Inspection on 26/02/06 for 261 Passage Road

This inspection was carried out on 26th February 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

261 Passage Road 12/09/07

261 Passage Road 10/10/06

261 Passage Road 13/09/05

261 Passage Road 01/02/05

261 Passage Road 13/07/04

261 Passage Road 13/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 261 Passage Road Brentry Bristol BS10 7JA Lead Inspector Karen Walker Unannounced Inspection 26th February 2006 09:30 261 Passage Road DS0000026544.V284309.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 261 Passage Road DS0000026544.V284309.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. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 261 Passage Road Address Brentry Bristol BS10 7JA 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) 0117 9593223 0117 9699000 The Brandon Trust Mrs Susan Alexandra Massey Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate 1 named person under the age of 40 with physical disabilities until that person leaves the home then the registration reverts May accommodate persons aged from 40 years upwards Date of last inspection 13th September 2005 Brief Description of the Service: 261 Passage Road is operated by the Brandon Trust to provide residential care for up to five residents all of whom are currently female with a learning disability, aged 40 years and over. The home is registered with the Commission for Social Care Inspection. The manager is Mrs Susan Massey who has a wealth of experience supporting residents with learning disabilities and with the current resident group. She is a qualified Learning Disability nurse as is the Deputy Manager Joyce Montague. This home blends in well with its neighbouring properties and is close to many local community facilities. There is the shopping area of Crow Lane within walking distance; Henleaze and Westbury village are a short car or bus ride away. The home has access to major bus routes and is a short ride away from the Mall Shopping precinct and the facilities it has to offer. The home has the added benefit of a large wellmaintained garden that is accessible to all residents. The garden provides a safe environment in that it is well fenced off and the home is not on a main road. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on a Sunday with the support of the homes manager and two members of the staff team. All of the residents were at home and provided input to this report. Two residents were case tracked and documentation was examined in respect of them. Requirements of the last inspection were also reviewed. What the service does well: What has improved since the last inspection? What they could do better: Residents will benefit from individual PRN medication protocols to ensure staff are aware of when they can give PRN medication and how often. Residents and staff will benefit from recording ‘triggers’ to behaviours that challenge in order to avoid or manage the behaviour appropriately. Risk areas should be individually recorded and assessments put in place accordingly. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 6 It is recommended that resident meetings take place more frequently so that residents can benefit from making any concerns known and can be reminded of the policies and procedures in place to protect them. They can also have greater impact into decision-making processes. Residents will benefit from up to date contracts in place to ensure they are aware of the terms and conditions of occupancy. 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. 261 Passage Road DS0000026544.V284309.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 261 Passage Road DS0000026544.V284309.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): 3,5 Prospective residents know that their assessed needs will be met and to ensure they are also aware of the terms and conditions of occupancy they require up to date contracts. EVIDENCE: The newest resident to move into the home was case tracked. Although the admission process was accelerated it was agreed by the resident and the staff team that the move was positive and the right choice of home was made. The resident said of the placement “I really like it here im glad I came”. The placement has been reviewed by the appropriate social services and two planning for life meetings have been held. The person centred plan in place is suited to the individual and it was agreed that her goals and aspirations are being met. The resident said, “I really want to go to Blackpool and its being arranged”. It was noted that there is no contract yet in place for two residents and this is a requirement that will be met by the Brandon Trust. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 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): 6-10 Residents are able to make informed decisions about aspects of their own care and the running of the home. Residents are supported to take risks and risk assessments link with the care plans in place. EVIDENCE: Two planning for life folders were examined. Care plans and associated risk assessments are in place. Currently the risk assessments seen cover a range of activities on the one assessment and it was recommended that risk areas be separated for clarity. One resident said, ‘I know what my needs are, I went to the cinema for the first time ever and enjoyed it a lot’. The staff members on duty when questioned about the needs of the resident group were knowledgeable and showed a commitment to meeting assessed needs. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 10 Residents were asked how they are supported to make everyday choices and one said ‘I am asked about all sorts of things and make a lot of choices, staff help me’. The manager was able to demonstrate how the team had offered ‘choices’ to another new resident to the home who has limited communication skills. Photographs were taken of the home and with the statement of purpose and service user guide was used to inform her of the type of house and activities that are regularly carried out. Residents meetings take place and minutes show the last meeting was carried out in October 2005. The agenda included the recent loss of two residents, new people proposed to live at the home and the new cat. The residents had signed the minutes and the manager said she was planning to improve the frequency of the meetings, this is recommended. It was seen that there is a confidentiality policy in place and staff were able to explain the meaning of the policy. The home has been provided with a PC and only the manager currently has access. The manager said that all staff would be given their own PIN when they have received the appropriate training. It was noted that there is an IT policy in place and data protection was discussed. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 11 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): 11,16 EVIDENCE: It was evidenced that there are many opportunities for personal development. One new resident said ‘I am getting to know the residents and staff better and staff help me do the things I want to do’. The statement of purpose highlights the need to ‘support people and enable them to live the life they choose’. Staff confirm this ethos and gave positive examples of the support they provide to individuals. Staff records show that training courses have been accessed in order to facilitate positive communication. One staff member was able to accurately describe one of the new residents communication needs and how best to support her to ensure they are met. The manager said that all of the residents have the opportunity to lock their bedroom doors but chose not to. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 12 Residents are supported to vote and the deputy manager gave an example of supporting a resident with little knowledge of political affairs and the importance of not influencing her decision. Residents confirmed they were able to visit friends and relatives and staff were very helpful with the provision of transport. Staff support residents to use the community by providing transport in the form of staff cars, a motobility car and public transport. Family members are welcomed into the home at any reasonable time and join in with celebrations where possible. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 13 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 Residents are supported in a way that suits them. Their healthcare needs are adequately assessed and met. Medication practices are sound although residents will benefit from individual PRN protocols to ensure staff are fully aware of when and how often they can administer PRN medication. EVIDENCE: The opportunity was taken to examine the medication administration sheets. It was noted that one resident was written up for Diazepam on an ‘as and when’ (PRN) basis. This was discussed with the manager and it was agreed that a protocol must be put in place to ensure staff are aware of any triggers to the behaviour that may challenge, when they can administer and how often. The home has a walk in shower facility to meet the needs of those residents who are growing older and whose mobility needs are changing. The home has a stair lift in place to enable residents’ easy access to personal bedrooms. Its use has now been risk assessed. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 14 Records show that additional specialist support is accessed where necessary, this includes input from the physiotherapist, speech therapist and occupational therapist. One new resident confirmed she had been registered with the general practitioner and had undergone a new patient check. She said “I’ve had my eyes tested and I’m seeing someone about a new shower seat and a hoist to help me get in the bath if I want to”. Staff members told the inspector that individuals are supported to choose and buy their own clothes and visit the hairdressers, the inspector saw that the residents’ appearance reflects their personality. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 15 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 Residents can feel confidant that they will be protected from abuse and that their concerns will be listened to and acted upon. EVIDENCE: Training records show and two staff members confirmed that they attended Adult Protection training in February this year. Staff were aware of the Protection policies in place including whistle blowing and the DOH ‘No Secrets’ in Bristol guidance. There are no protection issues in this home. The complaints book was examined and the Service Development Manager (SDM) appropriately followed up one complaint. The complaints book now takes the following format: Date, nature of complaint, action taken and timescale, outcome and signature. It was seen that the complaints procedure was available in the service user guide this includes details of how to contact the CSCI. How to make a complaint was also detailed on the notice board in the kitchen. The staff member spoken with said the staff team and residents were supported to complain. A staff member spoken with at the last inspection told the inspector that a member of the staff team attends a monthly ‘communication’ meeting. These meetings are used as a forum to discuss concerns, managerial and organisational issues. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 16 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): 26 Residents’ bedrooms promote their independence and lifestyles. EVIDENCE: One resident was happy to show the inspector her new bedroom. She said ‘ I love it all my things can go in it, its nice’. All of the bedrooms have sinks and the appropriate furniture necessary to ensure comfort and the meeting of individual needs and lifestyles. Residents chose not to hold keys and lock their bedroom doors and the manager said she would continue to offer this choice through resident meetings. When residents become ill and require extra support with equipment this is sought appropriately and includes pressure relieving mattresses, commodes and chairs. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 17 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): 32,33,36 A motivated, competent and effective staff team who are appropriately supervised supports residents. EVIDENCE: Records show and staff members confirm regular supervision sessions take place. The manager said, “My staff team don’t have to wait until supervision to discuss things”. The manager is planning to carry out annual appraisals for all staff once she has received her own. Staff confirm they have clearly defined job descriptions and are aware of their roles and responsibilities within the home. Staff are aware of the General Social Care Council Code Of Conduct and have all received their own copies. They are also aware of their own skill limitations and one staff member said, ‘if I didn’t know I would ask’. Training records show a varied choice of training courses are offered. Staff confirm they have learnt a lot about palliative care through experience and instruction from the district nurses. One staff member wrote a touching article about ‘death’ in the Brandon Trust ‘news 4 u newsletter’. She said, ‘ the team really worked together we have been through a lot with two deaths’. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 18 The deputy manager is a part of the ‘ethnic and minority group’ that meet regularly and offer support to other staff members who need support or advice regarding racial issues. They have links with the Support Against Racial Incidents (SARI) group who offer professional advice and support. Other training courses accessed include, medication training, mental health in Learning Disabilities, autism, loss and bereavement, Person Centred Planning, empowering practice, abuse awareness, epilepsy and positive communication. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 19 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): 40,41,42,43 The health safety and welfare of residents are promoted and protected. Residents best interests are safeguarded by the homes various policies and procedures. EVIDENCE: The inspector saw a number of policies and procedures put in place by the organisation and staff are expected to sign up to these policies. There was a specific policy for ‘service user involvement’ that was in an accessible style and encouraged resident involvement in service user forums. The inspector saw the bullying and harassment policy; whistle blowing and other staff related policies as well as generic policies and procedures needed to comply with current legislation. An emergency and crisis policy has been put in place June 2004. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 20 The Brandon Trust is a large organisation with overall responsibility for the home. There is a business plan in place that is produced annually; this then feeds into the homes annual plan. Monthly regulation 26 visits take place carried out by the service development manager. The inspector saw the liability insurance document was displayed along with the registration certificate. There are clear lines of accountability throughout the Trust that the staff are aware of. Records show and staff confirm that regular fire drills and fire training takes place within the times dictated by the Fire Brigade. The deputy manager said that weekly checks include the fire points and carbon monoxide testing. The stair lift is serviced annually and was last done in December 2005. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 21 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 X 3 3 4 X 5 2 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 X 25 X 26 3 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 X 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 3 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X X 3 3 3 3 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 22 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. 2 Standard YA5 YA20 Regulation 5(1)(c) 13(2) Requirement Provide appropriate up to date contracts for all residents. Individual protocols must be put in place to ensure staff are aware of when and how to administer PRN medication. Timescale for action 03/04/06 03/04/06 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 YA9 YA8 Good Practice Recommendations Separate risk areas and keep separate risk assessments. Increase the frequency of the residents meetings. 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. Extracts may not be used or reproduced without the express permission of CSCI 261 Passage Road DS0000026544.V284309.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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