CARE HOME ADULTS 18-65
Bardsley Drive 63/65 Bardsley Drive Farnham Surrey GU9 8UQ Lead Inspector
Fiona Cole Unannounced 19 April 2005 10:00 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. Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Bardsley Drive Address 63/65 Bardsley Drive, Farnham, Surrey, GU9 8UQ 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) 01252 727148 Thames and Chiltern Trust Ltd Ms Zoe Measures CRH Care Home 3 Category(ies) of LD Learning Disability, 3 registration, with number MD Mental Disorder, 1 of places Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The age range of the persons to be accommodated will be 35-65 years. 2. One of the persons accommodated may be within the category (MD) in addition to being within the category (LD). 3. There must be one to one support to the named service users 24 hours (including waking nights) during his stay at the home. Date of last inspection 2 September 2004 Brief Description of the Service: 65/67 Bardsley Drive has been developed from two independant semi-detached houses to an intergrated establishment whereby the some of the facilities are shared. It provides accommodation for 3 adults with learning disabilities. The house is located in a quiet residential road and within walking distance of Farnham town centre. The home has its own transport to support service users to access the wider community. There is off street parking at the front of the property, for two vehicles.. The bedrooms are all sited upstairs in both halves of the house. In addition, the ground floor area in both houses has a kitchen/diner and comfortable sitting room. The rear garden of the house Is made up of one large patio area, with garden furniture. This is used as additional communal area, particularly in the summer months. Age range of persons accommodated 18-65years Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The visit was the homes first inspection for the year 2005/2006. This was an unannounced visit, this meant staff and residents were not aware that it was due to happen. The inspectors arrived at 10am, and spent the first part of their visit in discussions with the manager, looking at documentation in particular care plans, reports and medication. This led in to looking at some of the policies and procedures, statement of purpose, in particular one care plan where the manager had raised a query in relation to employing night staff as “sleep-in” as opposed to “waking”. The manager had written to CSCI asking for a change over from waking to sleeping nights. In addition there is a requirement for a deed of variation as mental health in one service user is the primary concern, not learning disabilities Care and health plans were found to provide a good level of information about each individual based upon a sound assessment of their needs and wishes. The most recent resident had appeared to settle well from the documentation read by the inspectors. The second half of the inspection involved a tour of the building. The damp patch that had been raised on the last inspection had been dealt with, and the exposed wires in a service users room had been removed. Inspectors spoke briefly to two service users who were on their way out to pursue a horse riding activity and a food-shopping trip. Unfortunately the inspectors had no other opportunity to ask the service users for their comments on the running of the home, on this inspection. What the service does well:
Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 6 The relationship between service users and staff was observed to be relaxed and friendly creating a warm and homely feel. Residents are actively encouraged and well supported. Service users are as independent as they were able and they all appeared to lead busy and interesting lives, which included a small amount of adult education, frequent visits to The Anvil Theatre in Basingstoke, in particular for classical music events. They also go out to the Cinema, pub trips, music lessons library and three individual holidays per service user per year. The registered provider has implemented a good system of person centred care planning. This identifies individual personal and health care needs and how these are to be met. The system has a very focussed approach with evidence to confirm that service users were consulted and maintained control of their lives. Training and development of staff has been given a high priority, both the manager and the deputy manager have their assessors awards and are part of the Surrey Trainers Network. The manager is enrolled to study for the Registered Managers Award and NVQ 4. The manager is aware of the requirement for a fifty percent staff group being NVQ qualified by 2006. What has improved since the last inspection?
The training and development of staff continues to be high on the agenda, the manager is now offering cascade training for the South East Region. Supervision is being undertaken on a regular basis and staff notes confirm this. The homes statement of purpose has been revised and improved. A new resident has been admitted. Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 7 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. Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 8 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 Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 9 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) 1, 2, and 3. The home was found to be operating effectively in respect of these standards. Inspectors were impressed by the availability and quality of information about the home, the service users, and the company as a whole. This detailed information would serve to help prospective service uses to make an informed choice as to whether the home would be a suitable place to live. EVIDENCE: The home has recently reviewed its statement of purpose and updated policies, procedures and guidelines and provided copies to CSCI. Sampling of care plans provided evidence that the home has a sound process of assessing service users, this was evidenced from the most recent admission where the assessment, addressed both needs, and aspirations of the service user. The inspector was unable to ask the particular service user about his admission, as he was out for the day. Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 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 standard(s) 6 7 8 9 and 10 Evidence gathered from this inspection indicated that each of these standards was being met effectively. This gives confidence that each individuals needs and aspirations are being met. Discussions held with the manager and one resident together with documented evidence showed that service users were encouraged to be as independent, and in control of their lives as possible. Risk assessments were in place. EVIDENCE: Evidence gathered from this inspection indicated that each of these standards was being met effectively. This gives confidence that each individuals needs and aspirations are being met. Discussions held with the manager and one resident together with documented evidence showed that service users were encouraged to be as independent, and in control of their lives as possible.
Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 11 The daily diary notes and through discussion with two staff members and one service user provided evidence that service users were encouraged to be as independent and in control of their lives as possible. Risk assessments evidenced a joint working relationship, with staff and service users agreeing on risks involved and possible outcomes, Restrictions only applied when the level of risk was considered unacceptable Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 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 standard(s) 11, 12 13 14 15 16 Evidence gathered during this inspection confirmed the home meets each of the assessed standards. This meant the home demonstrated that residents were encouraged and supported to lead as independent and fulfilling life as they were able. EVIDENCE: The relationships between service users and staff were observed to be relaxed and encouraging creating a warm friendly, and homely appeal. Service users were actively encouraged to maintain their independence and follow active lives which included music lessons, riding, visits to the theatre cinema and pub. One service user played the piano and had a display of his artwork in the sitting room Evidence indicated that service users rights were only limited if risks were assessed as being unacceptable. For example some service users walked home unsupervised from their days activity where as others were collected by staff. This was found in the detailed care plans and daily activity log.
Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 13 Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 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 standard(s) 18 19 20 and 21 Evidence gathered during this inspection confirmed that the home meets each of the assessed standards with the exception of standard 20 and 21. The home was able to demonstrate that service users health and personal care needs were being met. Standard 20 was almost met and adhered to the homes, practice policies and procedures. EVIDENCE: Medication agreements need to be rewritten and more specific, in their usage and instructions. Medication quantities need to be recorded and match the log. Medication records must be monitored to ensure that service users medication profiles correlate with the medication administered records. Evidence gathered from discussions with the manager, substantiated by care and health plans indicated the home worked hard to ensure that service users health and personal care needs were met consistently. Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 15 Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 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 standard(s) 22 and23 Evidence collected during this inspection confirmed the home meets each of the assessed standards. The home was able to demonstrate that residents were being appropriately protected and that resident’s views were important and acted upon. EVIDENCE: Positive interactions between staff and residents were observed the staff actively listened and encouraged service users. All staff were said by the registered person to have completed the vulnerable adults training and were aware of the protection procedures should they ever need to invoke them. Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 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 standard(s) 2 25 26 27 28 30. Evidence gathered during this inspection confirmed that the home meets all of the require standards and provides and offers a good level of accommodation appropriate to the needs of the service users. EVIDENCE: The home has been upgraded in recent years offering widely spacious and flexible living accommodation. Both kitchens are well equipped and allow service users to access them independently and safely. The home is operating to a good standard, however inspectors were informed that Staff were permitted to smoke in the upstairs office this was unacceptable practice when no service users were smokers, and a dedicated smoking area should be made outside of the building for staff. Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 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) 35 and 36 Evidence showed that the home meets each of the assessed standards. It was evident from written and spoken information that the staff were enthusiastic and committed to supporting residents, with training and development given a high priority. EVIDENCE: Service users are encouraged and supported to be as independent as possible giving them confidence to access the wider community for regular leisure and educative activities. The relationship between service users and staff were observed to be friendly and warm. Training and development of staff is high on the agenda. This was evidenced by the number of staff already NVQ trained or in training, including the manager and the deputy who are both enrolled for RMA and NVQ4. A detailed and impressive supervision process is offered to all staff including agency staff and was available as a group as well as individually. Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 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 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) 38 39 40 42 43 Evidence collected during this inspection confirmed that the home meets each of the assessed standards and was well run with sound and accountable management support. EVIDENCE: Training and staff development is of high priority and the evidence showed this in the supervision information held on staff files. Care plans, revised policies and procedures, statement of purpose all support the high standards of practice The manager and deputy manager have started the Registered Managers award and NVQ level 4. Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 20 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 3 3 3 3 4 Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 4 4 4 4 4
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 4 3 3 3 3 N/A 3 Standard No 11 12 13 14 15 16 17 4 4 4 4 4 4 4 Standard No 31 32 33 34 35 36 Score N/A 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Bardsley Drive Score 4 4 N/A 1 Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 3 3 H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 21 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 YA 20 Regulation 13 (2) Requirement Medication records must be monitored to ensure that service users medication profiles correlate with the medication administered records. Timescale for action Ongoing from date of inspection 19/4/05. 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 21 Good Practice Recommendations Create a policy that recognises the ageing process.Ensure the policy determines how this process is managed, in particular paying attention to dementia and terminal illness. Bardsley Drive H58_s13525_Bardsley Drive_v217330_190405_stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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