Inspection on 24/07/06 for Birches Grove

This inspection was carried out on 24th July 2006.

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 no outstanding requirements from the previous inspection report, but made 5 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 22/06/07

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 24th & 26th July 2006 10:00 Birches Grove DS0000066546.V305639.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.V305639.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.V305639.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 01594 564136 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 Mrs Jennifer Ann Thomas 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.V305639.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 N/A 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 area. There is also a patio and sheltered garden. A vehicle is provided in order that service users can 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 manager stated that fees range from approximately £600 to £1000 per week. Birches Grove DS0000066546.V305639.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 Monday in July, lasting from mid-morning to late afternoon. A return visit was made on the following Wednesday from about 10.30 to 14.00. The manager was present throughout the inspection. All of the service users were met, along with several members of the staff team. During the inspection a range of records was looked at including samples of care plans, daily records, risk assessments, healthcare notes and staffing files. Most of the building was also checked. NB: New services cannot be rated as excellent since a sustained track record at this level is required. What the service does well: What has improved since the last inspection? What they could do better: Assessments of service users’ needs must be kept up to date so that there is a clear picture of each person’s support requirements. Care plans need to be made more wide ranging and individual. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 6 Improvements need to be made to some parts of the way that service users’ money is handled. Staff need to have formal one to one supervision meetings with the manager. Some shortfalls related to the service being new and not yet established. Progress will be checked in future inspections, and requirements or recommendations then made if the issues are not addressed. A number of recommendations are made for consideration. 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. Birches Grove DS0000066546.V305639.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.V305639.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 adequate. This judgement has been made using available evidence including a visit to this service. A suitable framework is in place for handling admissions, although some work is still required in respect of people admitted to the service to ensure that their support needs are identified as fully as possible. EVIDENCE: People living in the home had previously been living together in a home which has now closed. The manager said that they had chosen to continue living together and had wished to take up the opportunity of moving into the new service at Birches Grove as a group. Service users spoken with about this confirmed that they had chosen to move to the home and were happy with it. Due to the above pre-admission assessments of need were not completed. Some old assessments from the previous setting were seen on file. It was agreed that these needs assessments must be updated (either using the same format or a more person-centred alternative). For example, some aspects of assessments relating to mental health were seen to be out of date. The home has an appropriate admissions procedure. The manager described the steps that she would go through when admitting a new service user in the future. This included seeking support from peers since the manager has not overseen the admission of a person not previously known to the service. Birches Grove DS0000066546.V305639.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 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are not sufficiently individualised and comprehensive, potentially compromising the quality of care provided. Similarly, shortfalls with risk assessments may promote inconsistent practice. Service users are offered choices in day-to-day life, helping them to feel respected and empowered. EVIDENCE: Care planning files for two people were looked at. Some of the organisation’s person-centred formats had been completed, in some cases by the service user themselves. This included some information about goals. Besides one or two variations the care plans for the two people were identical, with headings borrowed from other settings in the group. They could not therefore be described as person-centred or sufficiently individualised. Nor did they include the full range of support needs that could be expected given some of the issues identified in assessments and other documentation. There was Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 10 little evidence of service users’ involvement in care planning besides some plans being signed. Some contradictions were evident such as one person’s care plan saying ‘requires full staff support whilst outside of the home’ but with some staff reporting that the person was able to go out on their own to places such as the local shop. The manager was aware of these shortcomings and was intending to create appropriate care plans using a new company format due to be available shortly. She intended to seek advice from her mentor. It was also agreed that it would be helpful to seek some training in person-centred care planning. Daily records were checked and were generally satisfactory. However, the following observations are made: • • Some days just had entries for the morning or afternoon rather than providing a full account of the day. Some entries used inappropriate language such as ‘went upstairs in a strop’ and ‘went into a sulk’. Accounts need to be as objective and descriptive as possible. The manager said that she had picked this up and had already spoken with staff about this terminology. A clinical audit had recently been carried out in the home. Among recommendations for care planning were that there should be more evidence of service users’ input, that care plans around mental health issues needed to be in place where appropriate and that care plan reviews should not simply state ‘no changes’. The manager said that one person likes to read and sign their daily records. This is good practice. Service users said that they were offered choices in day-to-day life, giving examples. Discussion with the manager and staff provided further evidence of practices where service users were supported to make and follow through decisions. Examples were observed during the inspection, such as around food choices and activities. People were seen moving freely around the home and garden. However, the ground floor toilet had been designated as a staff toilet, with service users expected to ask permission to use it. It was agreed that this was inappropriate practice. Two service users’ risk assessments were checked. Whilst these were more individualised than care plans the following was noted: • Some contained contradictions such as ‘…always needs to be on a 1:1 whilst out in the local community…can use the local shops on own’. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 11 • • Many were still standardised risk assessments such as about prevention of abuse and medication. Some were vague in their guidance, for example stating that a person needed ‘support as necessary’ in respect of mobility issues but without clarifying what this meant. Another indicated that a person may become aggressive but did not say what form the aggression may take and how staff should respond. Again, the manager acknowledged these shortfalls and described plans to improve the system for assessing and managing risk. Some staff stated that they had not read all of the service users’ care plans and risk assessments, focussing more on the person for whom they were keyworker. The home has a missing person’s procedure. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to pursue activities in the home and community which reflect their needs and interests, promoting their quality of life and wellbeing. Appropriate support is provided for people to maintain and develop relationships with important people in their lives. Routines are flexible and people’s rights generally respected, helping service users to feel valued and in control of their lives. A varied and balanced diet is provided which reflects individual preferences. EVIDENCE: Service users were very positive about their activities, describing a range of leisure and vocational opportunities. On the first day of the inspection people were supported to visit a local college to discuss options for the new term and Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 13 to enrol according to their interests. The manager said that many had been attending a day centre but had felt that they now needed to move on. Samples of daily records provided further evidence of people leading active lives in the home and community. Examples included attending church, visiting pubs, restaurants and cafes, shopping in local towns, swimming and going to the cinema. Holidays and short breaks were planned for later in the year. Activity planners in people’s files were identical. These should be individualised. It was agreed that, as part of promoting independence people should be encouraged to access the community independently (by foot and/or public transport) where appropriate, as part of a staged programme if necessary and within a risk management framework. Service users described staying in touch with family and friends by phone and also seeing them regularly. Some people had just returned from home visits. Daily records provided further evidence of this contact. A system of designated phone nights for each person had been set up. The manager said that this was an attempt to regulate phone usage and also to promote fairness. She said that the home paid for phone calls. Service users spoken with about this said that they were happy with the arrangement and confirmed that they could call people on different nights if they requested. As noted, service users were seen moving freely about the home, choosing where to spend time (although as noted, one toilet had been designated as a staff facility). They confirmed that they were in control of their routines, and flexibility was observed throughout the inspection. People confirmed that they could access drinks and snacks as they wished. The manager said that service users have keys to their rooms. This was confirmed by people spoken with. The manager said that post was given to service users, with support offered to deal with correspondence as necessary. Service users described taking part in household chores and indicated that they were happy with this expectation. Whilst staff were observed to interact in a respectful manner, many terms of endearment were heard such as ‘darling’, ‘sweetheart’ and ‘good girl’. Use of these terms should be considered and service users’ views and preferred forms of address established. Service users expressed satisfaction with the food and confirmed that they were offered choice about what they ate. There was reference in minutes of residents’ meetings to food being discussed, including healthy eating. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 14 Daily records included evidence of people eating out regularly, and also of service users helping to prepare and cook food if they were interested in this. Service users were observed making their own choices about what to have for breakfast and lunch. Weight charts were being kept and these provided evidence of some people losing weight where they had identified that they would like to. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Where personal care support is required this is provided in a way which meets people’s preferences and needs, though care planning could improve in order to promote consistency of this support. Appropriate assistance is also provided for people’s healthcare needs to be met, though there is scope for improvement in this area as part of promoting people’s overall wellbeing. Appropriate frameworks are in place for the management of medication, although aspects of these arrangements could be improved to make the systems safer. EVIDENCE: Service users spoken with described being able to choose when they went to bed and when they bathed or showered. One service user who required more personal support had a care plan in place but discussion with the manager and staff showed that the plan did not fully reflect the care that was being offered/provided. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 16 The same person’s mobility had shown a decline. The manager described the support that was being offered accordingly, and confirmed that a referral had been made for OT and physiotherapy assessments. It was agreed that this was urgent given the apparent change in the person’s presentation and their move to a new environment. Healthcare notes along with discussion with the manager provided evidence of people’s routine and specialist healthcare needs being met and/or that referrals and appointments were being made. The concept of health action planning was discussed. It was agreed that the manager would research this with a view to introducing it in to the home. The manager confirmed that a chiropodist visited the home regularly. However, it appeared that these appointments were not being recorded. A note in one person’s file was discussed. This stated that the person was ‘unable to consent to medical treatment’. It was unclear who had made this assessment and on what basis. It was agreed that this would require review should circumstances arise where capacity was an issue, particularly in the light of forthcoming changes to legislation making a presumption of capacity. One person was not well during the visit. The manager and staff were seen providing appropriate support for the person and helping to access medical advice. Medication systems in the home were briefly checked. However, as is usual procedure with a new service the specialist pharmacist inspector will be asked to conduct a detailed audit of the arrangements in place in the home. A recent external audit had resulted in the service being told to cease a ‘potting up’ practice. The manager said that this had been done and that she was seeking ongoing support about the handling of medication in the home. During the inspection an experienced staff member from a sister home visited and provided advice about aspects of this. The manager had completed a medication self-audit based on a format provided by the organisation. The manager said that the home was set up to adopt a monitored dosage system. However, the small size of the medication cabinet meant that this could not yet begin. Even with existing arrangements the cabinet was seen to be crowded. This is poor practice and may increase the likelihood of errors. A larger cabinet should be provided. The manager said that all staff had received basic training in the handling of medication from a local pharmacy besides some people who had recently joined the team. Some staff had also received more in-depth training in 2003 or 2004 in previous settings. The manager should ensure that all staff who Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 17 administer/handle medication are appropriately trained. This is likely to include accessing a more in-depth course of the kind provided by local colleges. The home did not have a BNF on site. A copy should be obtained. Medication records sampled appeared to be in order. The organisation has a policy covering the handling of medication. It was agreed that the idea of service users self-administering should be kept on the agenda, within an appropriate assessment and risk management framework, as part of the home’s remit to promote independence. The manager said that only one medication error had been noted since the home opened, resulting in a change of practice to reduce the likelihood of recurrence. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are suitable arrangements to support service users to raise concerns and complaints, helping them feel listened to. Measures are in place to help protect service users from the risk of harm and abuse, although systems for handling service users’ money need improvement. EVIDENCE: The home has a text and more accessible version of the complaints procedure, copies of which were on display in the home and are included in the Service Users Guide. Comment cards and discussion with service users provided evidence that people knew how to complain and felt able to raise issues. Daily records provided evidence of staff recognising and responding to expressions of dissatisfaction. No complaints had been received about the service before the inspection. However, around the time of the visit one was received by CSCI and passed to the organisation to investigate. The whistle blowing policy along with definitions of abuse were on display in the home. Staff spoken with were aware of their responsibilities to report abuse or concerns. Adult protection issues form part of induction, foundation and NVQ work in the service. Training records also showed that many staff had taken a course about the protection of vulnerable adults earlier in 2006. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 19 Two service users’ finances were checked. In both cases running records did not tally with cash balances held. The manager admitted that she sometimes did not count change in and out. It was agreed that this was essential, and that there also needed to be more balance checks (ideally after every transaction). The manager was planning to slightly change the systems in place to make the records clearer, for example by subdividing receipts. All four service users were leaving money with the home for safekeeping. It was agreed that, as part of promoting people’s independence, service users should be encouraged as much as possible to manage their own finances within the context of individual care planning and risk assessment. The manager confirmed that each person had a safe in their room and was also able to lock their door. The manager said that one person’s finances were still not coming through from the placing authority. However, she understood that this was now being resolved and that the backdated money would be paid shortly. Another person was possibly entitled to receive all of their benefits rather than making any contributions towards their care. The manager said that this was being looked into. Some service users’ money was being held in the organisation’s corporate account. The manager agreed that there was no reason for this, and that service users’ money would be better placed in their own accounts. The corporate account was said to pay interest, although no interest payments were evident on records seen. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 20 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean, homely and pleasant environment is provided, promoting service users’ comfort and wellbeing. EVIDENCE: The home is on newly-built estate and appeared to be in good condition throughout. Communal areas were attractive and homely. Service users expressed satisfaction with their rooms, which were personalised and well furnished. Some bedrooms have en-suite facilities and service users sharing a bathroom have a basin in their room. The manager described proposals to convert the garage into another bedroom with en-suite facilities as well to create a larger office with a sleep-in facility. The system for applying for applications for variations to registration was discussed. It was agreed that communal space may need to increase should an additional bedroom be created. The manager said that there were plans to add a conservatory to the building. She also hopes to create a sheltered area for people to smoke in bad weather. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 21 Some fire doors were propped open. The manager was aware that this was unsafe and said that automatic closing devices linked to the alarm system would be ordered. The manager added that there had been accidents around the kitchen door area, suggesting that it was unsafe both to keep this door closed and also to hold it open without a proper device linked to the alarm system. There was a maintenance sheet in the office where staff were logging parts of the home which needed attention. The home appeared to be very clean throughout. Systems were in place for keeping the home clean, tidy and hygienic. Service users asked about this confirmed that the home was kept fresh and clean. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 22 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 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are committed and skilled, enhancing the quality of care provided. Appropriate frameworks are in place for recruitment and selection, reducing the risk of unsuitable staff being employed. Staff have access to a range of appropriate training, helping to ensure that they have the necessary skills for the role. However, a formal supervision programme is not yet in place, which may compromise the standard and consistency of care provided. EVIDENCE: The pre-inspection questionnaire and training records indicated that 50 of the staff team had achieved NVQ in care to at least level 2. Service users were very positive about the staff in conversation and through their survey cards. Comments included that they were ‘brilliant’, ‘nice’ and ‘friendly and kind’. People said that they felt listened to when they spoke with staff. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 23 Staff were observed to be warm, friendly and supportive in their interactions with service users. Staffing levels appeared to be appropriate to meet service users’ needs. The manager said that waking nights were in place only because of a lack of sleepin accommodation (see environment section) rather than due to service users’ needs. Night staff are expected to complete a range of allocated tasks during their shifts. The organisation has policies and procedures covering recruitment and selection, as well as a centralised human resources section. The manager had not yet recruited any staff, having inherited a staff team. She described the steps that she would go through and the support she would seek when overseeing the recruitment process herself. Some staffing files were checked and appeared to be in order, although one file did not have any evidence of a CRB check having been done. The manager was aware of this and was chasing it up. Selected training records provided evidence that staff were mostly up to date with mandatory training, and that they had also undertaken a range of other relevant courses. However, some gaps were noted, such as food hygiene and moving & handling for some staff. The manager described some training which was booked for the near future, and it is expected that these gaps should quickly be addressed. The manager said that training in the management of challenging behaviour was regarded as compulsory for all staff in the organisation and that this was booked for August 2006. Some people felt that more training in mental health issues would be helpful. This should be considered. A copy of the induction booklet was looked at which was in the process of being completed by a newer staff member. This was detailed and was mapped to Skills for Care standards. There was a discussion with the manager about staff who are related to each other working on the same shift, particularly in the absence of other staff. It was agreed that this is not good practice in a care setting. The manager admitted that she had not yet begun the programme of formal supervision for staff due to not yet having a copy of the company’s template. This must begin as soon as possible. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 24 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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Aspects of the service are well run though there is scope for further development in this area in order to promote better outcomes for service users. Good frameworks are in place for assessing the quality of the service, helping to create a basis for continual monitoring and improvement. Measures are in place to promote staff and service users’ health and safety. EVIDENCE: Staff spoken with praised the manager saying that she was adapting to the new role well and was very client-centred. The manager was registered at the same time as the service. Conditions were attached to this registration, as noted earlier in the report. The manager described how these were working out and felt satisfied with the level of Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 25 support that she was receiving in the role, though had felt a little unsupported around the time of the home opening. The manager said that she was hoping to have a deputy or team leader in post in the near future to create more of a management structure. The manager has completed the Registered Manager’s Award and plans to complete NVQ 4 in health and social care as soon as possible. Given that the manager is not yet fully qualified and that shortfalls have been identified in key areas such as care planning and supervision, it is not yet possible to say that this standard is met. However, it is anticipated that this will change as the requirements are addressed, the manager’s knowledge and skills develop and the home becomes more established. Service users confirmed that there were regular residents’ meetings. Examples of minutes from these were seen, with discussion taking place about issues such as menus and activities. Some recent regulation 26 reports were seen on file. However, these have not been forwarded to CSCI. It was confirmed that copies of these need to be forwarded to the Commission. The organisation has a system of internal and external audits, some of which have been referred to in this report. These provide a good framework for assessing the quality of different aspects of the service. Evidence will be looked for in future inspections that these are effective in identifying areas for improvement and that action then follows. The home has policies and procedures covering health and safety. An internal health and safety audit was conducted on 30/05/06 resulting in a score of 72 and a list of actions arising. At the time of the home opening in Spring 2006 evidence was seen of necessary checks having been undertaken and of a fire risk assessment having been completed. Documentary evidence was seen of regular checks on showerheads, doors, sockets, appliances, the tumble drier filter, window restrictors and water temperatures. A staff member reported that one water temperature had been a little high and that the test would be repeated, with a view to calling in an a contractor if the reading remained concerning. The fire log demonstrated that checks on emergency lighting and fire alarms were being done at suitable intervals and that there were also regular fire drills. Minutes from a health and safety meeting in May 2006 were seen. A service user had been present at the meeting. An irritant chemical was found accessible under the sink. This was pointed out to the manager who said that it should have been locked away. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 26 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 2 ENVIRONMENT Standard No Score 24 2 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 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 2 2 2 x 2 x 3 x x 3 x Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 YA2 Regulation 14 (2) Requirement Ensure that assessments of service users’ needs are kept under review and updated as necessary. Care plans must describe how individual service users’ needs are to be met. They must be kept under review and include appropriate consultation with service users. Keep accurate records of money held for safekeeping on behalf of service users. Fire doors must not be propped open. They must either remain close or be held open with appropriate self-closing devices linked to the fire alarm. In view of health and safety issues around the kitchen door area a self-closing device linked to the fire alarms must be fitted. Ensure that staff are appropriately supervised. Timescale for action 31/10/06 2 YA6 15 31/10/06 3 4 YA23 YA24 12 (1) 17 (2). Sch.4 (9) 13 (4). 23 (4) 31/08/06 15/10/06 5 YA36 18 (2) 30/09/06 Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA6 Good Practice Recommendations The manager and others who will be involved in care planning should access training in person-centred care planning approaches and principles. Daily records should provide a full account of the day rather than having periods missing. Entries in daily records should be as objective and descriptive as possible (see examples in text). Ensure that all staff have appropriate knowledge of each service user’s care plans and risk assessments. Cease to designate the ground floor toilet as a facility exclusively for the staff. Address the points made about risk assessments in the text. Individualise people’s activity programmes/timetables. Use of terms of endearment should be considered and service users’ views and preferred forms of address established, as noted in text. Research the concept of health action planning and associated tools. Introduce this into the home. Ensure that appointments with the chiropodist are recorded. Provide a larger medication cabinet. Staff who handle medication should all access in-depth training about the safe handling of medication to supplement in house training and input from a pharmacy. 9 YA23 Obtain a copy of the most recent BNF. Conduct more frequent balance checks on service users’ money held for safekeeping. Support service users to move their money out of the corporate account and into their own accounts. Ensure that they receive any interest due for the period that their money was in this account. Aim for staff who are related to each other to work DS0000066546.V305639.R01.S.doc Version 5.2 Page 29 3 4 5 6 7 YA7 YA9 YA12 YA16 YA19 8 YA20 10 YA33 Birches Grove 11 12 YA35 YA42 different shift patterns rather than working together. Consider whether further training in mental health issues would be appropriate for some or all staff. Remind staff of the need to adhere to the COSHH policy. Birches Grove DS0000066546.V305639.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. 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