought permission from individual service users before entering their rooms. This Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 13 created an atmosphere of independence, respect and empowerment amongst the service users. Staff involve service users in the drawing up of the weekly menus and also take part in the weekly shopping for the home. Service users are offered choice of meals and are encouraged by staff to maintain some level of independence regarding meals. There was documentary evidence in the daily records showing that service users dietary needs were being met. Service users are frequently offered the opportunity to go out for meals, and there was documentary evidence to support this. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. Service users health care needs are identified and arrangements are made to ensure they are promoted and met. There are good arrangements in place to ensure the safe administration of medicines, including support for self-medication. The home provides appropriate in-house training to staff on ageing and age related illnesses and death. This ensured that staff have good understanding of the care needs required to care for people in old age. EVIDENCE: Services users were supported to attend GP service and other healthcare related appointments such as out patient appointments, district nursing support, appointments with dentists, opticians, chiropody, psychologists and community psychiatric nurses. Details of contact with these services have been documented in the individual life plans and in daily report books. Medication and other healthcare related risk assessments have been carried out and the details available on individual files. This enables each service user to lead their preferred and chosen life style within an acceptable risk level. One service user has been given appropriate support to enable him to manage his Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 15 medication when he goes out. This promotes his independence, selfconfidence and sense of responsibility. The manager confirmed that suitable training have been provided for the staff such as Alzheimer awareness and mental health in old age. The manager had also acquired a training manual entitled “Dying Matters” and would be using this for in-house training for the staff. Such training is necessary in ensuring that staff are equipped to provide the necessary care for people who are ageing. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected on this occasion. EVIDENCE: The standards relating to this part of the section had not been assessed on this occasion. These standards were examined at the last unannounced inspection of the 28 July 2005. All the standards were met and at this inspection it was observed that the standards have been maintained and remain satisfactory. Readers wishing to read about these standards should refer to the last inspection report of 28 July 2005. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected on this occasion. EVIDENCE: The standards relating to this part of the section had not been assessed on this occasion. These standards were examined at the last announced inspection of the 28 July 2005. All the standards were met and at this inspection it was observed that the standards have been maintained and remain satisfactory. Readers wishing to read about these standards should refer to the last inspection report of 28 July 2005. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 18 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, 33, 35, 36. The home maintains adequate staffing levels to meet the needs of the service users. Suitable arrangements for staff training and supervision are in place, which ensured that staff are equipped to provide good quality service that benefits the service users. EVIDENCE: Examination of past rotas showed that the home consistently maintains adequate staffing levels to meet the needs of the service users. The staff training log contained details of the training provided for the staff which included moving and handling, first aid, fire safety training, food hygiene, challenging behaviour management and protection of vulnerable adults awareness training. Some of the staff have completed NVQ 2 training and arrangements are in place to extend this to all staff. All the staff have been provided with induction training followed by foundation training within the first six months of employment (LADAF). The staff member who was interviewed confirmed the training she had received and felt that this had help to maintain a safe environment for the service users to live in. The use of agency staff has ceased and the manager had arranged for the extra shifts to be managed with the existing staff team. This ensured consistency of service for the service users. The arrangements for promoting Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 19 consistent staffing for the benefit of the service users are good and should maintained where at possible. The staff are well supported by a management team. The manager and his deputy provide regular supervision to all staff and records are maintained. The staff member who was interviewed described the support mechanisms in place and considered them as helpful to all the staff. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 20 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, 38, 39, 40, 41, 42. The manager provides good leadership and direction for the staff. This ensured that the service is run for the interest of the service users, promoting and safeguarding their rights and wellbeing. EVIDENCE: Interview with a staff member indicated that the manager and his senior team continue to provide regular one-to-one supervision and support to all staff. The manager and the senior team are readily available to staff and service users at all times and both staff and service users stated that they find this approach helpful. The manager was described as very caring and service user focused. One service user who spoke wit the inspector confirmed that he and other service users have good relationship with the staff and are able to discuss any concerns without fear of intimidation. The manager confirmed that monthly audit system had enabled him to review all aspect of the service ranging from life plans to health and safety in the home. The manager has continued to maintain evidence of proper maintenance of the home. Maintenance certificates for the servicing of Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 21 electricity, electrical equipment, gas, heating and bath hoist servicing were available and up to date. Records of the regular internal maintenance of the home and equipment are also kept. This ensures safe and secure environment for the service users. This was further reinforced by the provision of health and safety training including first aid, fire training, moving and handling and food hygiene to all staff. The company has produced detailed Health and Safety policies and procedures and copies of these were made available for inspection. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). The policy guidelines are aimed at ensuring that the staff maintain safe working practices which safeguard the safety and wellbeing of the service users. Other health and safety related training such as emergency first aid, food hygiene and fire training have been provided. However, some of the policy documents have not been reviewed for some time, and to be reviewed to ensure that they are still relevant and current. Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 22 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 X Briarlea DS0000015753.V263255.R01.S.doc Version 5.1 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA5 Good Practice Recommendations The housing association responsible for the accommodation should consider issuing tenancy agreement with individual service users so they are aware of what their responsibilities and obligations are. 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