Inspection on 22/06/07 for Birches Grove

This inspection was carried out on 22nd June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birches Grove 05/05/09

Birches Grove 08/05/08

Birches Grove 24/07/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Birches Grove 14 Fairmoor Close Parkend Nr Lydney Gloucestershire GL15 4HB Lead Inspector Mr Richard Leech Unannounced Inspection 10:30 & 22nd & 25th June 2007 10:40 Birches Grove DS0000066546.V339101.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 Birches Grove DS0000066546.V339101.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. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birches Grove Address 14 Fairmoor Close Parkend Nr Lydney Gloucestershire GL15 4HB 01594 564081 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) www.craegmoor.co.uk Parkcare Homes Limited To be appointed Care Home 4 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (4) of places Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Registered Manager works with a mentor for a period of a minimum of 1 year. The mentor is a person approved by the CSCI and that the mentor can not be changed without prior agreement of the CSCI. The conditions are reviewed after 1 year of registration. Date of last inspection 7th January 2007 Brief Description of the Service: Birches Grove opened in Spring 2006. The home is situated in a quiet residential area in the village of Parkend. Prior to opening, various adaptations and improvements were made in accordance with the National Minimum Standards. The service provides care and accommodation for people with a learning disability and/or mental health difficulty. People are accommodated in single rooms on the first floor. On the ground floor there is a lounge, kitchen and dining room. The home also has a patio and garden. A vehicle is provided in order for people to access the local community. Prospective service users are offered information about the home including a copy of the Statement of Purpose and Service Users Guide. The weekly base fee was reported to be £885.10, with actual fees ranging from £811.80 to £1097.84. There are some additional costs for service users, including for toiletries and chiropody. It was reported that no additional charge was made for transportation. At the time of the inspection the registered manager had just resigned from the post. An acting manager had been brought in from another home run by the same organisation whilst recruitment for a permanent manager took place. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on a Friday between 10:30 and 14:30. A second visit was made on the following Monday from around mid morning to early evening. All of the people living in the home were met, along with several members of the staff team and the acting manager. During the visit a range of records was checked. These included selected care plans, risk assessments, medication charts and training information. Before the inspection an AQAA (Annual Quality Assurance Questionnaire) form was completed and returned to CSCI. Written feedback was also obtained through survey forms from people living in the home as well as from family members. What the service does well: People moving into the home can be confident that their needs will be assessed to ensure as far as possible that the service will be able to meet these. Birches Grove is homely and clean and provides good quality accommodation. Health and safety is generally well managed. The people living in the home are supported to stay in touch with family and friends. They are supported to lead full and busy lives based around their needs and interests. Food served in the home is reasonably balanced and reflects people’s likes and choices. People have their personal and healthcare needs appropriately met in accordance with their wishes. People using the service are confident raising concerns and complaints and have the opportunity to comment on the home and wider organisation. They also feel safe and secure. Measures are in place which help to protect people from the risk of harm and abuse. The people living in the home are supported by skilled and caring staff and have good relationships with them. Family members also feel confident that the staff provide good care. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Birches Grove DS0000066546.V339101.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 Birches Grove DS0000066546.V339101.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A good framework is in place to ensure as far as possible that the service can meet the needs of people who move in, although there may be scope to improve the information given to staff about the support they should provide. EVIDENCE: The Statement of Purpose and Service Users Guide were not looked at. However, in view of the change of manager these documents will need revision once a new manager is in post. One person had moved in since the previous inspection. The former manager, who still works at the home, described how the admission had been handled. This had included meeting the person at the place where they were receiving care at the time, speaking to the staff providing the care and obtaining written information. There was also involvement from family members. A written assessment and a care plan from a social worker was seen on the person’s file. Assessment material completed by staff from the home was also seen. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 9 It was noted on the AQAA form that introductory visits are offered if required. It was confirmed that the person who had most recently moved in had visited the home with family members. There was external feedback from an involved professional saying that there had been good liaison from the home prior to and around the time of admission. Survey forms provided evidence that people living in the home and their family members generally felt that they had been given enough information about the service before making any decisions. For example, one relative wrote that they were given the opportunity to visit the home and had a lot of information about the service. Staff spoken with felt that the most recent admission had been appropriate and that the person’s needs could be met by the service. However, there was some feeling that the team could have been provided with more information about the person’s needs and how to provide necessary support to meet these. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning in the home is unsatisfactory, potentially compromising the consistency and quality of care. Whilst the people in the home exercise considerable control over their lives, there is scope for further development to promote people’s independence and autonomy. Risk assessment in the service needs to improve in order to provide a more robust framework for managing risk and promoting independence. EVIDENCE: Two people’s care planning files were checked. The acting manager said that a new care planning format was being introduced by the organisation and that this should be in place by September 2007. Nonetheless it is necessary to Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 11 comment on the plans in place at the time. The following observations were made: • There was insufficient information about the care intervention in some cases. For example, one ‘intervention’ was ‘I would like staff to teach me how to budget my money daily’ with no further explanation offered. Another person’s plan about mental wellbeing made no reference at all to some important symptoms regularly experienced by the person and how staff should specifically respond to these. Whilst there was evidence of monthly reviews of care plans some of the review notes indicated that significant changes were needed to the actual care plan. There was little or no documentary evidence of service users being involved in the care planning process besides occasional signatures, although the AQAA reported that they were fully involved. Some of the plans had sentences which appeared to be quotes but which staff confirmed were not. For example, “I would like staff to ensure that I only smoke in designated areas”. Many significant areas were not the subject of care plans, such as (in one case) mental health and memory issues, management of challenging behaviour and independent living skills. Some documents were undated. There was some duplication. For example, one person had three care plans making reference to aspects of budgeting and finance. • • • • • The acting manager had recognised the above shortfalls and expressed confidence that they would be addressed through the forthcoming overhaul of care plans. People living in the home felt that they exercised a high degree of control over their lives and that they were offered choices about areas such as food, activities and general lifestyle. Staff spoken with were able to give many examples of the kinds of decisions made by people living in the home. During the inspection people were observed to be making decisions about diet, how they spent their time and who they interacted with. There was some conflicting information about whether people living in the home were expected to retire for the night by a certain time. Three of the service users said that they were expected to be in their rooms (not necessarily in bed) by 10pm, with an opportunity for a last hot drink about half an hour before. One person had a care plan about going to bed at 10pm to get a good night’s sleep. However, discussion with staff and the acting manager indicated that there were no set bedtimes in the home and that people went to bed at different times. There was also reference in daily entries to people staying up later to chat. The acting manager agreed to investigate this to find out what the situation was and whether practice varied between staff. Whilst there may be a role for encouraging people to keep to a reasonable routine, Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 12 there needs to be a flexible approach which respects people’s right to adopt the routines which suit their wishes/lifestyles. There was discussion about whether the home could be doing more to promote people’s independent living skills more. For example, one person who used to go out on their own had not done this since moving to the home. Between the two inspection dates they did so, but the service appeared not to have been very proactive about this. Another person said that they were not allowed out on their own as they might ‘run off’. It is for the service to assess and document such issues in consultation with the person and other relevant parties. However, decision-making must be sound and evidence-based and kept under review such that restrictions and limitations are justified and minimal. The service should begin to formally adopt the approaches to choice, decision-making and best interests described in the Mental Capacity Act and accompanying code of practice. Risk assessments for two people were checked. The acting manager agreed that there were some shortfalls that needed addressing, adding that these would be part of the new care planning structure being introduced. The risk assessments did not give any indication of likelihood or severity of a given risk. Nor did they consistently give sufficient information about the nature of the actual risk. For example, one assessment noted the risk as ‘of inadequate support in the community’, rather than indicating what the risks were for the person when out in the community. Interventions were sometimes unclear, such as ‘speak with [service user] and focus on positive aspects’ in response to an identified risk of distressing symptoms of a mental health condition. As indicated under Standard 7 there was some evidence that the service may be being overprotective in some areas. Whilst services must not promote the taking of irresponsible risks which compromise the duty of care, there was evidence that there was scope to promote some aspects of people’s independence within an appropriate risk assessment and management framework. The team may wish to consult recent Government guidance about risk taking*. Forms had been completed for each person living in the home in case they went missing, although this had not been done for the person who had recently moved in. *http:/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_074773 Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported to take part in a wide range of activities in the home and community which reflect their needs and interests, leading full and stimulating lives as a result. This includes promoting contact with family and friends. People’s rights are generally respected, though there is scope for improvement in aspects of documentation and practice. The people living in the home are offered choice about what they eat and have a balanced diet, promoting their wellbeing. EVIDENCE: People living in the home expressed satisfaction with the activities that they took part in through written and verbal feedback. These included shopping, going out for meals, visiting places of interest and using local services and Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 14 facilities. There were also more vocational activities like going to college. One person wrote, “We all have a busy week and go out every weekend”. Daily records provided further evidence of people leading full lives, participating in a wide range of activities in the home and community. Some of the people living in the home enjoy going to a local church. Staff spoken with felt that service users led full, busy lives. During the visits to the home people were seen to have a trip to local shops and to go out for lunch. It was reported that some people were going on a holiday to the South coast later in the year. Some service users expressed a wish to go abroad on a holiday, but mentioned that staffing issues were impacting on this idea (see section about staffing). Plans for one person to become more independent using public transport were described. The AQAA noted an aim to offer more opportunities to people to promote their independence. Daily records provided evidence of people having regular contact with family. During the visits one person went to stay with a relative for the weekend. Arrangements were being made for two people to spend a few days with family later in the year. Positive written feedback was obtained from family members of people using the service. Comments included, “…needs are always met” and “I believe that Birches Grove supports all the clients as individuals”. Standard 16, relating to rights and responsibilities, was considered. People living in the home have keys to their rooms. Staff confirmed that people were offered the opportunity to vote in elections and that their post was given to them to open. People living in the home were seen to move around freely and to help themselves to drinks when they wished. They were also seen doing household chores in their rooms or in communal areas in a very natural and spontaneous manner. One daily entry for 09/06/07 read, “continual and persistent requests for cigarettes, food, drinks etc and became agitated and confrontational if…requests were declined.” The acting manager agreed that there was insufficient information about the situation and why requests were refused. If a request is declined this should be accompanied with the rationale as evidence that this is reasonable and does not represent an inappropriate denial of the person’s rights. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 15 Records indicated that on 31/05/07 one person was asked to dry their hair before having a cigarette, resulting in some verbal aggression. Staff spoken with said that they would not refuse requests for cigarettes outside of scheduled times as such, but would use delay and distraction techniques or suggest that the person waited. Staff described agreements that were in place about frequency of smoking. One of the people living in the home was asked about this. They confirmed that they had agreed and were happy with the arrangement. There was a discussion with the acting manager about the difficult balance between promoting health/financial wellbeing against the right to smoke at will. It was agreed that, ultimately, people have the right to access their cigarettes when they want to, though there is a role for helping people to manage how much they smoke. The only exceptions might come through appropriately enacting the provisions of the Mental Capacity Act. This links to comments and the recommendation made under Standard 7. The acting manager felt that daily entries were not always detailed enough and planned to speak with the team about this. It was also noted that some daily record entries were missing, such as for the morning of 11/06/07 for one person. See also comments made under Standard 7 about restrictions/limitations. People living in the home confirmed that they went food shopping and felt that they had a lot of choice about what they ate. People living in the home choose their own lunch. A menu operates for the evening meal, with each person contributing choice(s) for the week. The acting manager said that people can have an alternative to what is on the menu if they wish. Menus provided evidence of reasonable variety and balance. The manager said that she was taking steps to promote more variety and choice for the people living in the home. Ideas for further improvements were discussed, including the possibility of each person choosing what they want on an individual basis at each mealtime. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are offered personal care support in ways that meet their needs and wishes, promoting their dignity and wellbeing. Healthcare needs are also met, helping people to stay well. There are significant shortfalls with the handling of medication in the home, potentially putting the people using the service at risk from errors. EVIDENCE: Care plans made some reference to personal issues where relevant, though as noted some plans were in need of updating. Discussion with the acting manager and staff provided good evidence that the people living in the home were in control of how personal care support was delivered. Records and discussion with staff also provided evidence that people were being supported to access appropriate routine and specialist healthcare Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 17 services. Records were being kept where this had been requested by external professionals as part of overall monitoring of people’s conditions. The acting manager reported that a specialist was due to visit the home in the near future to help develop plans relating to mental health and challenging behaviour. Notes provided evidence of the service keeping in close contact with professionals in community teams. A visiting healthcare professional provided positive feedback about the service and felt that their clients’ needs were being appropriately met. Communication with the team was described as ‘excellent’. Another professional working in the community felt that the service was meeting their client’s needs, adding that the person had ‘turned around’ since moving into the home. The manager described plans for further developing health action planning in the home. This should be a positive move. Arrangements for handling medication were checked. The following recommendations were made: • A consent form for staff to hold and administer one person’s medication was seen. The manager understood that this had been done for all of the people living in the home, though these could not all be located. This should be checked. Some service users said that they were asked to return from evening trips (e.g. to the pub) by mid evening in time for administration of medication. There was a discussion with the acting manager about ideas for ensuring that this kind of impact on people’s lifestyles was minimised. A protocol for a PRN (as required) medication was seen, including information from the prescriber. Although stated on the administration record, the maximum dose should be repeated on the protocol. On the same protocol there was guidance saying that staff needed to obtain a senior’s agreement to administer. The acting manager was proposing to drop this requirement, though it was agreed that usage would need to be monitored to ensure that the medication continued to be used only when appropriate. It was agreed that the potential for people to self-administer some or all of their medication should be considered. At the time there was no selfadministration. • • • • In addition the following issues must be addressed: • • Some handwritten entries on the medication administration record (MAR) were not double signed. In some cases there was no signature at all. One person had two separate MAR charts for the same medications covering the same period (around April 2007). The former manager DS0000066546.V339101.R01.S.doc Version 5.2 Page 18 Birches Grove • • • • outlined the reasons for this. However, a handwritten entry on one of the forms stated that two tablets at a given strength were to be given, whereas the former manager confirmed that this should have read ‘one’. This needs to be investigated and action taken to ensure that there is no repetition of this error. One of the above MAR sheets had no recorded start and end date. One person had gaps on their MAR sheet for May 13th-15th 2007. It was conformed that the code ‘D’ for social leave should have been entered. Two creams in the cabinet had not been dated when opened. One cream which had been dated was opened on 16/03/07. It had a shelf life once opened of 3 months and therefore needed to be disposed of. A replacement had not been ordered. This was done during the visit. The acting manager said that all staff administering medication had received external training. She was planning to access refresher training for staff. In view of the above this should be regarded as a priority. A larger medication cabinet has been obtained since the last inspection. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are confident raising concerns and complaints, helping them to feel valued and listened to. Measures are in place which help to protect people from the risk of harm and abuse. EVIDENCE: There were copies of the complaints procedure in people’s files and on display. People living in the home expressed confidence about raising concerns and complaints in discussion as well as through written survey forms. There was also written feedback from family members saying that they knew how to complain and would feel confident doing so. Written comments included, “every time I have raised a concern it has been dealt with in a professional and appropriate way”. A whistle blowing policy dated February 2007 was seen. A read and sign approach was in operation, though not all staff had yet signed. The organisation also has a new policy about the protection of vulnerable adults dated December 2006. At the time of the inspection people were being supported to open savings accounts. This is good practice. It was reported that people living in the home held their own money and had secure places to store this in their rooms. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 20 A financial audit by a team from Craegmoor had been undertaken in May 2007. This gave the service three stars (out of five), with a rating of ‘reasonable’. Printouts were seen of some of the Craegmoor operated accounts where some service users’ money is held. The acting manager understood that they were interest bearing. Some records were seen for people being given money, subsequently deducted from their account balances. In some cases these were not double signed (either by another staff member or, as is preferable, the service user). Discussion with staff provided evidence that they understood their responsibilities around adult protection and that they would report any concerns. The AQAA reported that staff received training about adult protection and this was further evidenced on a training summary. People living in the home said that they felt safe there. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A clean, homely and pleasant environment is provided, promoting the comfort and wellbeing of the people living there. EVIDENCE: People living in the home showed their rooms and expressed satisfaction with them. They were seen to be personalised and spacious. Two bedrooms have en-suite facilities. The two people without en-suite facilities have a basin in their room. People said that they had a key to their bedrooms as well as a safe in their rooms for valuables. The acting manager described plans to introduce more colour into the home, both in bedrooms and communal areas since, being a new-build, décor was rather neutral. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 22 People living in the home expressed satisfaction with the décor and furnishings in the communal areas of the home. Shared spaces were seen to be well used, with people looking relaxed and comfortable. A new automatically closing door had been fitted in the kitchen, in response to health and safety concerns. There were plans for an extension to be built which would provide an extra bedroom and a larger office. The existing office may then be converted into a sleep-in room. It was agreed that having a dedicated sleeping-in room would be preferable to the existing arrangement of using a communal area. The designated smoking area was just outside the building. A recommendation from the last report about providing a sheltered area is repeated. There were plans to put up a gazebo as a temporary shelter. Guidance about new legislation on smoking should be checked. The home was seen to be very clean throughout. The laundry is sited such that clothing is carried through the kitchen. However, this was seen to be done in containers with lids and the infection control risk associated with this was assessed as low. Staff spoken with felt that Birches Grove was very homely. Several people used the word ‘lovely’ to describe the atmosphere. Written feedback from people living in the home included that the home was kept very clean. A visiting professional described the environment as tidy and homely. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are caring and skilled, enhancing the quality of care provided. However, the lack of a robust programme of staff supervision could compromise this. Whilst the recruitment and selection framework is generally sound, some minor shortfalls need to be addressed to help safeguard the people using the service. Staff have access to relevant training although work is needed to further equip the team with the skills and knowledge to provide more effective support. EVIDENCE: Training records indicated that 50 of the existing staff team (excluding the acting manager) had achieved NVQs (National Vocational Qualifications) in care to level 2 or 3. One person also had the Registered Manager’s Award. People living in the home were positive about the staff team, both in written and verbal feedback. Comments included that staff were nice and that care was good. Feedback from family members about staff included the following: Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 24 “[Staff] have the relevant knowledge, skills and experience to work with vulnerable people.” “[Service user] is looked after very well. Excellent.” As noted in the section about training and other parts of the report, there may be scope to develop the team’s knowledge and skills in areas such as specific mental health issues, the Mental Capacity Act and service users’ rights. The acting manager said that she had begun a recruitment exercise in May 2007, the service being short staffed at the time. She described the stages of recruitment and the respective roles of the manager and the Human Resources section. It was reported that staff may start on a PoVA-first basis but under supervision and with a limitation in the range of tasks they could perform. There was discussion about the need for an individual risk assessment if it is proposed to start somebody on this basis. A staffing file for one person who had not yet started was checked. There was evidence of relevant information being gathered and checks being done. However, there was a gap in the employment history between 2002 and 2005. It was agreed that this needed to be checked before the person could start, with the outcome being documented. Another person was due to start on the second day of the inspection (though had not been able to). Their application form had a gap from 1991 to 2000. Other information appeared to be in order besides a risk assessment not having been done in respect of starting the person on a PoVA-first basis. The acting manager described an initiative whereby people using the services run by the organisation would be encouraged to become involved in recruitment and selection. This should be taken forward. A training summary provided evidence that some mandatory training was required for certain staff, although much was seen to be up to date. Gaps were identified in moving and handling, fire safety and first aid. Some training was planned for July including adult protection, equality & diversity and fire safety. The acting manager said that moving and handling training was being sourced. In view of evidence that gaps in training had not only been identified but that action was being taken to address them, a requirement is not made. This is on the understanding that necessary training will take place without unnecessary delay. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 25 Records showed that staff had also accessed training in areas such as health & safety, infection control and challenging behaviour. Staff spoken with expressed general satisfaction with the training provided. However, there was some feeling that more training about mental health issues and how to support people with particular conditions would be very helpful. Staff expressed some lack of confidence about specific mental health issues and the best approaches to adopt to provide effective support. The acting manager agreed with this and said that she was looking into providing further training in this area. Staff spoken with did not have a clear understanding of the Mental Capacity Act. It is recommended that training/input be provided about this. This could be linked to discussion about people’s rights in general (see earlier discussion). It was reported that the frequency of staff meetings had tailed off in recent months. However, one was planned for the week of the inspection. In the last report a requirement had been made to ensure that staff were appropriately supervised. One person said that they had last been supervised in January 2007. Another person said that they had had three supervision meetings in the last year. The acting manager had identified that improvements needed to be made to the supervision programme for staff. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst steps are being taken to ensure that the home is appropriately managed, stable management needs to be restored as soon as possible to promote optimal outcomes for service users. People using the service have the opportunity to comment on the home and wider organisation, helping them to feel included and listened to. Health and safety is generally well managed, helping to protect the people living and working in the home. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 27 EVIDENCE: As noted, at the time of the inspection the home was without a permanent, registered manager. Notification had been received of the interim management arrangements. Discussion with the acting manager provided evidence that she had appropriate knowledge and experience for the role. Staff spoken with were very positive about the acting manager and were clearly appreciative of having direction and leadership following an unsettling period of change. However, it is clearly essential that a permanent manager is appointed and applies for registration as soon as possible. It was understood that the recruitment process was already well underway. The acting manager thought that there would be a period of overlap for handover. Some staff felt that the on-call system should be formalised so that it was always clear who they should contact if they needed advice and support. A residents’ meeting was planned for the week after the inspection. Service users confirmed that they had regular meetings where they were asked what they thought about the home and invited to talk about issues such as activities and menus. Some minutes from a recent meeting were seen. It was agreed that an ‘actions arising’ section would be useful to ensure that issues are taken forward and outcomes reported back. The acting manager had already identified this, as written in the AQAA. People living in the home also described attending a regional residents’ forum the day before the beginning of the inspection. This had provided opportunities for networking, information exchange and giving feedback to the organisation about their services. The organisation has a series of audits covering different areas of operation. Recent audits included food safety, health & safety and infection control, with generally good outcomes shown and evidence of actions being taken forward. A wide-ranging overview audit from May 2007 gave a score of 89.5 , the least good outcomes being in ‘risk taking’. An action plan was seen on the office wall. The acting manager was planning to distribute annual questionnaires to family members and people living in the home as part of the quality assurance strategy. A representative of the organisation is forwarding Regulation 26 reports to CSCI following monthly visits to the service. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 28 The AQAA document provided evidence that the acting manager had a clear idea of the service’s strengths and areas where improvements were necessary or desirable. Some minutes were seen from health and safety meeting in May 2007. Discussion provided evidence of issues being taken forward. The AQAA stated that portable appliances had been tested in September 2006. Stickers were seen on some equipment confirming this. Fire safety records were seen. An external contractor had checked the systems in May 2007. Fire records seen appeared to be in order with the exception of ‘weekly’ tests of the fire alarm. The last had been on June 4th 2007. One person was responsible for doing these checks. Arrangements need to be made to cover this role if the person is on leave or unwell. The manager was planning to create a structure around the bins and recycling boxes in the yard to prevent animals getting in. Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 29 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 3 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 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 x 3 x x 3 x Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15 Requirement Care plans must describe how service users’ needs are to be met. There must be consultation with service users about their care plans. Care plan reviews must include consultation with service users. Following these reviews make any appropriate revisions to care plans. Make arrangements for the safe handling of medication in the home, noting the points made in the text. Ensure that there is a full employment history for all staff, together with a satisfactory written explanation of any gaps in employment. Ensure that staff are appropriately supervised. Timescales of 30/09/06 and 31/01/07 not met. Timescale for action 31/10/07 2 YA20 13 (2) 16/07/07 3 YA34 19. Sch. 2 (5) 16/07/07 4 YA36 18 (2) 31/07/07 Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 31 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 YA2 Good Practice Recommendations Consider comments about improving the information given to staff prior to and following a new admission in order to help them to feel as confident as possible about the person’s needs and the support they must provide. Give fuller information in care plans about support and interventions expected of staff. Document more fully the involvement of service users in care planning and review. Ensure that all documents are dated. Consider whether there is any unnecessary duplication of care plans. Investigate whether there continues to be any expectation that people will usually retire to their bedrooms by 10pm. Take steps to avoid this kind of arbitrary and inflexible approach if so, whilst also providing encouragement for people to keep to a reasonable routine if requested/assessed as appropriate. Consider whether the service is being sufficiently proactive in promoting independent living skills, for example, going out alone. Consider also whether restrictions/limitations in place are assessed as necessary, based on sound evidence, and are subject to regular review. Begin to adopt the approaches to choice, decision-making and best interests described in the Mental Capacity Act and accompanying code of practice. Address the points made in the text about risk assessments. Consult new Government guidance about risk taking. Complete a missing person form for the person who has most recently moved in. Explore some people’s wish to go abroad on a holiday and aim to facilitate this. DS0000066546.V339101.R01.S.doc Version 5.2 Page 32 2 YA6 3 YA7 4 YA7 5 YA9 6 YA12 Birches Grove 7 YA16 Ensure as far as possible that daily records are complete/do not miss out parts of the day. Ensure that daily entries contain sufficient information. See example in text. Consider the recommendations made in the text about the handling of medication. Ensure that records of service users being given their money are double signed either by another staff member or, preferably, by the person themselves. A shelter should be provided so that people can smoke outside in poor weather. Check that current and planned arrangements comply with new regulations and guidance about smoke free legislation. When it is proposed that a person starts on the basis of a PoVA-first check (pending return of full CRB) there should be an individual risk assessment. This should include points such as the reason for taking this risk, information gathered to date indicating that the risk is low (e.g. good references) as well as safeguards (such as working under supervision and limitation of tasks that can be performed). Source and provide appropriate training about mental health issues as relevant to the needs of the people living in the home. Also aim to provide training about the Mental Capacity Act. Consider creating a more formal on-call system. Make arrangements to ensure that fire alarms are tested weekly and that these do not rely on just one staff member. 8 9 10 YA20 YA23 YA24 11 YA34 12 YA35 13 14 YA37 YA42 Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Birches Grove DS0000066546.V339101.R01.S.doc Version 5.2 Page 34 - 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. 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