Inspection on 27/10/05 for Birchgrove

This inspection was carried out on 27th October 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 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 1 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 18/05/05

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 Inspection 27th October 2005 03:00 Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 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 Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 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. Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Birchgrove Address 82 Lumsdale Road Matlock Derbyshire DE4 5NG (01629) 584161 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.unitedresponse.org.uk United Response Mrs Deborah North Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2005 Brief Description of the Service: Birchgrove 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 DS0000019938.V258225.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was primarily to meet with the service users who were not present on the previous inspection. All three service users were spoken with and a check was made of the environment. The care plan of one of the service user was checked in detail. What the service does well: What has improved since the last inspection? What they could do better: Whilst the care plans contained a wide range of useful information, the home needs to continue to ensure that they can be a useful working document. Some outstanding building work needs to be finished. Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 Page 6 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 DS0000019938.V258225.R01.S.doc Version 5.0 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 Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 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): 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 checked on the previous inspection. Copies were available for service users using images and pictorial language (Makaton). Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 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): 6789 The service focuses on understanding the needs and wishes of the service users. They are fully involved in decisions on how they spend their time. EVIDENCE: Whilst it was difficult to verbally ascertain the views of the service users, the care plans seen were focused on their needs and wishes. The interaction between the staff and the service users was respectful and apparently genuinely warm. Service users were engaged in activities in the home on the day of the inspection, they had been attending activities during the day and some were preparing to be involved in social activities in the evening. One service user’s care plan checked reflected closely the way in which staff worked with this person. Decisions about daily routines, social activities and holidays were recorded – outside advice or advocacy is sought wherever possible. Risk assessments have been regularly updated and reviewed. Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 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 the following standard(s): 11 12 13 14 16 The home supports the service users in having a varied and fulfilling work and social life. EVIDENCE: The service users are offered appropriate staff support to ensure that they can attend a range of vocational, educational and social activities. The care plans identify that each of the service users attends a day service from around 9.a.m – 3.30p.m during the week. Activities take place at the day service. The manager said that staff often work beyond their fixed hours in order that service users can attend social events in the evening. Service users appear well-integrated into the local community. Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 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 the following standard(s): 18 19 Personal and healthcare support is provided in a way that takes into account the wishes of the service users. EVIDENCE: The service users have complex emotional and social needs and these were fully explored and considered in the care plan checked. Specialist advice has been sought for service users who need it. Staff spoken confirmed that the routines at the home are focused as much as possible on the needs of the service users. Healthcare needs were identified in the care plan seen. It is clear that there is consultation with a range of healthcare professionals in order to ensure that the appropriate support can be provided. Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 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 the following 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 and Adult Protection systems were not checked during the current inspection - it was identified in the previous report that 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. There are links with an external advocacy service. There were systems in place to report and record any allegations or suspicions of abuse –linked into the local social services adult protection procedures. Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 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 the following standard(s): 24 25 26 27 30 Improvements to the home mean that both the communal and private areas provide a pleasant and homely environment for service users. EVIDENCE: The communal areas, such as the lounge and the dining-room had been redecorated since the previous inspection, the wooden ceilings had been repainted and the settees had been replaced. The garden had been fully cleared of hazardous areas and was now a pleasant, safe space for the service users to use. This has impacted significantly in a positive way on the daily lives of the service users. Fencing has been provided at the front of the building, improving safety and security at the home. The bedrooms seen were highly personalised, containing pictures, posters, music centres and other personal items. They were brightly decorated and the manager said that the service users had chosen the colours for their rooms. A number of carpets had been replaced with the service users being involved in this. There were sufficient bathrooms and toilets for the service users. Some minor decorations are in the process of being finished. Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 Page 14 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 33 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. The manager provides some management support for another non-registered project within the organisation – up to 8 hours per week. Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 Page 15 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 38 There is a warm, professional and friendly atmosphere at the home, which encourages service users to communicate their needs or concerns. EVIDENCE: The manager has significant experience in management and working with this client group and she has achieved NVQ Level IV in Management and Care. She was very aware of her obligations and responsibilities regarding the promotion of service users’ rights and was very knowledgeable both of individual service user needs and how they managed in a communal setting. There were no obvious hazards noted within the home and the problems in the garden areas had been addressed. Records examined were of a good standard, up-to-date and securely stored. From observation of the service users, it would seem that they felt comfortable in the home and were looked-after by staff who understood their needs and responded well to them. Birchgrove DS0000019938.V258225.R01.S.doc Version 5.0 Page 16 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 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 4 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 X X 3 LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 3 16 4 17 Standard No 31 32 33 34 35 36 Score X 3 3 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Birchgrove Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 3 DS0000019938.V258225.R01.S.doc Version 5.0 Page 17 Yes 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 The remaining repairs and decorations must be completed. Timescale for action 28/02/06 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 DS0000019938.V258225.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 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 DS0000019938.V258225.R01.S.doc Version 5.0 Page 19 - 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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