Inspection on 21/08/06 for 41 Birdwood Grove

This inspection was carried out on 21st August 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

41 Birdwood Grove 08/08/07

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

CARE HOME ADULTS 18-65 41 Birdwood Grove Fareham Hampshire PO16 8AJ Lead Inspector Debbie Oliver Unannounced Inspection 21st August 2006 11:00 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 41 Birdwood Grove Address Fareham Hampshire PO16 8AJ 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) 01329 221623 01329 221623 www.hantspt.nhs.uk Hampshire Partnership NHS Trust Mrs Paula Thane Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2005 Brief Description of the Service: 41 Birdwood Grove is a semi-detached property situated in a residential area between Fareham and Porchester and is undistinguishable as a care home from other homes in the street. Hampshire Partnership NHS Trust oversees the service and the home is registered to accommodate three people under the age of 65 with a learning disability. Each service user has a single bedroom. Communal space includes a lounge cum dining room, a kitchen and a large conservatory, although the service users rarely use the latter. The organisation was not willing to inform us of the weekly fees. Information about the service provided at the home would be made available to potential service users by providing a copy of the home’s service users guide and statement of purpose. A copy of the last inspection report is available in the home. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was unannounced and took place over four hours. During the visit, records and documents were examined, an opportunity was taken to tour the premises and staff working practices were observed. The inspector met three service users, but due to their communication needs did not have direct conversations with them. Observation enabled the inspector to gain a better understanding of how the needs of service users were being met. There were no service users from ethnic minority groups. Three relative comment cards were received and staff assisted the three service users to complete comment cards. What the service does well: What has improved since the last inspection? What they could do better: A little more information is needed in plans to give detailed instructions to staff when supporting an individual and regular reviews need to happen. As an added precautionary measure the controlled medication cupboard must also be bolted to the wall along with the main medication cupboard. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 6 The risk assessment relating to the gate on the stairs needs to be more detailed to show it is in the best interest and safety of one service user and that it doesn’t limit the other service users. A risk assessment should be devised to give instructions to staff on how to minimise the risk of cross infection in relation to laundry being taken through the dining area. Criminal record bureau disclosure numbers must be available in the home to show staff have received the necessary checks and are able to work with the service users. All staff must receive training in basic first aid to further protect service users. 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. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home’s systems and procedures ensure the needs of existing and prospective service users are identified. EVIDENCE: As the three service users living in the home have lived there for many years and there have been no new admissions the assessments were not viewed on this occasion. The three service users had evidence of regular reviews within their plans. On observation throughout the day it was evident staff can meet service users’ needs. The manager confirmed that should any new service users move in an assessment would be completed prior to them moving in and a positive transition process would be undertaken. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a clear and consistent care planning system in place that adequately provides staff with the information they need to satisfactorily meet service user’s needs and enables them to support service users to make decisions about their lives. Risk assessments are in place and ensure service users are able to take risks as part of an independent lifestyle. EVIDENCE: Three service users were case tracked and the plans were clear and detailed giving relevant information to staff. The plans included information relating to how an individual communicates and how they demonstrate their emotions. The plans also showed they were being reviewed on a regular basis. One staff member spoken to said they feel the plans give staff the information they need to support service users and are an essential tool in the home. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 10 It was apparent throughout the visit that service users are supported to make decisions using object of reference and Makaton. Additionally it is detailed in the plans how service users make choices such as what they want to eat and when they want to go out. Evidence was seen within the files to support that risk assessments are available and that service users are supported to take risks including taking part in various activities. It was discussed with the manager the need for regular reviews to be undertaken to ensure the assessments are up to date. The three relative comment cards received stated they are informed of important matters in relation to their family members’ care. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users have opportunities to engage in suitable activities and are part of the local community, so promoting independence and choice. Contact with families is well supported, and nutritional needs of service users are well managed. EVIDENCE: It clearly states in the plans what service users do socially such as going to clubs, pubs, swimming and the cinema. There is also a section on the best way to motivate service users. On the day of the visit two service users were attending the local day service. The comment cards received stated service users have lots of things to do. Contact with families is very positive. All service users have regular contact with their families and this is documented in their plans. On the day of the visit 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 12 a family member spoke with the manager as their relative had just been home for the weekend. It was evident rights are adhered to as one service user had chosen not to get up until eleven that morning and this was respected by staff and staff were seen using appropriate language for service users and asking rather than demanding things of service users. There was also a board in the lounge detailing pictures of the staff members on duty that day. There is no set menu as this is not appropriate for the service users living in the home. However all food eaten is recorded as well as a list of likes and dislikes. On the day of the visit one service user went to the kitchen and chose what they wanted for lunch. Staff then supported them appropriately during the meal encouraging their independence. Service users are also involved in the shopping, planning and preparation of food and picture cards are used as assistance. Each service user has a nutrition checklist within their plans. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The personal, physical and health care needs of service users are generally well met and the procedure for the receiving and administering of medication is robust ensuring a safe system for service users. EVIDENCE: Care plans show how service users like to be supported in regard to their personal care but it was discussed with the staff member on duty that on occasions more information is needed rather than ‘needs support’. Staff spoken to confirmed service users have positive input from opticians, general practitioners, dentists and chiropodists and there was evidence in the plans to show this happens. There is also a section relating to general health and this includes specific issues such as epilepsy. Daily records show visits to health professionals and the outcomes of these visits. A handling profile is also in the plans detailing what support is needed within the area of moving and handling. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 14 The home has a policy on medication and the pre-inspection questionnaire stated there have been no changes so the policy was not viewed during this visit. The system for receiving, administering and disposal of medication is satisfactory. All staff have received training in administering medication and the two staff members spoken to confirmed this. It is detailed in individual plans how service users show pain but the manager confirmed staff must contact the on call manager before administering any ‘as required’ medication. No one in the home is prescribed any controlled medication but it was discussed with the manager the controlled medication cupboard must be bolted to the wall along with the main medication cupboard. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements for protecting service users and responding to concerns are satisfactory. EVIDENCE: The complaints procedure is available and copies can also be made available to relatives. Staff spoken to were clear on what to do if they received a complaint or had a complaint themselves. The home also has advocacy involvement. The relative comment cards received said they were aware of the complaints procedure but have never made a complaint. There have been no complaints in the home. The home has the relevant procedures and policies and all staff have received training in adult protection. Staff spoken to felt it gave them the confidence to know what to do in the event of an allegation. The home has also produced risk assessments about bruising seen on service users that are not seen as an everyday occurrence, this ensures extra vigilance of staff. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A comfortable, safe and hygienic standard of accommodation is provided for the service users, which meet their needs. EVIDENCE: The inspector toured the home and it is well maintained and suited to the service users’ needs. It is decorated to a standard that creates a comfortable and homely ambience. The home is well furnished with good quality domestic fixtures and fittings. One of the service users has increased mobility issues and they may need to move on to more accessible accommodation. It was agreed with the manager that the risk assessment relating to the gate on the stairs needs to be more detailed to show it is in the best interest and safety of one service user and that it doesn’t limit the other service users. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 17 The laundry room is accessed by going through the dining area and it was discussed with the manager that a risk assessment should be devised to give instructions to staff on how to minimise the risk of cross infection. The laundry room is where the gloves and aprons are kept and is suitable for the service users living in the home. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has procedures and systems in place that ensure staff are properly recruited and that there is always enough staff on duty. The training in place shows staff have the necessary skills and knowledge to meet the complex needs of service users accommodated in the home. Regular supervision for staff ensures they are well supported. EVIDENCE: From observation and discussion with staff members, they have built good relationships with service users and have a good understanding of their needs. One staff member and the manager were spoken to and they indicated that they have generally received good training since starting in the home. The training received included fire safety, moving and handling and food hygiene. However none of the staff in the home had received training in basic first aid and a requirement was made for this to happen, especially as on most occasions staff work on their own. Three staff have either started or completed a National Vocational Qualification. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 19 Staff spoken to confirmed they receive regular supervision and that the manager is approachable and easy to talk to. They also said any new staff are always shadowed for a number of shifts so they are able to get to know the service users properly. There was adequate staff on duty at the time of the visit and this was confirmed on the rota. The inspector sampled three staff files and they contained all the necessary information relating to recruitment but it was discussed with the manager that although criminal records bureau checks have been undertaken the disclosure numbers need to be made available in the home to document they have happened. One relative commented ‘I have always been very satisfied with the love and care that my family member gets at the home, the staff always greet you just like family’. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a well organised home and the quality assurance system ensures service users and their families are able to contribute their views for the development of the home. The system for maintaining the health, safety and welfare of service users is satisfactory. EVIDENCE: The manager has completed their registered managers award and is now working towards their national vocational qualification level four in care. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 21 Senior managers of Hampshire Partnership NHS Trust visit the home every month to assess the service being provided and a copy of the report is sent to the Commission. One staff member spoken to said their thoughts regarding the service are asked during these visits. Families are fully involved and are asked their views on an informal basis. The manager confirmed if there were particular views from families these could be used as part of the objectives for the year. Staff discuss their views through supervision and team meetings. There are review meetings held every month for the service users and this gauges if the service user is still happy living at the home and the service is continuing to meet their needs. Issues are discussed such as one service user not liking the hot weather but that having a fan helps. Goals are also set and these are reviewed at the next meeting. The home’s fire alarm system and extinguishers are checked regularly and this was confirmed on the pre-inspection questionnaire received. Fire safety training has been provided to staff and the staff member spoken to confirmed this. The gas and electrics have also been tested and this was confirmed on the pre-inspection questionnaire. There is an accident, incident or near-miss report form and copies are kept locked in the office. There have been no accidents and the home informs the Commission through regulation 37 notifications. 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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 X 2 2 3 X 4 X 5 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA32 Regulation 13 (4) Timescale for action The registered person shall make 21/12/06 suitable arrangements for the training of staff in first aid. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 41 Birdwood Grove DS0000067325.V303248.R01.S.doc Version 5.2 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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