Inspection on 18/05/05 for Birchgrove

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birchgrove 23/10/08

Birchgrove 25/10/06

Birchgrove 27/10/05

Birchgrove 08/12/04

Birchgrove 28/04/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Birchgrove 82 Lumsdale Road Matlock Derbyshire DE4 5NG Lead Inspector Stuart Hannay Unannounced 18 May 2005, 10.00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Birchgrove Address 82 Lumsdale Road Matlock Derbyshire DE4 5NG 01629 584161 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) United Response (Amber Service) Mrs Deborah North Care Home 3 Category(ies) of Learning Disability registration, with number of places Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None recorded Date of last inspection 8th December 2004 Brief Description of the Service: Birch Grove is a bungalow situated in a residential area on the edge of Matlock. It blends in well with the surrounding properties. The home provides a service for three people with learning disabilities and is run on domestic lines. Accommodation consists of 3 single bedrooms and there are also suitable bathroom/toilet facilities and lounge areas. There are spacious garden areas for the use of residents. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. All three service users were on educational or work placements on the morning of the unannounced inspection. Therefore the focus of the inspection was on checking the previous requirements, which were mostly related to issues with the building and the gardens. A further visit will be made to meet with the service users. What the service does well: What has improved since the last inspection? The home’s risk assessments had been updated as required. Some minor repairs had been made to the building. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 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 standard(s) 5 Service users are provided with information about the home, written in a form which makes it easier for them to understand. EVIDENCE: The home has not had any new admissions for over 10 years. The statement of terms and conditions was seen. Copies were available for service users using images and pictorial language (Makaton). Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 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 standard(s) 9 The home has well-developed risk assessments which protect the interests of service users whilst allowing them to undertake a full range of activities. EVIDENCE: The risk assessments had been updated regularly, as required in the previous report. The date of the review of the risk assessment is recorded both on the assessment itself and on a monitoring log. The manager said that the assessments had been updated before but that some staff had not transferred this information onto the monitoring sheet. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11 12 13 14 The home supports the service users in having a varied and fulfilling work and social life. EVIDENCE: Each of the 3 service users attends a day service from around 9.a.m – 3.30p.m during the week. Activities take place at the day service such as arts and crafts and a range of physical activities, including horse riding, canoeing, walking and gym work. One of the service users attends a different day centre where a similar range of activities is available. The rota was designed to fit round the needs of the service users. The manager said that staff often work beyond their fixed hours in order that service users can attend social events in the evening. This was reflected in the flexibility of the staffing rota seen. The manager said that she feels the service users are well-integrated into the local community and have good contact with their neighbours. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The home ensures that medication is securely stored, administered and recorded by trained staff. EVIDENCE: The medication system was checked. No service users handle their own medication at the home. All staff have accredited medication training prior to dispensing any medications. Further training and updating of information is provided by the home’s pharmacist, who regularly checks the system. All the MAR (medication administration records) sheets were fully completed and there were no handwritten entries. All the medications were securely stored in bottles or boxes that were clearly labelled. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 23 Systems are in place to enable service users and staff to complain about the service and to contact outside agencies for support. Procedures are established for the reporting and recording of any potential abuse. EVIDENCE: The complaints system contained all the required information and was written in a pictorial language (Makaton) which would help some of the service users to understand it. One of the service users is provided with an external advocacy service and the home hopes to extend this to all the service users. The home had systems in place to report and record any allegations or suspicions of abuse – these are linked into the local social services adult protection procedures. Both staff members interviewed on the day had undertaken adult protection training. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 25 27 28 30 The communal areas were not of the same standard as the service users’ bedrooms and the outside areas of the home were potentially hazardous to service users and staff. The condition of the gardens did not allow service users to fully enjoy them. EVIDENCE: The bedrooms seen were highly personalised, containing pictures, posters, music centres etc. they were brightly decorated and the manager said that the service users had chosen the colours for their rooms. There were sufficient bathrooms and toilets for the service users. The communal areas, such as the lounge and the dining-room were not as well-decorated. The wooden ceiling in the lounge had been painted but there were patches where the paint had peeled. The window ledge in the lounge was marked and needed repainting. The settees were not very comfortable and it was difficult to get up from them as they sank down. Work identified in the previous report had not been fully addressed. The wrong glass had been fitted in the service user’s bedroom at the front of the house and the kitchen work surface was still in the process of being replaced. The garden at the rear and the driveway at the front of the house had still not been fully attended to: the pathways are uneven and are potential tripping hazards, the garden furniture is in poor condition, the flower Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 14 beds were unkempt and plants and bushes were overgrown. There is an unused outbuilding on which the wooden slats appeared to be loose. The back gate did not appear to provide any security and there was open access to the drive at the front of the bungalow and around the side. Staff have to sometimes leave the bungalow at night to access the laundry. The drive had been completed without any wall or fencing along the edge on one side which is above a slope. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 32 33 36 Staff were employed in sufficient numbers and they had undertaken training which enabled them to meet the needs of the residents in the home EVIDENCE: Staffing levels at the home met the agreed levels and the rotas showed that staff worked flexibly in order to maximise the service users’ potential to live a fully balanced life. Staff training was comprehensive, all new staff undertake a full two-week induction and there was regular on-going statutory training. One staff member interviewed said that further training around the specific needs of the service users is ongoing. There is a high level of NVQ qualified staff at Level II and above. The manager provides some management support for another non-registered project within the organisation – up to 8 hours per week. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 40 42 There is an open and friendly atmosphere at the home which encourages staff and service users to communicate their needs or concerns. Some outside areas of the home are potentially hazardous to service users. EVIDENCE: The senior support worker interviewed felt that the manager made it clear what is expected of her in her role. She said that staff are able to make suggestions about the care of service users and are encouraged to express concerns in one-to-one supervision sessions, staff meetings or at any other time. The manager has experience in management and working with this client group and has achieved NVQ Level IV in Management and Care. The home’s fire alarm testing records and staff fire training records were checked and these were fully completed. The senior support worker interviewed had undergone all required statutory training, including First Aid, Moving and Handling, Food Hygiene and Health and Safety. There was a central record of which staff required statutory training and when this was due. There were no Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 17 obvious hazards noted within the home, however, as noted above, problems remain with the garden areas. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 2 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x x x Standard No 31 32 33 34 35 36 Score 3 3 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Birchgrove Score x x x 3 Standard No 37 38 39 40 41 42 43 Score x 3 x 3 x 2 x C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 (2) (d) Requirement A programme for the improvement of the internal and external environment of the home must be developed and implemented. (Previous timescale of 30/9/04 not met) Pathways and surfaces in the rear garden must be made safe. (Previous timescale of 31/3/05 not met) Lighting in the patio area must be repaired.(Previous timescale of 31/3/05 not met) New glass must be fitted in the front door and adjacent bedroom window to ensure privacy.(Previous timescale of 31/3/05 not met) Appropriate curtains must be fitted in the bedroom at the front of the property.(Previous timescale of 31/3/05 not met) Timescale for action 31/8/05 2. YA24 23 (2) (o) 31/6/05 3. YA24 23 (2) (p) 31/6/05 4. YA24 12 (2) (a) 31/9/05 5. YA26 16 (2) (c) 31/8/05 6. 7. YA24 YA24 16 (2) (g) 13 (4) (a) A new kitchen work surface must 31/6/05 be fitted.(Previous timescale of 31/3/05 not met) The home must ensure that the 31/10/05 gardens and driveway are safe Version 1.30 Page 20 Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc and appropriate security measures are put in place. 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 YA6 Good Practice Recommendations The Home should continue to streamline care plan files. Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road DERBY DE4 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Birchgrove C52-C02 S19938 Birchgrove V226955 180505 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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