Inspection on 03/08/05 for Washington

This inspection was carried out on 3rd August 2005.

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 12/01/06

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 NE38 7JA Lead Inspector Sam Doku Unannounced 28 July & 3 August 2005 : 10:00 th 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 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 Stationary 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 B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Briarlea Address 18a Bede Crescent, Washington Village, Washington, NE38 7JA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 419 1867 0191 419 1867 SHAW Mr Philip Coverdale Care home only 6 Category(ies) of 6 x LD; 1 x LD(E) registration, with number of places Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17 February 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 SHAW. 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 user’s 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 B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 28 July 2005 and the person in charge on the first day was the senior support worker. A second visit was made five days later to meet with the manager for further clarification on some aspects of the running of the home. The inspection process involved time spent in talking to service users, sitting in the lounge and observing staff interaction between staff and the service users, discussions with the senior support worker and later with the manager and care staff, tour of the house, examination of health and safety records and service users personal file including care plans. Verbal communication with the service users was difficult in some cases as some of the service users had communication difficulties. The inspector was, however, able to determine from their demeanour and body language that they were comfortable and happy with the care that they receive. What the service does well: The home delivers 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 and staff that the staff are highly motivated and offer a service that is generally consistent with the expressed wishes of the service users. The service users have very 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 were 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 excellent ways of empowering the service users to be involved in the planning and review of their care. 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 B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 standard(s) 2 Service users are involved in the formulation and evaluation of their care plans. This ensured that the views of the service users are established and incorporated into their plan of care. EVIDENCE: The service users files were examined and these contained details of assessments carried out to identify their care needs, and care plans being formulated to address those needs. There was evidence of regular reviews and evaluation of care plans. This is to ensure that the care provided for the service users are relevant to their current needs. There was evidence of service users being supported to take part in the formulation of their care plans, thus providing them with the opportunity to be involved in decisions about their care. In this way the individual’s wishes are established and provisions made in the care plans to meet those needs. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, 9. Each service user has an individual care plan, which clearly sets out how assessed needs will be met. These also demonstrate the involvement of service users in making choices about day-to-day life, which involves an element of risk taking as a way of developing their independence. EVIDENCE: Three service users personal files, which were examined contained details of care plans, assessments, risk assessments and daily record of events. The care plans related to care needs such as personal care, social care, healthcare and educational opportunities. Assessments were first carried out to identify the care needs and then corresponding care plans are formulated to address those identified needs. Record of reviews indicated that service users have contributed to their care plans. Their views are reflected in the personal care plans. The home’s written policies and procedures are designed to ensure that service users are able to exercise their rights, and that they are sufficiently supported by staff or advocates to do so. Records of review meetings demonstrate that Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 10 service users’ views are sought about the care they receive and that they are encouraged and supported to achieve their potential. The risk assessments have been carried out for all the service users and cover areas such as transport journeys, eating out, kitchen safety, shopping trips, use of bed rails and bus journeys. The process ensures the safety and wellbeing of the of each service user, both within the home and outside the home, while at the same time enabling them to lead independent life as much as possible. Care plans are regularly reviewed and evaluated to ensure that the care that is provided is relevant to the current care needs of the service user. The key worker and Life Plan meetings are used to involve the service users in the evaluation of their care. This ensures that the service users are actively involved in the planning of their care. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 16. There are suitable arrangements in place to ensure that the service users participate in all aspects of daily living activities including involvement in their personal care and in social and recreational activities. There is strong awareness amongst the staff group to support the service users in making decisions for themselves, thus promoting their independence and right to make choices. EVIDENCE: The service users are supported to access community facilities such as college, social and recreational activities. The staff described the varied social activities that service users are engaged in and the opportunities for access to all community facilities where appropriate. These include regular visits to local pubs, cinema, restaurants, shops and visits to other places of interest and entertainment. Service users were also involved in their holiday arrangements for themselves. Details of how service users enjoyed these services were documented in the daily activities books. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 12 Practices observed during this inspection showed that staff always respect the privacy of the service users and were noticed to knock on bedroom door or seek the individual’s permission before entering their room. Staff confirmed that it is the policy of the home that personal mail is given to the individuals unopened. Staff however, offer support to the individuals in dealing their mails. Service users are encouraged by staff to undertake a number of household tasks including doing the laundry and cleaning their rooms. Some service users are able to assist with washing up and are supported to prepare snacks for themselves. Two service users who were spoken with stated that they enjoy taking part in household tasks. Such practices enable service users to maintain a level of independence and interest. 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 were offered choice of meals and were encouraged by staff to maintain some level of independence regarding meals. There was documentary evidence in the care plans showing that service users dietary needs were being met. Service users are frequently offered the opportunity to go out for meals, thus providing them with experience of normal social activities. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 standard(s) 18, 19, Service users receive support from staff to ensure that all aspects of their individual personal and health needs are met and their individual preferences are documented in their case files. EVIDENCE: Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 14 Staff empower the service users to make independent decisions such as whether individuals wanted to assist with household tasks. At the commencement of the inspection, one service user offered to assist with hovering. Service users were treated with respect and given opportunities to be involved in the day-to-day running of the home and in their own care. The written care plans are followed by all staff and these were reviewed regularly. Services users were supported to attend GP service and other health related appointments such as out patient appointments, district nursing support, appointments with dentists, opticians and chiropodists. These were recorded in the individual life plans and in daily report records. Two service users confirmed that they have regular access to medical care and feel that their healthcare needs are met. The regular review of care plans with service user involvement ensured that the care provided is relevant to the current care needs of the service users. Service users files indicate regular access to such specialist medical services such as psychiatry and behaviour psychology services to ensure their psychological and emotional wellbeing are addressed. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 standard(s) 22, 23. Policies, procedures and practices within the home ensure that the service users are protected from all forms of abuse. EVIDENCE: The home has a written complaint procedure, which is part of the SHAW corporate complaint procedure. Summary of the complaint procedure is included in the Statement of Purpose/Service User Guide, which is made available to all the service users. There is also a company-wide “Whistle Blowing” policy in place and copies of these procedures are available in the home. The staff who were spoken with confirmed that they have received training in the Sunderland vulnerable adult protection procedures (MAPPVA) and whistle blowing policies. Two service users said they are aware of the complaint procedure and would know what to do if they had any concerns. Examination of the staff training record showed that staff have had training in adult protection. Such training and awareness amongst staff and service users is one effective way of reducing the likelihood of abuse to service users. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 30. The home is comfortable, clean and homely and provides service users with a safe and well maintained environment in which to live. However, it is not designed to meet the need of people with physical disabilities. EVIDENCE: The home is purpose built dwelling but it is ideally not suited to meet the needs of people with physical disabilities. Service users who have mobility difficulties are accommodated on the ground floor. The generous room sizes allow individual service users to furnish their rooms with personal items while leaving sufficient spaces for movement within their rooms. The home meets the needs of the service users who currently reside there. Service users commented positively on their rooms which reflected personal preferences in terms of the furnishing and general decoration. The staff maintain good standard of environmental hygiene. On the day of the inspection the home was clean and maintained to a good standard. Antibacterial hand washing facilities were available in the toilets. The kitchen, lounge and bedrooms were all noted to be clean and in good order. Laundry Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 17 machines have programme facilities to meet disinfecting standards, thus ensuring good control of infection practices. Service users were very pleased to show the inspector the decking, which had been constructed in the garden with their involvement, providing a comfortable sitting facility for them. There was obvious sense of achievement amongst the service users who were involved in the construction of this pleasant garden facility. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35. There are sufficient staff available to meet the current needs of service users presently living at the home but the home’s reliance on agency staff meant that consistency of approach to care is sometimes compromised. EVIDENCE: Examination of past rotas showed that the home consistently maintains adequate staffing levels to meet the needs of the residents. 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. New staff are provided with induction training followed by foundation training within the first six months of employment (LADAF). The staff who were interviewed confirmed the training they had received and felt that this had helped to maintain a safe environment for the service users to live in. The manager confirmed that the company adheres to proper employment policies in recruiting staff. It was evident from discussions with staff that the proper recruitment procedures have been followed by the manager. This Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 19 included completion of application form, job description, contract of employment, two satisfactory references, interviews, and Criminal Records Bureau checks. These procedures are in place to ensure further protection of service users from possible abuse. Discussions with the manager and the senior support worker indicated that there is a history of regular reliance on agency staff. It was pointed out that only five of the current staff, including the manager, have worked in the home for more than two years. The reliance on agency staff had sometimes led to inconsistency of approach to care and disruptions to the routines of some of the service users. Consequently, this may have contributed to one service user displaying challenging to the behaviour. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 42. The manager is appropriately qualified and experienced to ensure that service users benefit from a well run home which promotes the health, safety and welfare of service users. However, some safety measures, which are designed to safeguard the welfare of the service users were not observed by the staff at the time of the inspection. EVIDENCE: Staff commented that they have regular one-to one supervision from the senior staff and are able to approach the management to discuss any issues relating to both personal and professional matters. The staff feel that the manager provides them with good support and is very approachable. He was described as very caring and service user focused. This ensures that the staff are aware of the changing care needs for the service users and of any new approach to meeting their needs. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 21 There are comprehensive maintenance checks carried out on the fabric of the building. Certification and records are kept of all systems including PAT tests, gas servicing and electric wiring, fire alarms, tests and drills, and emergency lighting. 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. Risk assessments have been formulated for all service users relating to specific areas of concerns. One such risk assessment for a service user stipulated that he should be supervised when in the kitchen. However, at a particular point in time during the inspection, this was not the case. This exposes the service users to possible risk of harm or injury and must be addressed. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 x Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Briarlea Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 2 x B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 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. 1. Standard 42 Regulation 12(1)(a ) Requirement Risk assessment guidleines for the prevention of harm to service users must be followed at all times. Timescale for action 28.7.05 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 33 Good Practice Recommendations The company should review the impact of the use of agency staff in home with view to reducing the possible detrimental effects on service users and the morale of permanent staff. Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Baltic House Port of Tyne South Shields NE34 9PT 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 Briarlea B52-B02 S15753 Briarlea V237253 28 Jul 3 Aug 05 Stage 4.doc Version 1.40 Page 25 - 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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