Inspection on 08/05/08 for Birches Grove

This inspection was carried out on 8th May 2008.

CSCI found this care home to be providing an Adequate service.

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 10 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 22/06/07

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 27/09/2008.

CARE HOME ADULTS 18-65 Birches Grove 14 Fairmoor Close Parkend Nr Lydney Gloucestershire GL15 4HB Lead Inspector Mr Richard Leech Key Unannounced Inspection 10:40 – 18:10 & 14:10 – 8th & 27th May 2008 17:30 Birches Grove DS0000066546.V362154.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.V362154.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.V362154.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) birches.grove@craegmoor.co.uk Craegmoor.co.uk Parkcare Homes Ltd 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.V362154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 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. 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. Up to date information about fees was not obtained during this inspection. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The inspection began on a Thursday morning, lasting until early evening. The home did not know that there would be a visit from us. A second visit was made on a Tuesday a couple of weeks later in order to complete the inspection. Unfortunately the manager was not available during either visit. Also the service’s annual self-assessment (called the AQAA) had not yet been received and was overdue. Surveys had been sent out to people with an interest in the service but these were not yet available at the time of writing the report. During the site visits all of the people living in the home were spoken with along with most of the staff team. Various records were sampled including care plans, risk assessments, medication charts, staffing files and training records. The building was checked and some general observation of life in the home took place. What the service does well: What has improved since the last inspection? Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 6 There has been some improvement with the standard of care planning in the home, helping to ensure that people’s goals and support needs are identified and met. Some people have made progress towards independence, for example with moving towards self-medicating. There have been some improvements with the way that medication is handled. What they could do better: Shortfalls in admissions procedures increase the chance of people’s needs not being met and of placements failing. There is evidence of a lack of flexibility in respect of some aspects of life in the home, restricting people’s freedom of choice. People living in the home cannot always be confident that information about them is being appropriately stored. People living at Birches Grove feel able to speak up and to say if they are unhappy about something. However, the complaints procedure needs to be updated so that people have the information they need to raise concerns and complaints more formally if necessary. More care needs to be taken to appropriately document and report any safeguarding concerns in order to demonstrate that these have been properly handled. Whilst staff have skills and qualities valued by the people living in the home, further input is necessary in order to ensure that all care workers have the necessary knowledge and competence to meet people’s complex needs. Shortfalls in recruitment procedures could put the people living in the home at risk. Supervision arrangements in the home have been poor, resulting in staff feeling unsupported and increasing the chance of them working in different ways. The presence of a permanent and registered manager would promote stability and consistency in the service. There is potential to develop the quality assurance system so that it is more robust and results in real and demonstrable improvements. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 7 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.V362154.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Shortfalls in admissions procedures (including dissemination of assessment material and provision of relevant training) increase the chance of people’s needs not being met and of placements failing. EVIDENCE: The Statement of Purpose was not checked in detail. However, it was noted that a copy in the dining room said that the primary needs of the people living in the home would relate to learning disabilities. This clearly requires updating to reflect the fact that the service also aims to meet the needs of people with severe and enduring mental health difficulties. Information was seen in respect of the person most recently admitted to the home. At the time of the visit they were in hospital and it was considered unlikely that they would return. The file included basic biographical details and assessment information. Assessment material was seen to be incomplete. For example, substantial sections about aspects of mental health, memory, independence skills and communication were largely blank. Some of the documentation was undated. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 10 A care plan was seen from the organisation making the placement. However, there was no evidence on file of a thorough assessment by staff at the care home, or of a care manager’s assessment. Some further assessment information was said to be in a separate file but this could not be located. Some staff said that they had seen this file and that it provided useful background information. However, other staff indicated that they had never seen this or had found out about it some time after the person moved in, leaving them feeling that they had not been given enough information about the person’s background and their needs. Some staff spoken with struggled to name the condition that the person was diagnosed with and the impacts this had. Some staff said that they had not received any training about mental health conditions. Others said that they had received this training but that it had been some time ago and they felt that they needed further related training. The majority of staff spoken with felt that the admission had been inappropriate. This may be the case, or it may be more that staff lacked the training and background information to be able to appropriately meet the person’s needs. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 11 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 & 10 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. A reasonable framework for care planning and assessing risk is in place, helping to ensure that people’s goals and support needs are identified and met. There is evidence of a lack of flexibility in respect of some aspects of life in the home, restricting people’s freedom of choice. People living in the home cannot always be confident that information about them is being appropriately stored, compromising their confidentiality. EVIDENCE: Care plans for two people were looked at. These provided relevant background information, in some cases completed by the person themselves. Care plans were seen to cover areas such as personal care, health, eating & drinking, activities and independent living skills. The care plans were seen to be subject Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 12 to regular review. There was reference to the person’s goals, and written evidence that they had been involved in writing and reviewing the plans. The information was generally adequate. However, in some cases a fuller description was needed. For example, for one aspect of personal care one person’s plan stated that they needed staff to ‘support me’ without giving any further explanation. As with the assessment material, some care plans were undated. Discussion with staff provided evidence of knowledge of care plans and that they were being followed. People living in the home were asked about the choices they made and control they had over their lives. They felt that they did have a high degree of choice, such as about how they spent their time and what they ate. However, there were some indications that rules and restrictions may be in place. These included that people had their last hot drink by 21:30, with the kettle base being taken away overnight to prevent people making hot drinks. Staff understood that this was to promote people having a good night’s sleep rather than making drinks/using the toilet throughout the night, and for health & safety reasons. However, no documentation could be seen about this. For such a restriction to be in place there would need to be individual care planning and risk assessment, based on the principles of the Mental Capacity Act 2005. Other staff said that they had no knowledge of this, indicating that practice may vary. Some staff also reported that the TV in the lounge went off at 22:00 and that people were asked to go to their rooms, though could watch television there if they wished to. Other staff said that they were flexible, with some indicating that there were no rules or expectations at all around this. People living in the home indicated that this varied between staff, but with some people they would not be able to remain downstairs beyond 22:00. One staff member was described as ‘very strict’ regarding people going to their rooms at this time. Again if such practice is in place, unless justified by individual written assessment, this represents an infringement of people’s rights and could be seen as institutional. There is a significant difference between this approach and providing encouragement for people to keep to a reasonable routine if assessed as appropriate. As noted, there was conflicting evidence around this and it was not possible to get a clear picture of what was happening. The manager should look into these claims about evening routine and whether practice is inconsistent. Times for supper were also reported to be set, rather than being flexible around when people felt like having an evening snack. It was not clear why it was thought necessary to have a set time. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 13 The people living in the home who were spoken with about the above did not complain about what they understood to be expectations around evening routine. However, great care needs to be exercised to ensure that people’s rights are respected and that an oppressive culture is not inadvertently imposed. Routines should be as flexible and individual as possible, with people making genuinely free choices. Minutes of residents’ meetings provided further evidence of a rigid approach. For example, those of a meeting on 25/03/08 stated that, “supper time is at 8pm if the service user wants any and it must be eaten at the table and not in bedrooms”. Although staff reported that this had changed in that not all of the people living in the home now had supper at 8pm, the tone of the entry suggests a culture of decisions being imposed without appropriate justification or consultation. The same minutes went on to say, “downstairs toilet is for staff use as service users have their own in their bedrooms”, thereby apparently denying the people living at Birches Grove the right to use a facility in their own home. No other documentation was seen about this. Daily notes provided some evidence of choice and flexibility of routine. For example, there was reference to people choosing to have a lie-in, and to electing whether not to take part in a particular activity. Risk assessments for two people were sampled. These appeared to cover significant risks for each individual and to provide appropriate guidance for how these were to be managed. Some were undated and unsigned. In some cases there was duplication, with two different risk assessments about the same issue. The dining room contained two box files which were fully accessible. Within these were found copies of recent daily records for two of the people living in the home and some incident forms relating to challenging behaviour. This is a clear breach of people’s confidentiality. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 14 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. Whilst people lead busy and full lives, there are indications that at times people’s rights are encroached upon and activities limited without clear and appropriate justification. Contact with family members is supported, helping people to stay in touch with important people in their lives. People have choice about what they eat and the menus are varied and balanced, promoting people’s health and enjoyment of their food. EVIDENCE: Activity timetables for two people were looked at. These indicated that people had access to a wide range of activities in the home and community. Daily entries were sampled for the same two people. These provided further Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 15 evidence that people had busy and varied programmes. The people living in the home expressed satisfaction with their activity programmes. During the period looked at one person had gone on holiday. There was evidence in the notes that this had been a successful and enjoyable trip for the person. Daily notes and contact sheets also provided evidence of people having regular contact with their family. Some of the daily notes viewed provided further evidence of an oppressive culture with people’s rights being infringed at times without apparent justification. For example, one entry on 22/03/08 read, “[one person] asked to buy some tobacco, but was told that until staff had checked what [the person] already had then she could not buy any”. The reason for this approach was not clearly conveyed in the entry and there did not appear to be a corresponding care plan which indicated that such an approach should be adopted. There may have been legitimate reasons for taking this stance, but such an entry would need to be clear about the rationale, and respect the person’s ultimate right to spend their money as they wish, with any limitations framed in terms of the Mental Capacity Act 2005. A second entry on the same day stated, “[person] did once mention going to Parkend club at 9:15 pm. [They were] told that not only was it too late to go out but the previous evening she had gone on a pub activity”. Again, the entry did not make it clear why it was considered ‘too late’ to go out, and the relevance of the person having been to the pub the day before. See also examples in previous section relating to evening routines. The people living in the home said that they were happy with the food. Comments included that it was ‘delicious’ and ‘brilliant’. Menus were reported to be drawn up every week in consultation with the people living at Birches Grove. Examples of recent menus were seen. These appeared to be varied and balanced. Birches Grove DS0000066546.V362154.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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Appropriate support is provided with personal care needs, promoting people’s dignity and wellbeing. Healthcare needs are also being met, and systems for handling medication in the home are generally sound, helping to ensure that people stay well. EVIDENCE: Care plans provided information about how people were supported with their personal care needs. Staff described the kinds of assistance they gave and how they went about this. People living in the home indicated that they were happy with the way this support was provided. They confirmed that staff respected their privacy and space, for example, by knocking on doors to seek permission to enter. The people living at Birches Grove were seen to be individually dressed in ways which reflected their choices. One person described using hairdressing facilities in the local community. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 17 Care plans were seen covering different aspects of people’s healthcare needs. In some cases people had completed their own healthcare needs summaries. Records of healthcare appointments provided evidence that people were being appropriately supported to access routine and specialist healthcare facilities. Arrangements for medication were checked. One person was reported to be making progress towards self-medicating. A risk assessment was seen on file about this. Medication was still being stored in the office, although it was understood that in due course the person would hold this in a suitable locked cupboard in their room. Copies of national guidance about handling medication in social care settings were seen in the home. There was also an up to date BNF (a reference guide about medication). Sheets were seen detailing medication taken out of the home and returned. However, one sheet was not dated. A returns book was seen, with entries signed by the pharmacist receiving the medication. Medication administration records appeared to be generally in order. One handwritten entry gave the dose of the medication but did not state the frequency. Whilst the majority of handwritten entries on the MAR sheets were double signed, some had only been signed by one staff member. A list of homely remedies for each person was seen approved by their GP. A PRN (as required) protocol for one person was not signed or dated. Storage appeared to be in order. The temperature of the cabinet was being monitored. Creams were dated on opening. Birches Grove DS0000066546.V362154.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 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. Updating the complaints procedure would help to ensure that people have the information they need to raise concerns and complaints. Care needs to be taken to appropriately document and report any safeguarding concerns in order to demonstrate that these have been properly handled. EVIDENCE: The complaints procedure was seen. A text and a more accessible version are available. These needed updating as the contact details for CSCI were out of date. People living in the home thought that staff were good listeners, and said that they felt able to say if they were unhappy about something. A complaint had been received about the service in March 2008. This had been passed to the service provider to investigate. A response was due on May 9th 2008. At the time of writing this had not yet been received, although a response was reported to have been sent to us by the deadline. The complaints folder contained information about one issue from November 2007. This had been reported to us at the time. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 19 The whistle blowing procedure was displayed in the hallway. Staff spoken with were aware of this procedure and of their responsibility to report concerns and poor practice. People living in the home confirmed that they felt safe and that they trusted the staff. Some reference was made to a difficult period earlier in the year which related to one person being poorly. They felt that the staff had handled this well (although, as noted, discussion with some staff indicated that they had not always felt confident, supported and sufficiently informed). Some staff expressed concerns about an issue relating to safeguarding. They said that they had reported this to the manager but felt that this had not been addressed. Other staff spoken with also raised this issue but framed it in terms of staff dynamics and said that they had no concerns about any practices in the home. Either way, if there has been an allegation of staff misconduct then we need to be formally notified under Regulation 37. This needs to be sent along with a summary of the investigation and any actions taken. No reference to the issue could be found elsewhere such as on staffing files and supervision notes. Discussion with staff indicated that they had undertaken training about safeguarding vulnerable adults. Training records confirmed this. Birches Grove DS0000066546.V362154.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. 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 expressed satisfaction with their bedrooms. They were seen to be personalised and spacious. Two bedrooms have en-suite facilities. The two bedrooms without en-suite facilities have a basin and access to a shared bathroom. People said that they had a key to their bedrooms as well as a safe in their rooms for valuables. 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. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 21 The office is now also being used as a sleeping-in room, rather than staff using the lounge for this purpose. The designated smoking area was just outside the building. A gazebo had been put up as a temporary shelter, although this blew over during the visit. The garden was seen to be reasonably maintained, although some areas were becoming a little neglected and would benefit from weeding. The home was seen to be generally clean throughout. However, carpets in some communal areas on the ground floor were becoming stained and should be either professionally cleaned or replaced. A cleaning schedule was seen for the home. The laundry is sited such that clothing is carried through the kitchen. However, containers with lids are used and the infection control risk associated with this was assessed as low. Birches Grove DS0000066546.V362154.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst staff have skills and qualities valued by the people living in the home, further input is necessary in order to ensure that all care workers have the necessary knowledge and competence to meet people’s complex needs. Shortfalls in recruitment procedures could put the people living in the home at risk. Supervision arrangements in the home have been poor, resulting in staff feeling unsupported and increasing the likelihood of inconsistent practice. EVIDENCE: The people living in the home were generally positive about the staff team. Comments included that they were ‘kind’, ‘caring’ and ‘fine’. One person who was asked felt that the staff understood their needs well. However, there was some reference to certain staff being ‘strict’ or ‘bossy’ at times. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 23 As noted, staff spoken with had a reasonable knowledge of people’s care plans and support needs. However, many expressed a lack of confidence around mental health conditions and related needs and were not able to clearly describe the conditions of people living in the home. Given the nature of the service it is essential that all staff have this knowledge and understanding. Some information was available in care planning files and in information leaflets about mental health conditions, but further training appears necessary. Information about NVQs (National Vocational Qualifications) was not obtained on this occasion. Three staffing files were checked, for people who had started within the last year. One person had a second reference from somebody different to the referee named on the application form. This alternative reference was from a friend and ex-colleague rather than a former line manager. No mention could be found on the file as to why a different (and less suitable) reference had been sought and accepted instead. The former acting manager gave a verbal explanation on the telephone, but this did not answer the question of why line managers from other previous jobs were not contacted as potential referees. Another person’s application form contained some discrepancies. A former employer had written that the person had been employed from May to June 2005 whilst on the application form the person had stated that this had been March to June 2005. No notes could be found on the file indicating that this had been picked up and explored. Another of the person’s references also gave different dates of employment to that stated by the person on their application form (October 2004 – April 2005 according to the reference. July 2004 – January 2005 on the application form). Again, there was no indication that this had been picked up and checked. The person above had two written references (including a personal one) and an email reference from an educational institution attended up until 2004. However, according to the application form they had begun a course at another educational establishment more recently. This may have been a potential source of a more up to date reference, thereby avoiding reliance on character references from friends. A third person’s application form had an unexplained gap from 2002, when they had apparently left full time education, through to 2005 when they had started a job. This person also had a reference from a friend. Potential other sources of references were discussed. Reference was seen on files to PoVA-first checks being done. Criminal Records Bureau certificates were seen in respect of two of the above staff. However, one person’s certificate was not available and there was no other evidence on Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 24 file of one having been returned. The staff member confirmed that they had undertaken a CRB check and would bring in their copy to replace the mislaid duplicate. Staff spoken with were reasonably satisfied with the training that they were provided with. As noted, many felt that some further training about mental health conditions specific to the needs of the people living in the home would be beneficial. Staff spoken with said that they had been on training covering areas such as the Mental Capacity Act 2005, health & safety, handling of medication, protection of vulnerable adults and COSHH (control of substances hazardous to health). They were confident that their core training was up to date or, in the case of newer staff, that this was booked. Samples of training summaries and certificates provided evidence that this was the case. Staff reported that the out of hours on-call system had not been formalised, as recommended in the last report. They said that they would still work through a list and hope to be able to contact somebody who could provide support and advice. A list was seen in the office of planned supervision dates. However, this was on hold as the manager had been unavailable to take this forward. Some staff were asked when they had last had a supervision meeting. One person reported that they had not had one since June 2007. Another person said that they had not had a meeting since joining the team in December 2007. A third person said that they had also not had a supervision meeting since joining the team late in 2007. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 25 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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The presence of a permanent and registered manager would promote stability and consistency in the service. There is potential to develop the quality assurance system so that it is more robust and results in real and demonstrable improvements. Health and safety is generally well managed, promoting the wellbeing of the people living and working in the home. EVIDENCE: At the time of the visits a new manager was in post. The home has had a number of different managers since opening. There are indications, as noted in Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 26 the report, that this may have impacted on the home, for example resulting in inconsistent practice and poor supervision arrangements. At the time of writing an AQAA (Annual Quality Assurance Assessment) had not been received by the service, despite being due on May 8th 2008. Some staff expressed concern at there being some favouritism towards staff who knew the new manager from previous settings, for example in terms of rotas. Whether there is substance to this or not, if there is a perception that this may be the case then the reason for this needs to be acknowledged and acted upon. All staff referred to some unpleasant dynamics in the team. This is clearly an issue requiring some attention. The new manager needs to register with CSCI as soon as possible. A quality assurance file was seen. The organisation has a system of regular audits undertaken by the home manager. Some of these are more general in focus, with others concentrating on specific areas of operation. These were seen to have been completed regularly and scores were high. However, there was patchy documentary evidence of whether identified actions had been followed up and completed or not. For example, one action from September 2007 was for an updated registration certificate to be available in the home. This had clearly not been achieved. There should be a more consistent audit trail in order to identify what action has been taken to follow up issues and whether they have been addressed. In some cases there was no action plan apparent. This should be done following each audit and a copy kept in the home clearly linked to the original audit. Reports from visits made under Regulation 26 are being forwarded to CSCI. This is when a representative of Craegmoor visits the home without warning at least once a month and writes a report about their findings. As noted there was evidence of residents’ meetings taking place. However, one example of minutes seen (dated 25/03/08) read as a series of rules and reminders for the people living in the home, with little evidence of them being consulted or of discussion. Some questionnaires had been sent out by the home in Summer 2007 to people with an interest in the service. A couple of responses were seen. Whilst these were largely positive, there was no evidence of any analysis of the results and action plan. The organisation has a ‘Your Voice’ forum whereby people from the area who use services attend events and are invited to give feedback. Records were seen of routine health and safety monitoring, including testing, walk-around inspections and visual checks. These provided evidence that Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 27 routine health and safety issues were being appropriately managed and regular maintenance carried out. The following was noted: • • Emergency lighting had last been tested on 12/03/08 ‘Weekly’ hot water temperature checks had last been done in April 2008. One bath had been recorded at 45°c, which is fractionally too hot. The recording sheet should note the acceptable parameters and what staff should do if a reading is outside of these. The fire risk assessment was not checked. Staff spoken with were generally satisfied with health and safety arrangements in the home. Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 28 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 1 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 2 23 2 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 2 33 x 34 1 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 3 2 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 3 x 2 x 2 x x 3 x Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 29 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 2 Standard YA1 YA2 Regulation 4 (1) c. Sch 3. 14 Timescale for action Update the Statement of Purpose 31/08/08 to accurately reflect the range of needs the service aims to meet. Prior to admitting a person to 30/06/08 the home ensure that there has been an appropriate assessment of needs. Confirm in writing to the person that the home is suitable for meeting their needs. Ensure that where any 31/07/08 restrictions are in place these are fully documented, based on individual assessments and consistent with the requirements of the Mental Capacity Act 2005. Ensure that there is a record of all limitations agreed with the people living in the home in respect of their freedom of choice, liberty of movement and power to make decisions. Store confidential records securely. Update the contact details for CSCI in all versions of the complaints procedure. Forward a regulation 37 notification in relation to any allegations of staff misconduct, DS0000066546.V362154.R01.S.doc Requirement 3 YA7 14. 15. 17 (1) a. Sch. 3 3 (q) 4 5 6 YA10 YA22 YA23 17 (1) 22 (7) 13 (6) 37 30/06/08 31/08/08 31/07/08 Birches Grove Version 5.2 Page 30 7 YA34 19. Sch. 2 (5) 8 YA34 19. Sch. 2 (2) 9 YA34 18 (1) 10 YA36 18 (2) along with a summary of the investigation and any actions taken. Ensure that there is a full employment history for all staff, together with a satisfactory written explanation of any gaps in employment. Timescale of 16/07/07 not met. Ensure that there is evidence available in the home that each member of staff has had an appropriate check undertaken through the Criminal Records Bureau. Ensure that all staff are competent to support people with mental health difficulties. Provide further relevant training as necessary to ensure that this is the case. Ensure that staff are appropriately supervised. Timescales of 30/09/06, 31/01/07 and 31/07/07 not met. 30/06/08 30/06/08 31/08/08 31/07/08 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 Ensure that all staff have access to background and assessment material about people admitted to the home at the earliest opportunity in order to promote their knowledge and understanding of the person and their support needs. As part of any assessment identify staff training needs and ensure that this training is provided before the person moves in. Ensure that all documentation is signed and dated. DS0000066546.V362154.R01.S.doc Version 5.2 Page 31 2 YA2 Birches Grove 3 4 5 YA6 YA7 YA7 6 7 YA9 YA20 Ensure that care plans contain sufficient information about the support that people need. The people living in the home should be free to use the ground floor toilet. This should not be designated as a facility exclusively for staff use. Investigate whether practice around late evening varies between staff in terms of any expectations around times for going to bed, having a last hot drink etc, as outlined in the text. Rationalise risk assessments where there is duplication. Ensure all medication-related documentation is signed and dated where appropriate. Ensure that handwritten entries on the MAR sheet are double signed by a second person checking for accuracy, and that full information/instructions are given. Provide a more stable shelter for people to smoke outside in poor weather. Attend to areas of the garden which are becoming neglected and overgrown. Stained carpets on the ground floor should be either professionally cleaned or replaced. Use character references from friends only as a last resort when all possible sources of more appropriate references have been exhausted. Ensure that the staffing file makes it clear who has been approached for references and with what outcome, for example if a named referee is no longer available or refuses to provide a reference. Pay greater attention to discrepancies with dates of employment between what is stated on the application form and the information from referees. Investigate and document on the staffing file. The on-call system should be formalised so that there is always a designated person available to be contacted. Note staff concerns about team dynamics as noted in the text. Note also a perception by some that there may be some favouritism towards certain staff. Ensure that an action plan is produced in response to each internal audit and that a copy is kept in the home. There should be more an audit trail for actions identified in audits, in order to identify what had been done and 8 YA24 9 10 YA24 YA34 11 12 YA36 YA37 13 YA39 Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 32 whether the issues have been addressed. Similarly, when surveys are returned there should be an analysis of the findings and an action plan. Minutes of residents’ meetings should more thoroughly reflect discussions with the people living in the home and their thoughts/views about issues and proposals. Note the points made in the text about health and safety. 14 15 YA39 YA42 Birches Grove DS0000066546.V362154.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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.V362154.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!